State Level Delivery System Requirements a. Provision of Integrated Care Services
i. State Requirements for Integrated Primary Care and Behavioral Health Care - With support from the ICOs, contracted primary care providers will offer integrated primary care and behavioral health services.
ii. State Requirements for Care Coordination - ICOs will offer care coordination services to all Enrollees:
1. through a Care Coordinator or Clinical Care Manager, for medical and behavioral health services; and
2. through an Independent Living and LTSS (IL-LTSS) Coordinator, contracted from a community-based organization, for LTSS. The IL-LTSS Coordinator would be a full member of the Interdisciplinary Care Team as appropriate, serving at the discretion of the Enrollee.
3. Information about the roles and qualifications of the Care Coordinator, Clinical Care Manager, and IL-LTSS Coordinator will be included in the three-way contract.
iii. State Requirements for an Interdisciplinary Care Team – ICOs will support an Interdisciplinary Care Team (ICT) for each member, which will ensure the integration of the member’s medical, behavioral health, and LTSS care. The primary care provider and ICT will be person- centered: built on the Enrollee’s specific preferences and needs, delivering services with transparency, individualization, respect, linguistic and cultural competence, and dignity.
1. All members of the ICT must agree to participate in approved training on the person-centered planning processes, cultural competence, accessibility and accommodations, independent living and recovery, and wellness principles, along with other required training, as specified by the Commonwealth.
iv. State Requirements for member Assessment, Care Planning, Monitoring and Continuous Improvement.
1. Assessments and Individualized Care Plan - Each Enrollee shall receive, and be an active participant in, an initial assessment of medical, behavioral health and LTSS needs. This initial assessment, using the MDS-HC tool, must be done by an RN and entered into the Virtual Gateway portal in order to establish the appropriate rating category. In addition, upon enrollment and as appropriate thereafter, the ICO will perform in-person comprehensive assessments, which will be the starting point for creating an Individualized Care Plan. The comprehensive assessment may be done at the same time or a different time as the initial assessment, and must be conducted by care teams using a MassHealth/CMS approved assessment tool in a location that meets ...
State Level Delivery System Requirements. A. Requirements for Care Management and Care Coordination: MMPs will offer Care Management services to all Enrollees as needed to support health and wellness, ensure effective linkages and coordination between the primary care provider (PCP) and other providers and services, and to coordinate the full range of medical and behavioral health services, preventive services, medications, LTSS, social supports, and enhanced benefits as needed, both within and outside the MMP. Care Management services include both Intensive Care Management (ICM) for Enrollees who are eligible for LTSS and other high-risk Enrollees who may benefit from such services, and Care Coordination services for individuals with more limited needs. All Care Management services will be person-centered and will be delivered to Enrollees according to their strength-based needs and preferences. Enrollees will be encouraged to participate in decision making with respect to their care. MMPs shall have effective systems, policies, procedures and practices in place to identify Enrollees in need of Care Management services, including an early warning system and procedures that xxxxxx proactive identification of high-risk Enrollees and to further identify Enrollees’ emerging needs. A determination of which Enrollees are at high risk will be made by the MMP as a result of its predictive modeling results, Initial Health Screen or Comprehensive Functional Needs Assessment, and/or State-established minimum required determinants of health status, as described below. Enrollees who are determined to be at high-risk and eligible for ICM may include, but not be limited to, individuals with complex medical conditions and/or social support needs that may lead to: the need for high-cost services; deterioration in health status; or, institutionalization.
i. The objectives of the ICI Demonstration Care Management model are to:
a. Ensure delivery of integrated care based on an Interdisciplinary Care Plan (ICP) in collaboration with community-based providers, with appropriate incentives to maximize quality and cost-effectiveness;
b. Offer person-centered, strength-based supports that empower Enrollees to participate in the care delivery process;
c. Increase the proportion of individuals successfully residing in a community setting;
d. Ensure that needed services identified through the assessment processes are obtained and that any existing gaps or barriers to necessary services are eliminated with a focus in transiti...
