Common use of Nursing Facility Level of Care Clause in Contracts

Nursing Facility Level of Care. For Members who have indicators that may warrant a NF LOC, the CONTRACTOR shall conduct an in-person CNA at the Member’s primary residence. The CONTRACTOR shall use the New Mexico Medicaid NF LOC Criteria and instructions to determine NF LOC eligibility for all Members. For Members in the ABP who meet NF LOC, the CONTRACTOR shall notify the Member that they may be ABP Exempt, explain the benefit differences for ABP Exempt individuals and facilitate their movement into the ABP exempt benefit package (the Covered Services included in Attachment 1: Turquoise Care Covered Services) at the Member’s choice. For Members transitioning from a Medicare NF stay to a Medicaid short-term acute NF stay, the CONTRACTOR shall complete the short-term stay authorization determination no later than five (5) Business Days before the transition occurs, and follow the process prescribed by HSD so as to ensure no lapse in payment to the NF if the Member is determined to meet the criteria for Medicaid payment. The CONTRACTOR's Care Coordination program description shall specify the CONTRACTOR’s process for the assignment of a Care Coordination Level, a change in Care Coordination Level, assignment of care coordinators, and care coordinator caseload ratios. The process shall be consistent with the Care Coordination assignment requirements in this Section 4.4.5 and dependent on the outcome of the CNA. Care Coordination Level Two (CCL2) The CONTRACTOR shall assign CCL2, at a minimum, to Members with one (1) or more of the following factors: Has multi-comorbidity; Has high emergency room use, defined as three (3) or more emergency room visits in ninety (90) days; Has a mental health or substance abuse condition causing moderate functional impairment; Requires assistance with two (2) or more ADLs and/or IADLs and is living in the community at low risk; Has mild cognitive deficits requiring prompting or cues: Has poly-pharmaceutical use, which is defined as simultaneous use of six (6) or more medications from different drug classes and/or simultaneous use of three (3) or more medications from the same drug class; Is a Member with a high risk pregnancy (including pregnant Members who are eighteen (18) years and younger); Is a CISC; Is a Justice-Involved Member (refer to Section 5.12 of the Managed Care Policy Manual for details); or Is a CARA Member. Care Coordination Level Three (CCL3) The CONTRACTOR shall assign to CCL3, at a minimum, to Members with one (1) or more of the following factors: Is medically complex or fragile; Has excessive emergency room use, which is defined as three (3) or more emergency room visits in sixty (60) days; Has a mental health or substance abuse condition causing high functional impairment; Has untreated substance dependency based on the current Diagnostic and Statistical Manual of Mental Disorders (DSM) or other functional scale determined by the State; Requires assistance with two (2) ADLs or IADLs and is living in the community at medium to high risk; Has significant cognitive deficits; or Has contraindicated pharmaceutical use. Changes in CCL The CONTRACTOR shall identify Members who may need a change in CCL. The CONTRACTOR shall assess a Member’s need for a change in CCL upon self-identification, internal and external referrals, and through DMRs. Assignment of Care Coordinator The CONTRACTOR shall assign a specific care coordinator to each Member assigned to CCL2 or CCL3. The CONTRACTOR shall notify the Member of the assigned care coordinator and how to contact the care coordinator as set forth in the Managed Care Policy Manual. When assigning care coordinators to Members, the CONTRACTOR shall consider the alignment of the care coordinator’s qualifications, expertise, geographic proximity, language, and cultural background with the needs or preferences of the Member. The CONTRACTOR’s considerations shall include, but are not limited to, the following: The assigned care coordinator for Members who choose the SDBC shall have specific experience with self-direction and additional training regarding self-direction. The CONTRACTOR must make reasonable accommodations for non-English speaking Members who request assignment to a care coordinator who speaks the Member’s preferred language. If a Native American Member requests assignment to a Native American care coordinator the CONTRACTOR must employ or contract with a Native American care coordinator or contract with a CHR to serve as the care coordinator. The CONTRACTOR shall make reasonable efforts to offer a Native American care coordinator from the same Tribe, Nation, or Pueblo as the Member. The CONTRACTOR shall allow the Member to change their assigned Care Coordination. However, in order to ensure continuity of care, the CONTRACTOR shall minimize the number of changes in a Member’s care coordinator initiated by the CONTRACTOR. Caseload Ratios The CONTRACTOR shall establish and maintain maximum caseloads ratios per care coordinator for Members and populations in CCL2 and CCL3 as approved by HSD. The CONTRACTOR’s proposed maximum caseload ratios shall not exceed the following: CCL2 Members not residing in a NF or who participate in the Self-Directed Community Benefit (SDCB) - 1:75 CCL2 and CCL 3 Members residing in a NF - 1:125 CCL3 Members not residing in a N F or who participate in the SDCB - 1:50 As the CONTRACTOR delegates more Care Coordination functions to local resources, the CONTRACTOR shall collaborate with HSD to adjust Care Coordination caseload requirements. The CONTRACTOR's Care Coordination program description shall specify the CONTRACTOR’s process for developing, sharing, and updating the Comprehensive Care Plan (CCP). The process shall be consistent with the CCP requirements in this Section 4.4.6. The CONTRACTOR shall develop and implement CCPs, using HSD’s standardized CCP, for Members in CCL2 and CCL3 within fourteen (14) Business Days of completion of the initial CNA, unless the Member is