Common use of Recommended Preventive Care Services Clause in Contracts

Recommended Preventive Care Services. Annually, OMPP will determine which recommended preventive services qualify a member for roll over or discount. The Contractor shall send preventive service reminders to their members throughout the benefit period, including in the monthly POWER Account Statements and redetermination correspondence. The Contractor shall have mechanisms in place to monitor when a member has obtained the preventive care services recommended for his or her age and gender, as well as pre-existing conditions, and report this information on the PRF one hundred and twenty (120) calendar days following the end of the member’s benefit period. The Contractor shall monitor whether a member has received recommended preventive care services by: 1. Utilizing claims data to determine if any of the certain specified disease conditions exist; 2. Utilizing claims data to determine if required services have been obtained (OMPP shall provide the qualifying CPT and/or ICD-10 codes, as applicable); and 3. If, after #1 and #2, preventive services cannot be verified, the Contractor may require the member to submit verification of preventive services. Members will only be required to complete disease-specific preventive services if they were diagnosed with the disease prior to the beginning of the benefit period. If a disease develops mid-benefit period, the member will not be required to complete preventive care services related to that disease until the next benefit period. Ninety (90) calendar days prior to the end of a member’s benefit period, the Contractor shall make an initial assessment (through claims and other information, as described above) of whether the member has completed the recommended preventive services. If the member has not received recommended preventive services, the Contractor shall send a reminder to the member. The reminder shall notify the member that the Contractor’s records indicate that the member has not received recommended preventive services based on medical claims received as of a specified date. A general listing that outlines what was required for different ages, genders and disease types is sufficient, it does not need to be specific to the member. The reminder shall also explain the appropriate roll-over incentive based on the member’s benefit plan that the member would be eligible to receive in the subsequent benefit period following completion of any recommended preventive service. This correspondence should be coordinated with other redetermination reminders and shall be provided no later than sixty (60) calendar days prior to the end of the member’s benefit period. Sixty (60) calendar days after the end of a member’s benefit period, the Contractor shall make an assessment (through claims and other information, as described above) of whether the member has completed the recommended preventive services. The Contractor shall send a letter to the member informing the member of its assessment if the assessment indicates that the member has not received the recommended preventive care. This letter shall go out within the sixty (60) calendar day period. 1. The letter to the member does not need to spell out what services the member received and what were not received. The letter shall only indicate that the required preventive care services were not completed. 2. The letter to the member shall list what the required preventive care services were for the member’s benefit period. A general listing that outlines what was required for different ages, genders and disease types is sufficient, it does not need to be specific to the member. 3. The Contractor shall develop a form that can be easily completed by a member’s physician which verifies that the member’s age and sex appropriate services have been obtained. This form shall be included in the letter to the member. 4. If the Contractor’s records indicated that the member has not received the recommended preventive services, the Contractor shall allow the member to file a grievance on the decision by submitting documentation that indicates that they did in fact receive the required preventive care. The form included in the member’s letter can be used as supporting documentation, but shall be completed by the member’s physician. 5. The letter shall indicate that the member has sixty (60) calendar days from receipt of the letter to file a grievance on the decision and submit additional information using the attached form. The Contractor may incorporate this grievance process into its existing grievance and appeals process, but shall ensure that the grievance is resolved in a time period that allows for timely submission of a complete and accurate PRF to the State. 6. If a member changes MCEs during their annual open enrollment period, the Contractor (e.g., original MCE) is responsible for resolving any grievances related to preventative care services. Example language that should be included in the letter to the member includes: i. The required preventive service(s) for the year was “X”.  For HIP Plus members: Because you regularly contributed to your POWER Account throughout the year, you are eligible to roll-over your unused share of the remaining POWER Account balance. If you also received the required preventive services, your “roll-over amount” will be doubled by the State in order to further reduce the cost of the plan in the next benefit period.  For HIP Basic members: If you received your required preventive services, you will be eligible to receive a discount on the required monthly POWER account contributions if you would choose to participate in HIP Plus in the next year. The discount will be based on a percentage of your remaining POWER Account balance at the end of your current benefit period. ii. A preliminary review of our records indicates that you have not received the required preventive service(s). iii. If you believe our preliminary determination is in error and you have received the preventive services listed above, please fill out the attached form and submit it to “X”. The form shall be filled out by your physician and returned within thirty (30) calendar days. Further detail regarding preventive service monitoring and reporting is set forth in the HIP MCE Policies and Procedures Manual.