State Level Delivery System Requirements. A. State Requirements for Care Management - Care management services will be available to all STAR+PLUS MMP enrollees. STAR+PLUS MMPs will be required to address the following components as part of their comprehensive care management programs as outlined below and in the three-way contract. Through the readiness review process, CMS and the State will review STAR+PLUS MMP capacity to deliver care management services.
i. Risk Stratification: The STAR+PLUS MMPs 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. The STAR+PLUS MMPs will stratify enrollees into two risk levels, with Level 1 the highest risk and Level 2 moderate and lower risk enrollees.
State Level Delivery System Requirements. Delivery system and care model requirements will continue to be established through separate Medicare Advantage Special Needs Plan contracts and State Medicaid contracts with the MSHO Plans. However, the following reforms and administrative changes will be implemented to the delivery system to enhance the Beneficiary experience under MSHO:
a) Network Adequacy - MSHO Plans have all demonstrated compliance with State network requirements for long term services and supports or other Medicaid services, and all have previously completed the Medicare Advantage network review.
State Level Delivery System Requirements. A. State Requirements for Care Management - Care management services must be available to all Enrollees. Participating Plans must address the following components as part of their comprehensive programs. Through the readiness review process, CMS and the Commonwealth will review Participating Plans’ capacity to deliver care management services. The Commonwealth will also review and approve the Participating Plans’ care management programs to ensure that all of the following required components are adequately addressed.
1. Identification strategy: Participating Plans must develop and implement an identification strategy that uses a combination of predictive-modeling software, assessment tools, referrals, administrative claims data, and other sources of information as appropriate, that will consider medical, behavioral health, substance use, and LTSS needs. Criteria and thresholds must be established by the Participating Plans and must be used to prioritize the timeframe by which Enrollees will receive timely health risk assessments in accordance with the requirements outlined below.
2. Health Risk Assessments (see Figure 7-1): Each Enrollee shall receive, and be an active participant in, a timely comprehensive assessment of medical, behavioral health, LTSS, and social needs completed by the Participating Plan care management team. All health risk assessment tools are subject to approval by DMAS. Assessment domains will include, but not be limited to, the following: medical, psychosocial, functional, cognitive, and behavioral health. Relevant and comprehensive data sources, including the Enrollee, providers, family/caregivers, etc., shall be used by the Participating Plans. More detail regarding required elements health risk assessments will be provided in the three-way contract. Results of the assessment will be used to confirm the appropriate stratification level for the enrollee and as the basis for developing the Plan of Care. During the first year of the Demonstration, all Enrollees meeting any of the following criteria (referred to as “Vulnerable Subpopulations” in the Virginia RFP) must receive a health risk assessment to be completed no later than 60 days from the individual’s enrollment date:
a. Individuals enrolled in the EDCD Waiver;
b. Individuals with intellectual/developmental disabilities;
c. Individuals with cognitive or memory problems (e.g., dementia or traumatic brain injury);
d. Individuals with physical or sensory disabilities;
e. Individ...
State Level Delivery System Requirements. Delivery system and care model requirements will continue to be established through separate Medicare Advantage Special Needs Plan contracts and State Medicaid contracts with the MSHO Plans. However, the following reforms and administrative changes will be implemented to the delivery system to enhance the Beneficiary experience under MSHO:
a) Network Adequacy - MSHO Plans have all demonstrated compliance with State network requirements for long term services and supports or other Medicaid services, and all have previously completed the Medicare Advantage network review. The Demonstration will not fundamentally change either the State or Medicare Advantage methodology for determining provider network standards. However, under this Demonstration, CMS (or its designated contractor) will work with the State to conduct a new network review for all MSHO Plans. The review process will begin in 2014 and be applicable for a contract year no earlier than contract year 2015. As part of the Demonstration, CMS will test new standards that apply the existing Medicare Advantage methodology to the Medicare-Medicaid population in order to more accurately reflect where the Medicare-Medicaid population resides. In addition, the State will have an opportunity to participate in the review of network submissions and provide input to CMS on local delivery system considerations. CMS and the State will concurrently review MSHO networks, and MSHO Plans will be required to address any network deficiencies identified in the review.