in the Treat First model of care. For Members in the Treat First model of care, the CCP shall be completed within fourteen (14) Business Days of the completion of four (4) therapeutic encounters, but no later than thirty (30) Business Days of the CNA completion. The CCP shall be individualized based upon the Member’s assessed needs, preferences, and circumstances and updated at each touch point, as necessary, to reflect changes in the Member’s needs, preferences, and circumstances. The CCP developed through Full Delegation or Shared Functions Models of Care Coordination is not required to adhere to timelines described in this Section 4.4.6.2; however, the CONTRACTOR must ensure the CCP is completed in within the timelines and in compliance with its agreement with the delegated individual or entity. The CONTRACTOR shall ensure at a minimum that the Member and the Member’s Representative participate in developing the CCP, and that care coordinators consult with the Member’s PCP, specialists, Behavioral Health Providers, other Providers, and interdisciplinary team experts as needed. For CISC Members, the CONTRACTOR shall consult with the CISC’s PPW as well as the CISC Member and the CISC Member’s Representative when developing the CCP. The CONTRACTOR shall receive a copy of the CANS and CAT from CYFD and utilize those screening tools in developing the CCP to inform service needs to avoid Members having to repeat sharing sensitive information. The CONTRACTOR shall ensure the CCP is developed to align with the CAT and CANS. The care coordinator shall ensure that the Member’s needs (including needs related to Social Determinants of Health [SDOH]) and services are documented in the Member’s CCP. As applicable, the care coordinator shall also include the Member’s choice to receive institutional care or HCBS, and the Member’s choice of HCBS and Providers. The care coordinator shall ensure that the Member (or the Member’s Representative, if applicable) understands, reviews, signs, and dates the CCP. The care coordinator shall provide a copy of the Member’s completed CCP, including any updates, to the Member and the Member’s Representative, as applicable. The Care Coordination team shall provide copies to other Providers authorized to deliver care to the Member, as allowable, or inform Providers in writing of services to be performed by the Provider, including all relevant information needed to ensure the provision of quality care for the Member. For Members in an institutional facility, the Care Coordination team shall develop the CCP but may use the Individual Plan of Care developed by the institution to supplement the CCP. The CONTRACTOR's Care Coordination program description shall specify the CONTRACTOR’s performance of Care Coordination activities. The process shall be consistent with the requirements for Care Coordination activities in this Section 4.4.7. Care coordinators for Members in CCL2 or CCL3 shall provide and/or arrange for the following Care Coordination services: Outreaching to Members to engage in Care Coordination; Offering and linking Members who would benefit from a Health Home; Leading the development, implementation, and ongoing updates to the CCP; Offering and linking Members to targeted health education, disease management (DM), and wellness/prevention coaching, as appropriate, offered through the CONTRACTOR or in the community; Coordinating Member access to Covered Services as needed (e.g., scheduling appointments, arranging transportation, making referrals); Educating the Member about available community resources and services and assisting the Member in accessing those resources and services; Facilitating access to supports that assess housing needs and identify appropriate resources to help Members attain and maintain community housing; Informing each Member of the Member’s Medicaid eligibility end date, the importance of maintaining eligibility, and that Members will be contacted near the date on which a redetermination is needed to assist them with the process (e.g., collecting appropriate documentation and completing the necessary forms); Performing in-person, in-home CNAs as needed, but at least annually for CCL2 Members and semi-annually for CCL3 Members, to determine if the CCP is appropriate and if a higher or lower level of Care Coordination is needed; Performing in-person and in-home visits with the Member as required in the Managed Care Policy Manual; Communicating and exchanging information with Providers (e.g., PCP, specialists, labs, imaging facilities, HCBS Providers) to coordinate the care of the Member; Participating in discharge planning activities with the discharging inpatient facility (including SUD and psychiatric facilities) to support a safe discharge placement and to prevent unplanned or unnecessary readmissions, ED visits, and adverse outcomes; Ensuring Member access to post discharge services as specified in the discharge plan; Facilitating clinical hand offs between the discharging facility and other Contract Providers involved in the care and treatment of the Member; Monitoring the CCP to determine if the services are delivered as recommended and if the CCP is meeting the Member’s identified needs; and Monitoring data and information to identify, address, and evaluate service gaps to determine their cause and to minimize gaps going forward to ensure that back-up plans are implemented and effectively working. For Members meeting a NF LOC, Care Coordination activities shall also include: Conducting a level of care reassessment at least annually and within five (5) Business Days of becoming aware of a change in the Member’s functional or medical status that may affect a level of care determination. No level of care reassessment is necessary for Members who meet ongoing NF LOC criteria as stated in Section 4.1.3 of this Agreement; and As appropriate, ensure that all Pre-Admission Screening and Resident Review (PASRR) requirements are met prior to the Member’s admission to a NF as required in 42 C.F.R. § 483.100-138.