Recommended Preventive Care Services. Annually, OMPP will determine which recommended preventive services qualify a member for roll over or discount. The Contractor shall send preventive service reminders to their members throughout the benefit period, including in the monthly POWER Account Statements and redetermination correspondence. The Contractor shall have mechanisms in place to monitor when a member has obtained the preventive care services recommended for his or her age and gender, as well as pre-pre- existing conditions, and report this information on the PRF one hundred and twenty (120) calendar days following the end of the member’s benefit period. The Contractor shall monitor whether a member has received recommended preventive care services by: 1. Utilizing claims data to determine if any of the certain specified disease conditions exist; 2. Utilizing claims data to determine if required services have been obtained (OMPP shall provide the qualifying CPT and/or ICD-10 codes, as applicable); and 3. If, after #1 and #2, preventive services cannot be verified, the Contractor may require the member to submit verification of preventive services. Members will only be required to complete disease-specific preventive services if they were diagnosed with the disease prior to the beginning of the benefit period. If a disease develops mid-benefit period, the member will not be required to complete preventive care services related to that disease until the next benefit period. Ninety (90) calendar days prior to the end of a member’s benefit period, the Contractor shall make an initial assessment (through claims and other information, as described above) of whether the member has completed the recommended preventive services. If the member has not received recommended preventive services, the Contractor shall send a reminder to the member. The reminder shall notify the member that the Contractor’s records indicate that the member has not received recommended preventive services based on medical claims received as of a specified date. A general listing that outlines what was required for different ages, genders and disease types is sufficient, it does not need to be specific to the member. The reminder shall also explain the appropriate roll-over incentive based on the member’s benefit plan that the member would be eligible to receive in the subsequent benefit period following completion of any recommended preventive service. This correspondence should be coordinated with other redetermination reminders and shall be provided no later than sixty (60) calendar days prior to the end of the member’s benefit period. Sixty (60) calendar days after the end of a member’s benefit period, the Contractor shall make an assessment (through claims and other information, as described above) of whether the member has completed the recommended preventive services. The Contractor shall send a letter to the member informing the member of its assessment if the assessment indicates that the member has not received the recommended preventive care. This letter shall go out within the sixty (60) calendar day period. 1. The letter to the member does not need to spell out what services the member received and what were not received. The letter shall only indicate that the required preventive care services were not completed. 2. The letter to the member shall list what the required preventive care services were for the member’s benefit period. A general listing that outlines what was required for different ages, genders and disease types is sufficient, it does not need to be specific to the member. 3. The Contractor shall develop a form that can be easily completed by a member’s physician which verifies that the member’s age and sex appropriate services have been obtained. This form shall be included in the letter to the member. 4. If the Contractor’s records indicated that the member has not received the recommended preventive services, the Contractor shall allow the member to file a grievance on the decision by submitting documentation that indicates that they did in fact receive the required preventive care. The form included in the member’s letter can be used as supporting documentation, but shall be completed by the member’s physician. 5. The letter shall indicate that the member has sixty (60) calendar days from receipt of the letter to file a grievance on the decision and submit additional information using the attached form. The Contractor may incorporate this grievance process into its existing grievance and appeals process, but shall ensure that the grievance is resolved in a time period that allows for timely submission of a complete and accurate PRF to the State. 6. If a member changes MCEs during their annual open enrollment period, the Contractor (e.g., original MCE) is responsible for resolving any grievances related to preventative care services. Example language that should be included in the letter to the member includes: i. The required preventive service(s) for the year was “X”.  For HIP Plus members: Because you regularly contributed to your POWER Account throughout the year, you are eligible to roll-over your unused share of the remaining POWER Account balance. If you also received the required preventive services, your “roll-over amount” will be doubled by the State in order to further reduce the cost of the plan in the next benefit period.  For HIP Basic members: If you received your required preventive services, you will be eligible to receive a discount on the required monthly POWER account contributions if you would choose to participate in HIP Plus in the next year. The discount will be based on a percentage of your remaining POWER Account balance at the end of your current benefit period. ii. A preliminary review of our records indicates that you have not received the required preventive service(s). iii. If you believe our preliminary determination is in error and you have received the preventive services listed above, please fill out the attached form and submit it to “X”. The form shall be filled out by your physician and returned within thirty (30) calendar days. Further detail regarding preventive service monitoring and reporting is set forth in the HIP MCE Policies and Procedures Manual.

