Common use of Service Coordination Clause in Contracts

Service Coordination. The MCO must furnish a Service Coordinator to all STAR+PLUS Members who request one. The MCO should also furnish a Service Coordinator to a STAR+PLUS Member when the MCO determines one is required through an assessment of the Member’s health and support needs. The MCO must ensure that each STAR+PLUS Member has a qualified PCP who is responsible for overall clinical direction and, in conjunction with the Service Coordinator, serves as a central point of integration and coordination of Covered Services, including primary, Acute Care, Long-term Services and Supports, and Behavioral Health Services. The Service Coordinator must work as a team with the PCP to coordinate all STAR+PLUS Covered Services and any applicable Non-capitated Services. This requirement applies whether or not the PCP is in the MCO’s Network, as some STAR+PLUS Members dually eligible for Medicare may have a PCP that is not in the MCO’s Provider Network. In order to integrate the Member’s Acute Care and primary care, and stay abreast of the Member’s needs and condition, the Service Coordinator must also actively involve and coordinate with the Member’s primary and specialty care providers, including Behavioral Health Service providers, providers of Non-capitated Services, and Medicare Advantage health plans for qualified Dual Eligible Members. When considering whether to refer a Member to a nursing facility or other long-term care facility, the MCO must consider the availability of the Program of All-Inclusive Care for the Elderly (PACE) for that Member. The MCO must identify and train Members or their families to coordinate their own care, to the extent of the Member’s or the family’s capability and willingness to coordinate care.

Service Coordination. The MCO must furnish a Service Coordinator to all STAR+PLUS Members who request one. The MCO should also furnish a Service Coordinator to a STAR+PLUS Member when the MCO determines one is required through an assessment of the Member’s health and support needs. The MCO must ensure that each STAR+PLUS Member has a qualified PCP who is responsible for overall clinical direction and, in conjunction with the Service Coordinator, serves as a central point of integration and coordination of Covered Services, including primary, Acute Care, Long-term Services and Supports, and Behavioral Health Services. The Service Coordinator must work as a team with the PCP to coordinate all STAR+PLUS Covered Services and any applicable Non-capitated Services. This requirement applies whether or not the PCP is in the MCO’s Network, as some STAR+PLUS Members dually eligible for Medicare may have a PCP that is not in the MCO’s Provider Network. In order to integrate the Member’s Acute Care and primary care, and stay abreast of the Member’s needs and condition, the Service Coordinator must also actively involve and coordinate with the Member’s primary and specialty care providers, including Behavioral Health Service providers, providers of Non-capitated Services, and Medicare Advantage health plans for qualified Dual Eligible Members. When considering whether to refer STAR+PLUS Members dually eligible for Medicare will receive most prescription drug services through Medicare rather than Medicaid. The STAR+PLUS Program does cover a Member to a nursing facility or other long-term care facility, the MCO must consider the availability limited number of the Program of All-Inclusive Care medications not covered by Medicare. See Section 8.2.13 for the Elderly (PACE) for that Membermore details on wrap around services. The MCO must identify and train Members or their families to coordinate their own care, to the extent of the Member’s or the family’s capability and willingness to coordinate care.