Nursing Facility Level of Care. For Members who have indicators that may warrant a NF LOC, the CONTRACTOR shall conduct an in-person CNA at the Member’s primary residence. The CONTRACTOR shall use the New Mexico Medicaid NF LOC Criteria and instructions to determine NF LOC eligibility for all Members. For Members in the ABP who meet NF LOC, the CONTRACTOR shall notify the Member that they may be ABP Exempt, explain the benefit differences for ABP Exempt individuals and facilitate their movement into the ABP exempt benefit package (the Covered Services included in Attachment 1: Turquoise Care Covered Services) at the Member’s choice. For Members transitioning from a Medicare NF stay to a Medicaid short-term acute NF stay, the CONTRACTOR shall complete the short-term stay authorization determination no later than five (5) Business Days before the transition occurs, and follow the process prescribed by HSD HCA so as to ensure no lapse in payment to the NF if the Member is determined to meet the criteria for Medicaid payment. The CONTRACTOR's Care Coordination program description shall specify the CONTRACTOR’s process for the assignment of a Care Coordination Level, a change in Care Coordination Level, assignment of care coordinators, and care coordinator caseload ratios. The process shall be consistent with the Care Coordination assignment requirements in this Section 4.4.5 and dependent on the outcome of the CNA. Care Coordination Level Zero (CCL0) The CONTRACTOR shall assign Members to CCL 0, as follows: Members the CONTRACTOR was unable to reach after making reasonable outreach efforts as described in Section 4.4.4.4.3, Members assessed to not have a current need for an assigned care coordinator; Members who have been contacted and refuse Care Coordination; In addition to outreach and engagement efforts, CCL0 care coordinators are responsible for reviewing and monitoring data including, but not limited to, encounters, utilization patterns including hospital and ED visits for individuals that are high-risk (would benefit and fit within the parameters of CCL1 or CCL2), pharmacy trends, or difficult to engage or refused to engage. CCL0 care coordinators are to monitor for membership in CCL0 on the high-cost high-needs report. CCL0 care coordinators are to re-engage in outreach upon indication of connection with an inpatient, crisis utilization, or ED facility. This can include face-to-face approach while inpatient, prior to discharge. Upon a member change in clinical presentation, CCL0 care coordination would attempt to engage again if the member previously was difficult to engage or refused. Care Coordination Level One (CCL1) The CONTRACTOR shall assign Members to CCL1, at a minimum, as follows: Members who meet NF LOC; Perinatal and maternal health Members, including Members in the MHV program Members receiving LTSS; Members in a Nursing Facility Level of Care Waiver populations not listed in CCL2; and Members with multiple (three or more) complaints, grievances, or appeals related to the Member’s experience with the service delivery system. Care Coordination Level Two (CCL2) The CONTRACTOR shall assign CCL2Members to CCL2 who, at a minimum, to have the following: HCHN Members; Members with one (1) or more of the following factors: Has multi-comorbiditySUD; Has high emergency room use, defined as three (3) or more emergency room visits in ninety (90) daysMembers with SED; Has a mental health or substance abuse condition causing moderate functional impairmentMembers with SMI; Requires assistance with two (2) or more ADLs and/or IADLs and is living in the community at low risk; Has mild cognitive deficits requiring prompting or cues: Has poly-pharmaceutical use, which is defined as simultaneous use of six (6) or more medications from different drug classes and/or simultaneous use of three (3) or more medications from the same drug class; Is a Member with a high risk pregnancy (including pregnant Members who are eighteen (18) years and younger); Is a CISC; Is a Justice-Involved Member (refer to Section 5.12 of the Managed Care Policy Manual for details)Individuals; or Is a CARA Member. Care Coordination Level Three (CCL3) The CONTRACTOR shall assign to CCL3, at a minimum, to Members with one (1) or more of the following factors: Is medically complex or fragileTBI; Has excessive emergency room use, which is defined as three (3) or more emergency room visits Members with housing insecurity; CISC Members; CARA Members; and Members in sixty (60) days; Has a mental health or substance abuse condition causing high functional impairment; Has untreated substance dependency based on the current Diagnostic and Statistical Manual of Mental Disorders (DSM) or other functional scale determined by the State; Requires assistance with two (2) ADLs or IADLs and is living in the community at medium to high risk; Has significant cognitive deficits; or Has contraindicated pharmaceutical useout-of-state placements. Changes in CCL The CONTRACTOR shall perform ongoing monitoring to identify reassessment triggers for Members who may need a change in CCL. The CONTRACTOR shall assess a Member’s need for a change in CCL upon self-identification, internal and external referrals, and through data mining review (DMRs. Assignment of Care Coordinator The CONTRACTOR shall assign a specific care coordinator to each Member assigned to CCL2 or CCL3. The CONTRACTOR shall notify the Member of the assigned care coordinator and how to contact the care coordinator as set forth in the Managed Care Policy Manual. When assigning care coordinators to Members, the CONTRACTOR shall consider the alignment of the care coordinator’s qualifications, expertise, geographic proximity, language, and cultural background with the needs or preferences of the Member. The CONTRACTOR’s considerations shall include, but are not limited to, the following: The assigned care coordinator for Members who choose the SDBC shall have specific experience with self-direction and additional training regarding self-direction. The CONTRACTOR must make reasonable accommodations for non-English speaking Members who request assignment to a care coordinator who speaks the Member’s preferred language. If a Native American Member requests assignment to a Native American care coordinator the CONTRACTOR must employ or contract with a Native American care coordinator or contract with a CHR to serve as the care coordinator. The CONTRACTOR shall make reasonable efforts to offer a Native American care coordinator from the same Tribe, Nation, or Pueblo as the Member. The CONTRACTOR shall allow the Member to change their assigned Care Coordination. However, in order to ensure continuity of care, the CONTRACTOR shall minimize the number of changes in a Member’s care coordinator initiated by the CONTRACTOR. Caseload Ratios The CONTRACTOR shall establish and maintain maximum caseloads ratios per care coordinator for Members and populations in CCL2 and CCL3 as approved