Recommended Preventive Care Services. Annually, Annually OMPP will determine which recommended preventive services qualify a member for roll over or discount. The Contractor shall send preventive service reminders to their members throughout the benefit period, including in the monthly POWER Account Statements and redetermination correspondence. The Contractor shall have mechanisms in place to monitor when a member has obtained the preventive care services recommended for his or her age and gender, as well as pre-existing conditions, and report this information on the PRF one hundred and twenty (120) calendar days following the end of the member’s benefit period. The Contractor shall monitor whether a member has received recommended preventive care services by: 1. Utilizing claims data to determine if any of the certain specified disease conditions exist; 2. Utilizing claims data to determine if required services have been obtained (OMPP shall provide the qualifying CPT and/or ICD-10 codes, as applicable); and 3. If, after #1 and #2, preventive services cannot be verified, the Contractor may require the member to submit verification of preventive services. Members will only be required to complete disease-specific preventive services if they were diagnosed with the disease prior to the beginning of the benefit period. If a disease develops mid-benefit period, the member will not be required to complete preventive care services related to that disease until the next benefit period. Ninety (90) calendar days prior to the end of a member’s benefit period, the Contractor shall make an initial assessment (through claims and other information, as described above) of whether the member has completed the recommended preventive services. If the member has not received recommended preventive services, the Contractor shall send a reminder to the member. The reminder shall notify the member that the Contractor’s records indicate that the member has not received recommended preventive services based on medical claims received as of a specified date. A general listing that outlines what was required for different ages, genders and disease types is sufficient, it does not need to be specific to the member. The reminder shall also explain the appropriate roll-over incentive based on the member’s benefit plan that the member would be eligible to receive in the subsequent benefit period following completion of any recommended preventive service. This correspondence should be coordinated with other redetermination reminders and shall be provided no later than sixty (60) calendar days prior to the end of the member’s benefit period. Sixty (60) calendar days after the end of a member’s benefit period, the Contractor shall make an assessment (through claims and other information, as described above) of whether the member has completed the recommended preventive services. The Contractor shall send a letter to the member informing the member of its assessment if the assessment indicates that the member has not received the recommended preventive care. This letter shall go out within the sixty (60) calendar day period. 1. The letter to the member does not need to spell out what services the member received and what were not received. The letter shall only indicate that the required preventive care services were not completed. 2. The letter to the member shall list what the required preventive care services were for the member’s benefit period. A general listing that outlines what was required for different ages, genders and disease types is sufficient, it does not need to be specific to the member. 3. The Contractor shall develop a form that can be easily completed by a member’s physician which verifies that the member’s age and sex appropriate services have been obtained. This form shall be included in the letter to the member. 4. If the Contractor’s records indicated that the member has not received the recommended preventive services, the Contractor shall allow the member to file a grievance on the decision by submitting documentation that indicates that they did in fact receive the required preventive care. The form included in the member’s letter can be used as supporting documentation, but shall be completed by the member’s physician. 5. The letter shall indicate that the member has sixty thirty-three (6033) calendar days from receipt of the letter to file a grievance on the decision and submit additional information using the attached form. The Contractor may incorporate this grievance process into its existing grievance and appeals process, but shall ensure that the grievance is resolved in a time period that allows for timely submission of a complete and accurate PRF to the State. 6. If a member changes MCEs during their annual open enrollment periodredetermination, the Contractor (e.g., original MCE) is responsible for resolving any grievances related sending out the letter and giving the member an opportunity to preventative care servicesfile a grievance. Example language that should be included in the letter to the member includes: i. :  The required preventive service(s) for the year was “X”.  o For HIP Plus members: Because you regularly contributed to your POWER Account throughout the year, you are eligible to roll-over your unused share of the remaining POWER Account balance. If you also received the required preventive services, your “roll-over amount” will be doubled by the State in order to further reduce the cost of the plan in the next benefit period.  o For HIP Basic members: If you received your required preventive services, you will be eligible to receive a discount on the required monthly POWER account contributions if you would choose to participate in HIP Plus in the next yearbenefit period. The discount will be based on a percentage of your remaining POWER Account balance at the end of your current benefit period. ii.  A preliminary review of our records indicates that you have not received the required preventive service(s). iii.  If you believe our preliminary determination is in error and you have received the preventive services listed above, please fill out the attached form and submit it to “X”. The form shall be filled out by your physician and returned within thirty (30) calendar days. Further detail regarding preventive service monitoring and reporting is set forth in the HIP MCE Policies and Procedures Manual.