State Level Delivery System Requirements a. State Requirements for Care Coordination –The ICOs will develop and implement a strategy that uses a combination of initial screenings, assessments, health risk assessment tools, functional assessments, referrals, administrative claims data, etc. to help prioritize and determine the level of care coordination needed by each enrollee. ICOs may also choose to use existing predictive modeling software to support the screening and assessment requirements but will not be required to do so. Care Coordination services will be available to all ICO enrollees. ICOs will be required to contract with Prepaid Inpatient Health Plans (PIHP) to jointly coordinate and manage care for enrollees with behavioral health, substance use disorder and/or intellectual/developmental disabilities (BH, SUD, and/or I/DD) needs. The ICO-PIHP contract will be monitored by MDCH to ensure ICOs meet all delivery system requirements of the Demonstration and all enrollees receive the appropriate care coordination services.
State Level Delivery System Requirements a. Provision of Integrated Care Services
i. State Requirements for Care Coordination - ICOs will provide care coordination services to all Enrollees through an Interdisciplinary Team (IDT) that will coordinate all medical, behavioral health, and long term care services. Primary care providers will participate on the IDT and offer integrated primary care and behavioral health services. ICOs’ care coordination models shall include evidenced based-practices to prevent hospitalizations and an established structure to improve management of transitions between care settings, and best practices to meet other care coordination goals as established by the ICO or dictated in the three-way contract.
ii. State Requirements for an Interdisciplinary Care Team – ICOs will support an Interdisciplinary Team (IDT) for each member, which will ensure the integration of the member’s medical, behavioral health, and long term care. The IDT will be person-centered: built on the Enrollee’s specific preferences and needs, delivering services with transparency, individualization, respect, linguistic and cultural competence, and dignity.
1. ICOs will make available a range of care coordination expertise appropriate to the acuity and complexity of the ICO’s members, with expertise available to each member based on that member’s specific needs. This range is expected to include care coordinators, social workers, nurses, nurse practitioners, paraprofessionals, peer support specialists, pharmacists, and medical practitioners, including those with diagnosis and target group expertise.
2. The intensity, frequency, and types of IDT involvement will be based on the needs of the member, coordinated with existing nursing home care planning processes and regulatory requirements, and meet any additional standards established in the three-way contract.
3. ICOs must establish training protocols for all members of the IDT , to include training on the person-centered planning processes, the Wisconsin Integrated Demonstration Bill of Rights, and other training topics to be established in the three-way contract.
iii. State Requirements for member Assessment, Care Planning, Monitoring and Continuous Improvement.
State Level Delivery System Requirements a. State Requirements for Care Management - Care management services will be available to all ICDS Enrollees. ICDS Plans will be expected to address the following components as part of their comprehensive programs. Through the readiness review process, CMS and the State will review ICDS Plan capacity to deliver care management services. The State will also review and approve the ICDS plans’ care management programs to ensure that all required components are adequately addressed.
i. Identification strategy: The ICDS Plans will develop and implement an identification strategy that uses a combination of predictive-modeling software, health risk assessment tools, functional assessments, referrals, administrative claims data, etc. The plan’s identification strategy will consider medical, mental health, substance use, long term care and social needs. Criteria and thresholds will be established by the plans and applied to the identification data in order to prioritize the timeframe by which Enrollees will receive a timely initial comprehensive assessment.
ii. Risk or Acuity stratification level: ICDS Plans will develop a risk or acuity stratification level for the purposes of resource allocation and targeting interventions to beneficiaries at greatest risk. The risk or acuity stratification will consist of the following: the number of levels and if they are risk or acuity based; the criteria for each of the levels; how the assigned level will be communicated to the provider and the Enrollee; and a minimum contact schedule and staffing ratio for each level.
State Level Delivery System Requirements