by HSD. The CONTRACTOR’s proposed maximum caseload ratios shall not exceed the following: CCL2 Members not residing in a NF or who participate in the Self-Directed Community Benefit (SDCB) - 1:75 CCL2 and CCL 3 Members residing in a NF - 1:125 CCL3 Members not residing in a N F or who participate in the SDCB - 1:50 As the CONTRACTOR delegates more Care Coordination functions to local resources, the CONTRACTOR shall collaborate with HSD to adjust Care Coordination caseload requirements. The CONTRACTOR's Care Coordination program description shall specify the CONTRACTOR’s process for developing, sharing, and updating the Comprehensive Care Plan (CCP). The process shall be consistent with the CCP requirements in this Section 4.4.6. The CONTRACTOR shall develop and implement CCPs, using HSD’s standardized CCP, for Members in CCL2 and CCL3 within fourteen (14) Business Days of completion of the initial CNA, unless the Member is in the Treat First model of care. For Members in the Treat First model of care, the CCP shall be completed within fourteen (14) Business Days of the completion of four (4) therapeutic encounters, but no later than thirty (30) Business Days of the CNA completion. The CCP shall be individualized based upon the Member’s assessed needs, preferences, and circumstances and updated at each touch point, as necessary, to reflect changes in the Member’s needs, preferences, and circumstances. The CCP developed through Full Delegation or Shared Functions Models of Care Coordination is not required to adhere to timelines described in this Section 4.4.6.2; however, the CONTRACTOR must ensure the CCP is completed in within the timelines and in compliance with its agreement with the delegated individual or entity. The CONTRACTOR shall ensure at a minimum that the Member and the Member’s Representative participate in developing the CCP, and that care coordinators consult with the Member’s PCP, specialists, Behavioral Health Providers, other Providers, and interdisciplinary team experts as needed. For CISC Members, the CONTRACTOR shall consult with the CISC’s PPW as well as the CISC Member and the CISC Member’s Representative when developing the CCP. The CONTRACTOR shall receive a copy of the CANS and CAT from CYFD and utilize those screening tools in developing the CCP to inform service needs to avoid Members having to repeat sharing sensitive information. The CONTRACTOR shall ensure the CCP is developed to align with the CAT and CANS. The care coordinator shall ensure that the Member’s needs (including needs related to Social Determinants of Health [SDOH]) and services are documented in the Member’s CCP. As applicable, the care coordinator shall also include the Member’s choice to receive institutional care or HCBS, and the Member’s choice of HCBS and Providers. The care coordinator shall ensure that the Member (or the Member’s Representative, if applicable) understands, reviews, signs, and dates the CCP. The care coordinator shall provide a copy of the Member’s completed CCP, including any updates, to the Member and the Member’s Representative, as applicable. The Care Coordination team shall provide copies to other Providers authorized to deliver care to the Member, as allowable, or inform Providers in writing of services to be performed by the Provider, including all relevant information needed to ensure the provision of quality care for the Member. For Members in an institutional facility, the Care Coordination team shall develop the CCP but may use the Individual Plan of Care developed by the institution to supplement the CCP. The CONTRACTOR's Care Coordination program description shall specify the CONTRACTOR’s performance of Care Coordination activities. The process shall be consistent with the requirements for Care Coordination activities in this Section 4.4.7. Care coordinators for Members in CCL2 or CCL3 shall provide and/or arrange for the following Care Coordination services: Outreaching to Members to engage in Care Coordination; Offering and linking Members who would benefit from a Health Home; Leading the development, implementation, and ongoing updates to the CCP; Offering and linking Members to targeted health education, disease management (DM), and wellness/prevention coaching, as appropriate, offered through the CONTRACTOR or in the community; Coordinating Member access to Covered Services as needed (e.g., scheduling appointments, arranging transportation, making referrals); Educating the Member about available community resources and services and assisting the Member in accessing those resources and services; Facilitating access to supports that assess housing needs and identify appropriate resources to help Members attain and maintain community housing; Informing each Member of the Member’s Medicaid eligibility end date, the importance of maintaining eligibility, and that Members will be contacted near the date on which a redetermination is needed to assist them with the process (e.g., collecting appropriate documentation and completing the necessary forms); Performing in-person, in-home CNAs as needed, but at least annually for CCL2 Members and semi-annually for CCL3 Members, to determine if the CCP is appropriate and if a higher or lower level of Care Coordination is needed; Performing in-person and in-home visits with the Member as required in the Managed Care Policy Manual; Communicating and exchanging information with Providers (e.g., PCP, specialists, labs, imaging facilities, HCBS Providers) to coordinate the care of the Member; Participating in discharge planning activities with the discharging inpatient facility (including SUD and psychiatric facilities) to support a safe discharge placement and to prevent unplanned or unnecessary readmissions, ED visits, and adverse outcomes; Ensuring Member access to post discharge services as specified in the discharge plan; Facilitating clinical hand offs between the discharging facility and other Contract Providers involved in the care and treatment of the Member; Monitoring the CCP to determine if the services are delivered as recommended and if the CCP is meeting the Member’s identified needs; and Monitoring data and information to identify, address, and evaluate service gaps to determine their cause and to minimize gaps going forward to ensure that back-up plans are implemented and effectively working. For Members meeting a NF LOC, Care Coordination activities shall also include: Conducting a level of care reassessment at least annually and within five (5) Business Days of becoming aware of a change in the Member’s functional or medical status that may affect a level of care determination. No level of care reassessment is necessary for Members who meet ongoing NF LOC criteria as stated in Section 4.1.3 of this Agreement; and As appropriate, ensure that all Pre-Admission Screening and Resident Review (PASRR) requirements are met prior to the Member’s admission to a NF as required in 42 C.F.R. § 483.100-138.

