Risk Stratification. 2.6.1.1. The STAR+PLUS MMP will develop and implement a risk stratification process that uses a combination of predictive-modeling software, assessment tools, referrals, administrative Claims data, and other sources of information as appropriate that will consider Enrollees’ physical and behavioral health, substance use, and LTSS needs and specifically, any Special Health Care Needs of the Enrollees.
2.6.1.2. The STAR+PLUS MMP will stratify Enrollees in two (2) risk levels, with level 1 the highest risk and level 2 moderate and lower risk Enrollees.
2.6.1.2.1. These levels of stratification should be based on:
2.6.1.2.1.1. Level 1 Enrollees: Highest level of risk/utilization includes HCBS STAR+PLUS Waiver, Nursing Facility, individuals with SPMI, and other Enrollees with complex medical needs.
2.6.1.2.1.2. Level 2 Enrollees: Lower level of risk/utilization includes Enrollees receiving LTSS for PAS or day activity and health services (DAHS and Enrollees with non-SPMI behavioral health issues).
Risk Stratification. Contractor will use an approved health risk stratification mechanism or algorithm to identify new Enrollees with high risk and more complex health care needs. The health risk stratification shall be conducted in accordance applicable DPL(s) as indicated in Section 2.1.5.
2.8.1.1. Contractor shall use the following data sources to identify an Enrollees’ risk level.
2.8.1.1.1. Medicare utilization data, including Medicare Parts A, B, and D.
2.8.1.1.2. Medi-Cal utilization data, including IHSS, MSSP, SNF, and Behavioral Health pharmacy data.
2.8.1.1.3. Results of previously administered assessments.
2.8.1.1.4. Other population- and individual-based tools.
Risk Stratification. An informed estimate of the probability of a person succumbing to a disease or benefiting from a treatment for that disease
Risk Stratification. The STAR+PLUS MMP will develop and implement a risk stratification process that uses a combination of predictive- modeling software, assessment tools, referrals, administrative Claims data, and other sources of information as appropriate that will consider Enrollees’ physical and behavioral health, substance use, and LTSS needs.
Risk Stratification. The Contractor shall implement a risk stratification process that meets the requirements of this Section.
a. The Contractor shall predictably model, stratify and define the Enrollee population into risk categories, with at least one method to calculate a risk score for each Enrollee. The methodology shall:
1) At a minimum, utilizes claims and pharmacy data, laboratory data, referrals, data related to utilization management, and care needs assessment results to:
2) Assess the Enrollee’s risk for high cost, high utilization, admission, re-admission, or other adverse health outcomes;
b. The Contractor shall document and detail the approach (e.g., use of specific risk assessment tool) and criteria employed to define and assign the risk categories of the population and provide such information to EOHHS upon request.
c. The Contractor shall utilize the stratification of Enrollees to inform its development and use of appropriate intervention approaches (such as Care Management) and maximize the impact of the services provided to Enrollees.
d. The Contractor shall stratify new Enrollees within 60 days of enrollment and re-stratify the all Enrollees at a minimum bi-annually.
Risk Stratification. The act or process of dividing Tenncare members into different levels of need based on their health risk. For TennCare’s Population Health program, risk stratification is accomplished by predictive modeling which is based on claims, pharmacy, lab and other data. Information from health risk assessments is also used to identify member’s risk level. Through this process members are identified for one of three health risk stratification levels. Level Zero is wellness, Level One is low to moderate health risk, and Level Two is the top three percent or the sickest of the sick.
Risk Stratification. 1.8.1 In the event DCFS is not in agreement with the risk level determination made by Contractor for a DCFS Youth in Care Enrollee, Contractor will work collaboratively with the Department and DCFS to resolve the disagreement and ensure that the best interest and needs of the DCFS Youth in Care Enrollee are met.
Risk Stratification. 2.6.1.1. The STAR+PLUS MMP will develop and implement a risk stratification process that uses a combination of predictive- modeling software, assessment tools, referrals, administrative Claims data, and other sources of information as appropriate that will consider Enrollees’ physical and behavioral health, substance use, and LTSS needs.
2.6.1.2. The STAR+PLUS MMP will stratify Enrollees into two (2) risk levels, with level 1 the highest risk and level 2 moderate and lower risk Enrollees.
2.6.1.2.1. These levels of stratification should be based on:
2.6.1.2.1.1. Xxxxx 0 Xxxxxxxxx: Xxxxxxx level of risk/utilization includes HCBS STAR+PLUS Waiver, Nursing Facility (except for nursing facility Enrollees listed under Level 3), individuals with SPMI, and other Enrollees with complex medical needs.
2.6.1.2.1.2. Level 2 Enrollees: Lower level of risk/utilization includes Enrollees receiving LTSS for personal assistance services or day activity and health services (PAS and DAHSand Enrollees with non- SPMI behavioral health issues.