Recommended Preventive Care Services. Annually, OMPP will determine which recommended preventive services qualify a member for roll over or discount. The Contractor shall send preventive service reminders to their members throughout the benefit period, including in the monthly POWER Account Statements and redetermination correspondence. The Contractor shall have mechanisms in place to monitor when a member has obtained the preventive care services recommended for his or her age and gender, as well as pre-existing conditions, and report this information on the PRF one hundred and twenty (120) calendar days following the end of the member’s benefit period. The Contractor shall monitor whether a member has received recommended preventive care services by: 1. Utilizing claims data to determine if any of the certain specified disease conditions exist; 2. Utilizing claims data to determine if required services have been obtained (OMPP shall provide the qualifying CPT and/or ICD-10 codes, as applicable); and 3. If, after #1 and #2, preventive services cannot be verified, the Contractor may require the member to submit verification of preventive services. Members will only be required to complete disease-specific preventive services if they were diagnosed with the disease prior to the beginning of the benefit period. If a disease develops mid-benefit period, the member will not be required to complete preventive care services related to that disease until the next benefit period. Ninety (90) calendar days prior to the end of a member’s benefit period, the Contractor shall make an initial assessment (through claims and other information, as described above) of whether the member has completed the recommended preventive services. If the member has not received recommended preventive services, the Contractor shall send a reminder to the member. The reminder shall notify the member that the Contractor’s records indicate that the member has not received recommended preventive services based on medical claims received as of a specified date. A general listing that outlines what was required for different ages, genders and disease types is sufficient, it does not need to be specific to the member. The reminder shall also explain the appropriate roll-over incentive based on the member’s benefit plan that the member would be eligible to receive in the subsequent benefit period following completion of any recommended preventive service. This correspondence should be coordinated with other redetermination reminders and shall be provided no later than sixty (60) calendar days prior to the end of the member’s benefit period. Sixty (60) calendar days after the end of a member’s benefit period, the Contractor shall make an assessment (through claims and other information, as described above) of whether the member has completed the recommended preventive services. The Contractor shall send a letter to the member informing the member of its assessment if the assessment indicates that the member has not received the recommended preventive care. This letter shall go out within the sixty (60) calendar day period. 1. The letter to the member does not need to spell out what services the member themember received and what were not received. The letter shall only indicate that the required preventive care services were not completed. 2. The letter to the member shall list what the required preventive care services were for the member’s benefit period. A general listing that outlines what was required for different ages, genders and disease types is sufficient, it does not need to be specific to the member. 3. The Contractor shall develop a form that can be easily completed by a member’s physician which verifies that the member’s age and sex appropriate services have been obtained. This form shall be included in the letter to the member. 4. If the Contractor’s records indicated that the member has not received the recommended preventive services, the Contractor shall allow the member to file a grievance on the decision by submitting documentation that indicates that they did in fact receive the required preventive care. The form included in the member’s letter can be used as supporting documentation, but shall be completed by the member’s physician. 5. The letter shall indicate that the member has sixty (60) calendar days from receipt of the letter to file a grievance on the decision and submit additional information using the attached form. The Contractor may incorporate this grievance process into its existing grievance and appeals process, but shall ensure that the grievance is resolved in a time period that allows for timely submission of a complete and accurate PRF to the State. 6. If a member changes MCEs during their annual open enrollment period, the Contractor (e.g., original MCE) is responsible for resolving any grievances related to preventative care services. Example language that should be included in the letter to the member includes: i. The required preventive service(s) for the year was “X”.  ▪ For HIP Plus members: Because you regularly contributed to your POWER Account throughout the year, you are eligible to roll-over your unused share of the remaining POWER Account balance. If you also received the required preventive services, your “roll-over amount” will be doubled by the State in order to further reduce the cost of the plan in the next benefit period.  ▪ For HIP Basic members: If you received your required preventive services, you will be eligible to receive a discount on the required monthly POWER account contributions if you would choose to participate in HIP Plus in the next year. The discount will be based on a percentage of your remaining POWER Account balance at the end of your current benefit period. ii. A preliminary review of our records indicates that you have not received the required preventive service(s). iii. If you believe our preliminary determination is in error and you have received the preventive services listed above, please fill out the attached form and submit it to “X”. The form shall be filled out by your physician and returned within thirty (30) calendar days. Further detail regarding preventive service monitoring and reporting is set forth in the HIP MCE Policies and Procedures Manual.