Nursing Facility Level of Care. For Members who have indicators that may warrant a NF LOC, the CONTRACTOR shall conduct an in-person CNA at the Member’s primary residence. The CONTRACTOR shall use the New Mexico Medicaid NF LOC Criteria and instructions to determine NF LOC eligibility for all Members. For Members in the ABP who meet NF LOC, the CONTRACTOR shall notify the Member that they may be ABP Exempt, explain the benefit differences for ABP Exempt individuals and facilitate their movement into the ABP exempt benefit package (the Covered Services included in Attachment 1: Turquoise Care Covered Services) at the Member’s choice. For Members transitioning from a Medicare NF stay to a Medicaid short-term acute NF stay, the CONTRACTOR shall complete the short-term stay authorization determination no later than five (5) Business Days before the transition occurs, and follow the process prescribed by HSD HCA so as to ensure no lapse in payment to the NF if the Member is determined to meet the criteria for Medicaid payment. The CONTRACTOR's Care Coordination program description shall specify the CONTRACTOR’s process for the assignment of a Care Coordination Level, a change in Care Coordination Level, assignment of care coordinators, and care coordinator caseload ratios. The process shall be consistent with the Care Coordination assignment requirements in this Section 4.4.5 and dependent on the outcome of the CNA. Care Coordination Level Zero (CCL0) The CONTRACTOR shall assign Members to CCL 0, as follows: Members the CONTRACTOR was unable to reach after making reasonable outreach efforts as described in Section 4.4.4.4.3, Members assessed to not have a current need for an assigned care coordinator; Members who have been contacted and refuse Care Coordination; Care Coordination Level One (CCL1) The CONTRACTOR shall assign Members to CCL1, at a minimum, as follows: Members who meet NF LOC; Child and maternal health Members, including Members in the MHV program Members receiving LTSS; Members in a Nursing Facility Level of Care Waiver populations not listed in CCL2; and Members with multiple (three or more) complaints, grievances, or appeals related to the Member’s experience with the service delivery system. Care Coordination Level Two (CCL2) The CONTRACTOR shall assign CCL2Members to CCL2 who, at a minimum, to have the following: HCHN Members; Members with one (1) or more of the following factors: Has multi-comorbiditySUD; Has high emergency room use, defined as three (3) or more emergency room visits in ninety (90) daysMembers with SED; Has a mental health or substance abuse condition causing moderate functional impairmentMembers with SMI; Requires assistance with two (2) or more ADLs and/or IADLs and is living in the community at low risk; Has mild cognitive deficits requiring prompting or cues: Has poly-pharmaceutical use, which is defined as simultaneous use of six (6) or more medications from different drug classes and/or simultaneous use of three (3) or more medications from the same drug class; Is a Member with a high risk pregnancy (including pregnant Members who are eighteen (18) years and younger); Is a CISC; Is a Justice-Involved Member (refer to Section 5.12 of the Managed Care Policy Manual for details)Individuals; or Is a CARA Member. Care Coordination Level Three (CCL3) The CONTRACTOR shall assign to CCL3, at a minimum, to Members with one (1) or more of the following factors: Is medically complex or fragileTBI; Has excessive emergency room use, which is defined as three (3) or more emergency room visits Members with housing insecurity; CISC Members; CARA Members; and Members in sixty (60) days; Has a mental health or substance abuse condition causing high functional impairment; Has untreated substance dependency based on the current Diagnostic and Statistical Manual of Mental Disorders (DSM) or other functional scale determined by the State; Requires assistance with two (2) ADLs or IADLs and is living in the community at medium to high risk; Has significant cognitive deficits; or Has contraindicated pharmaceutical useout-of-state placements. Changes in CCL The CONTRACTOR shall perform ongoing monitoring to identify reassessment triggers for Members who may need a change in CCL. The CONTRACTOR shall assess a Member’s need for a change in CCL upon self-identification, internal and external referrals, and through data mining review (DMRs. Assignment of Care Coordinator The CONTRACTOR shall assign a specific care coordinator to each Member assigned to CCL2 or CCL3. The CONTRACTOR shall notify the Member of the assigned care coordinator and how to contact the care coordinator as set forth in the Managed Care Policy Manual. When assigning care coordinators to Members, the CONTRACTOR shall consider the alignment of the care coordinator’s qualifications, expertise, geographic proximity, language, and cultural background with the needs or preferences of the Member. The CONTRACTOR’s considerations shall include, but are not limited to, the following: The assigned care coordinator for Members who choose the SDBC shall have specific experience with self-direction and additional training regarding self-direction. The CONTRACTOR must make reasonable accommodations for non-English speaking Members who request assignment to a care coordinator who speaks the Member’s preferred language. If a Native American Member requests assignment to a Native American care coordinator the CONTRACTOR must employ or contract with a Native American care coordinator or contract with a CHR to serve as the care coordinator. The CONTRACTOR shall make reasonable efforts to offer a Native American care coordinator from the same Tribe, Nation, or Pueblo as the Member. The CONTRACTOR shall allow the Member to change their assigned Care Coordination. However, in order to ensure continuity of care, the CONTRACTOR shall minimize the number of changes in a Member’s care coordinator initiated by the CONTRACTOR. Caseload Ratios The CONTRACTOR shall establish and maintain maximum caseloads ratios per care coordinator for Members and populations in CCL2 and CCL3 as approved by HSD. The CONTRACTOR’s proposed maximum caseload ratios shall not exceed the following: CCL2 Members not residing in a NF or who participate in the Self-Directed Community Benefit (SDCB) - 1:75 CCL2 and CCL 3 Members residing in a NF - 1:125 CCL3 Members not residing in a N F or who participate in the SDCB - 1:50 As the CONTRACTOR delegates more Care Coordination functions to local resources, the CONTRACTOR shall collaborate