Stratification & Level of Service. Based on the results of the initial screening as well as mining of historical claims data and clinical data from health information exchanges, the Contractor shall stratify its membership into various subpopulations to identify member level of service and ensure continuity of care. The outcome of the member assessment set forth above in Section 3.8.1 will determine the member’s needs in the stratification process resulting in the member’s assignment to one of the levels of care coordination service, set forth below in this section.
Stratification & Level of Service. Based on the results of the initial screening as well as mining of historical claims data, the Contractor shall stratify its membership into various subpopulations to identify member level of service and ensure continuity of care. The outcome of the member assessment set forth above in Section 5.1 will determine the member’s needs in the stratification process resulting in the member’s assignment to one of the levels of care coordination service, set forth below in this Section 5.2. Prior to the Contract’s effective date, the Contractor will propose to FSSA a stratification methodology, which shall include a “rush” designation for members with immediate needs. The stratification plan must be approved by FSSA prior to member stratification. In addition, the care coordination classification system may be modified if the Contractor receives written approval from FSSA.
Stratification & Level of Service. Based on the results of the initial screening as well as mining of historical claims data and clinical data from health information exchanges, the Contractor shall stratify its membership into various subpopulations to identify member level of service and ensure continuity of care. The outcome of the member assessment set forth above in Section 3.8.1 will determine the member’s needs in the stratification process resulting in the member’s assignment to one of the levels of care coordination service, set forth below in this section. Disease management is intended to help guide the care of members with chronic health conditions to improve the quality of care, adherence to care and control health care costs. Supporting the practitioner-member relationship and plan of care, the disease management program will emphasize the prevention of the exacerbation of the condition and its complications using evidenced based practice guidelines. The Contractor shall offer, at minimum, sickle cell disease, asthma, depression, pregnancy, attention deficit hyperactivity disorder (ADHD), autism/pervasive developmental disorder, chronic obstructive pulmonary disease (COPD), coronary artery disease, chronic kidney disease, congestive heart failure, hypertension, diabetes, and SUD disease management programs for eligible members. The Contractor may propose, for FSSA approval, programs for additional conditions. Members with excessive utilization or under-utilization for conditions other than those listed shall also be eligible for the disease management level of service described in this section. OMPP reserves the right to require the Contractor to have disease management programs for additional conditions in the future. OMPP will provide three (3) months advance notice to the Contractor if OMPP decides to add new diseases to the disease management program requirements. Disease management services should assist members in understanding their chronic conditions, set goals, and achieve self-selected outcomes through education, counseling, and on-going support. The Contractor will provide a customer call line for provider and community information, linkage to community resources and disease specific and general preventive health education and reminders for members. Disease management services must be provided to members with specific conditions and for prevention of related conditions. For example, disease management services for members diagnosed with diabetes or hypertension must...