with HSD to adjust Care Coordination caseload requirements. The CONTRACTOR's Care Coordination program description shall specify the CONTRACTOR’s process for developing, sharing, and updating the Comprehensive Care Plan (CCP). The process shall be consistent with the CCP requirements in this Section 4.4.6. The CONTRACTOR shall develop and implement CCPs, using HSD’s standardized CCP, for Members in CCL2 and CCL3 within fourteen (14) Business Days of completion of the initial CNA, unless the Member is in the Treat First model of care. For Members in the Treat First model of care, the CCP shall be completed within fourteen (14) Business Days of the completion of four (4) therapeutic encounters, but no later than thirty (30) Business Days of the CNA completion. The CCP shall be individualized based upon the Member’s assessed needs, preferences, and circumstances and updated at each touch point, as necessary, to reflect changes in the Member’s needs, preferences, and circumstances. The CCP developed through Full Delegation or Shared Functions Models of Care Coordination is not required to adhere to timelines described in this Section 4.4.6.2; however, the CONTRACTOR must ensure the CCP is completed in within the timelines and in compliance with its agreement with the delegated individual or entity. The CONTRACTOR shall ensure at a minimum that the Member and the Member’s Representative participate in developing the CCP, and that care coordinators consult with the Member’s PCP, specialists, Behavioral Health Providers, other Providers, and interdisciplinary team experts as needed. For CISC Members, the CONTRACTOR shall consult with the CISC’s PPW as well as the CISC Member and the CISC Member’s Representative when developing the CCP. The CONTRACTOR shall receive a copy of the CANS and CAT from CYFD and utilize those screening tools in developing the CCP to inform service needs to avoid Members having to repeat sharing sensitive information. The CONTRACTOR shall ensure the CCP is developed to align with the CAT and CANS. The care coordinator shall ensure that the Member’s needs (including needs related to Social Determinants of Health [SDOH]) and services are documented in the Member’s CCP. As applicable, the care coordinator shall also include the Member’s choice to receive institutional care or HCBS, and the Member’s choice of HCBS and Providers. The care coordinator shall ensure that the Member (or the Member’s Representative, if applicable) understands, reviews, signs, and dates the CCP. The care coordinator shall provide a copy of the Member’s completed CCP, including any updates, to the Member and the Member’s Representative, as applicable. The Care Coordination team shall provide copies to other Providers authorized to deliver care to the Member, as allowable, or inform Providers in writing of services to be performed by the Provider, including all relevant information needed to ensure the provision of quality care for the Member. For Members in an institutional facility, the Care Coordination team shall develop the CCP but may use the Individual Plan of Care developed by the institution to supplement the CCP. The CONTRACTOR's Care Coordination program description shall specify the CONTRACTOR’s performance of Care Coordination activities. The process shall be consistent with the requirements for Care Coordination activities in this Section 4.4.7. Care coordinators for Members in CCL2 or CCL3 shall provide and/or arrange for the following Care Coordination services: Outreaching to Members to engage in Care Coordination; Offering and linking Members who would benefit from a Health Home; Leading the development, implementation, and ongoing updates to the CCP; Offering and linking Members to targeted health education, disease management (DM), and wellness/prevention coaching, as appropriate, offered through the CONTRACTOR or in the community; Coordinating Member access to Covered Services as needed (e.g., scheduling appointments, arranging transportation, making referrals); Educating the Member about available community resources and services and assisting the Member in accessing those resources and services; Facilitating access to supports that assess housing needs and identify appropriate resources to help Members attain and maintain community housing; Informing each Member of the Member’s Medicaid eligibility end date, the importance of maintaining eligibility, and that Members will be contacted near the date on which a redetermination is needed to assist them with the process (e.g., collecting appropriate documentation and completing the necessary forms); Performing in-person, in-home CNAs as needed, but at least annually for CCL2 Members and semi-annually for CCL3 Members, to determine if the CCP is appropriate and if a higher or lower level of Care Coordination is needed; Performing in-person and in-home visits with the Member as required in the Managed Care Policy Manual; Communicating and exchanging information with Providers (e.g., PCP, specialists, labs, imaging facilities, HCBS Providers) to coordinate the care of the Member; Participating in discharge planning activities with the discharging inpatient facility (including SUD and psychiatric facilities) to support a safe discharge placement and to prevent unplanned or unnecessary readmissions, ED visits, and adverse outcomes; Ensuring Member access to post discharge services as specified in the discharge plan; Facilitating clinical hand offs between the discharging facility and other Contract Providers involved in the care and treatment of the Member; Monitoring the CCP to determine if the services are delivered as recommended and if the CCP is meeting the Member’s identified needs; and Monitoring data and information to identify, address, and evaluate service gaps to determine their cause and to minimize gaps going forward to ensure that back-up plans are implemented and effectively working. For Members meeting a NF LOC, Care Coordination activities shall also include: Conducting a level of care reassessment at least annually and within five (5) Business Days of becoming aware of a change in the Member’s functional or medical status that may affect a level of care determination. No level of care reassessment is necessary for Members who meet ongoing NF LOC criteria as stated in Section 4.1.3 of this Agreement; and As appropriate, ensure that all Pre-Admission Screening and Resident Review (PASRR) requirements are met prior to the Member’s admission to a NF as required in 42 C.F.R. § 483.100-138.

Nursing Facility Level of Care. For Members who have indicators that may warrant a NF LOC, the CONTRACTOR shall conduct an in-person CNA at the Member’s primary residence. The CONTRACTOR shall use the New Mexico Medicaid NF LOC Criteria and instructions to determine NF LOC eligibility for all Members. For Members in the ABP who meet NF LOC, the CONTRACTOR shall notify the Member that they may be ABP Exempt, explain the benefit differences for ABP Exempt individuals and facilitate their movement into the ABP exempt benefit package (the Covered Services included in Attachment 1: Turquoise Care Covered Services) at the Member’s choice. For Members transitioning from a Medicare NF stay to a Medicaid short-term acute NF stay, the CONTRACTOR shall complete the short-term stay authorization determination no later than five (5) Business Days before the transition occurs, and follow the process prescribed by HSD HCA so as to ensure no lapse in payment to the NF if the Member is determined to meet the criteria for Medicaid payment. The CONTRACTOR's Care Coordination program description shall specify the CONTRACTOR’s process for the assignment of a Care Coordination Level, a change in Care Coordination Level, assignment of care coordinators, and care coordinator caseload ratios. The process shall be consistent with the Care Coordination assignment requirements in this Section 4.4.5 and dependent on the outcome of the CNA. Care Coordination Level Zero (CCL0) The CONTRACTOR shall assign Members to CCL 0, as follows: Members the CONTRACTOR was unable to reach after making reasonable outreach efforts as described in Section 4.4.4.4.3, Members assessed to not have a current need for an assigned care coordinator; Members who have been contacted and refuse Care Coordination; Care Coordination Level One (CCL1) The CONTRACTOR shall assign Members to CCL1, at a minimum, as follows: Members who meet NF LOC; Perinatal and maternal health Members, including Members in the MHV program Members receiving LTSS; Members in a Nursing Facility Level of Care Waiver populations not listed in CCL2; and Members with multiple (three or more) complaints, grievances, or appeals related to the Member’s experience with the service delivery system. Care Coordination Level Two (CCL2) The CONTRACTOR shall assign CCL2Members to CCL2 who, at a minimum, to have the following: HCHN Members; Members with one (1) or more of the following factors: Has multi-comorbiditySUD; Has high emergency room use, defined as three (3) or more emergency room visits in ninety (90) daysMembers with SED; Has a mental health or substance abuse condition causing moderate functional impairmentMembers with SMI; Requires assistance with two (2) or more ADLs and/or IADLs and is living in the community at low risk; Has mild cognitive deficits requiring prompting or cues: Has poly-pharmaceutical use, which is defined as simultaneous use of six (6) or more medications from different drug classes and/or simultaneous use of three (3) or more medications from the same drug class; Is a Member with a high risk pregnancy (including pregnant Members who are eighteen (18) years and younger); Is a CISC; Is a Justice-Involved Member (refer to Section 5.12 of the Managed Care Policy Manual for details)Individuals; or Is a CARA Member. Care Coordination Level Three (CCL3) The CONTRACTOR shall assign to CCL3, at a minimum, to Members with one (1) or more of the following factors: Is medically complex or fragileTBI; Has excessive emergency room use, which is defined as three (3) or more emergency room visits Members with housing insecurity; CISC Members; CARA Members; and Members in sixty (60) days; Has a mental health or substance abuse condition causing high functional impairment; Has untreated substance dependency based on the current Diagnostic and Statistical Manual of Mental Disorders (DSM) or other functional scale determined by the State; Requires assistance with two (2) ADLs or IADLs and is living in the community at medium to high risk; Has significant cognitive deficits; or Has contraindicated pharmaceutical useout-of-state placements. Changes in CCL The CONTRACTOR shall perform ongoing monitoring to identify reassessment triggers for Members who may need a change in CCL. The CONTRACTOR shall assess a Member’s need for a change in CCL upon self-identification, internal and external referrals, and through data mining review (DMRs. Assignment of Care Coordinator The CONTRACTOR shall assign a specific care coordinator to each Member assigned to CCL2 or CCL3. The CONTRACTOR shall notify the Member of the assigned care coordinator and how to contact the care coordinator as set forth in the Managed Care Policy Manual. When assigning care coordinators to Members, the CONTRACTOR shall consider the alignment of the care coordinator’s qualifications, expertise, geographic proximity, language, and cultural background with the needs or preferences of the Member. The CONTRACTOR’s considerations shall include, but are not limited to, the following: The assigned care coordinator for Members who choose the SDBC shall have specific experience with self-direction and additional training regarding self-direction. The CONTRACTOR must make reasonable accommodations for non-English speaking Members who request assignment to a care coordinator who speaks the Member’s preferred language. If a Native American Member requests assignment to a Native American care coordinator the CONTRACTOR must employ or contract with a Native American care coordinator or contract with a CHR to serve as the care coordinator. The CONTRACTOR shall make reasonable efforts to offer a Native American care coordinator from the same Tribe, Nation, or Pueblo as the Member. The CONTRACTOR shall allow the Member to change their assigned Care Coordination. However, in order to ensure continuity of care, the CONTRACTOR shall minimize the number of changes in a Member’s care coordinator initiated by the CONTRACTOR. Caseload Ratios The CONTRACTOR shall establish and maintain maximum caseloads ratios per care coordinator for Members and populations in CCL2 and CCL3 as approved by HSD. The CONTRACTOR’s proposed maximum caseload ratios shall not exceed the following: CCL2 Members not residing in a NF or who participate in the Self-Directed Community Benefit (SDCB) - 1:75 CCL2 and CCL 3 Members residing in a NF - 1:125 CCL3 Members not residing in a N F or who participate in the SDCB - 1:50 As the CONTRACTOR delegates more Care Coordination functions to local resources, the CONTRACTOR shall collaborate with HSD to adjust Care Coordination caseload requirements. The CONTRACTOR's Care Coordination program description shall specify the CONTRACTOR’s process for developing, sharing, and updating the Comprehensive Care Plan (CCP). The process shall be consistent with the CCP requirements in this Section 4.4.6. The CONTRACTOR shall develop and implement CCPs, using HSD’s standardized CCP, for Members in CCL2 and CCL3 within fourteen (14) Business Days of completion of the initial CNA, unless the Member is in the Treat First model of care. For Members in the Treat First model of care, the CCP shall be completed within fourteen (14) Business Days of the completion of four (4) therapeutic encounters, but no later than thirty (30) Business Days of the CNA completion. The CCP shall be individualized based upon the Member’s assessed needs, preferences, and circumstances and updated at each touch point, as necessary, to reflect changes in the Member’s needs, preferences, and circumstances. The CCP developed through Full Delegation or Shared Functions Models of Care Coordination is not required to adhere to timelines described in this Section 4.4.6.2; however, the CONTRACTOR must ensure the CCP is completed in within the timelines and in compliance with its agreement with the delegated individual or entity. The CONTRACTOR shall ensure at a minimum that the Member and the Member’s Representative participate in developing the CCP, and that care coordinators consult with the Member’s PCP, specialists, Behavioral Health Providers, other Providers, and interdisciplinary team experts as needed. For CISC Members, the CONTRACTOR shall consult with the CISC’s PPW as well as the CISC Member and the CISC Member’s Representative when developing the CCP. The CONTRACTOR shall receive a copy of the CANS and CAT from CYFD and utilize those screening tools in developing the CCP to inform service needs to avoid Members having to repeat sharing sensitive information. The CONTRACTOR shall ensure the CCP is developed to align with the CAT and CANS. The care coordinator shall ensure that the Member’s needs (including needs related to Social Determinants of Health [SDOH]) and services are documented in the Member’s CCP. As applicable, the care coordinator shall also include the Member’s choice to receive institutional care or HCBS, and the Member’s choice of HCBS and Providers. The care coordinator shall ensure that the Member (or the Member’s Representative, if applicable) understands, reviews, signs, and dates the CCP. The care coordinator shall provide a copy of the Member’s completed CCP, including any updates, to the Member and the Member’s Representative, as applicable. The Care Coordination team shall provide copies to other Providers authorized to deliver care to the Member, as allowable, or inform Providers in writing of services to be performed by the Provider, including all relevant information needed to ensure the provision of quality care for the Member. For Members in an institutional facility, the Care Coordination team shall develop the CCP but may use the Individual Plan of Care developed by the institution to supplement the CCP. The CONTRACTOR's Care Coordination program description shall specify the CONTRACTOR’s performance of Care Coordination activities. The process shall be consistent with the requirements for Care Coordination activities in this Section 4.4.7. Care coordinators for Members in CCL2 or CCL3 shall provide and/or arrange for the following Care Coordination services: Outreaching to Members to engage in Care Coordination; Offering and linking Members who would benefit from a Health Home; Leading the development, implementation, and ongoing updates to the CCP; Offering and linking Members to targeted health education, disease management (DM), and wellness/prevention coaching, as appropriate, offered through the CONTRACTOR or in the community; Coordinating Member access to Covered Services as needed (e.g., scheduling appointments, arranging transportation, making referrals); Educating the Member about available community resources and services and assisting the Member in accessing those resources and services; Facilitating access to supports that assess housing needs and identify appropriate resources to help Members attain and maintain community housing; Informing each Member of the Member’s Medicaid eligibility end date, the importance of maintaining eligibility, and that Members will be contacted near the date on which a redetermination is needed to assist them with the process (e.g., collecting appropriate documentation and completing the necessary forms); Performing in-person, in-home CNAs as needed, but at least annually for CCL2 Members and semi-annually for CCL3 Members, to determine if the CCP is appropriate and if a higher or lower level of Care Coordination is needed; Performing in-person and in-home visits with the Member as required in the Managed Care Policy Manual; Communicating and exchanging information with Providers (e.g., PCP, specialists, labs, imaging facilities, HCBS Providers) to coordinate the care of the Member; Participating in discharge planning activities with the discharging inpatient facility (including SUD and psychiatric facilities) to support a safe discharge placement and to prevent unplanned or unnecessary readmissions, ED visits, and adverse outcomes; Ensuring Member access to post discharge services as specified in the discharge plan; Facilitating clinical hand offs between the discharging facility and other Contract Providers involved in the care and treatment of the Member; Monitoring the CCP to determine if the services are delivered as recommended and if the CCP is meeting the Member’s identified needs; and Monitoring data and information to identify, address, and evaluate service gaps to determine their cause and to minimize gaps going forward to ensure that back-up plans are implemented and effectively working. For Members meeting a NF LOC, Care Coordination activities shall also include: Conducting a level of care reassessment at least annually and within five (5) Business Days of becoming aware of a change in the Member’s functional or medical status that may affect a level of care determination. No level of care reassessment is necessary for Members who meet ongoing NF LOC criteria as stated in Section 4.1.3 of this Agreement; and As appropriate, ensure that all Pre-Admission Screening and Resident Review (PASRR) requirements are met prior to the Member’s admission to a NF as required in 42 C.F.R. § 483.100-138.