Supporting At-Risk Enrollees Requiring Transition. Contractor shall have an evaluation and transition plan in place for the Enrollees of the Exchange with existing health coverage including, but not limited to, those members transferring from Major Risk Medical Insurance Program, Pre-Existing Condition Insurance Plan, AIDS Drug Assistance Program, or other individuals under active care for complex conditions and who require therapeutic provider and formulary transitions. It is the intention of the Exchange to work with Contractors and State partners to facilitate early identification of at-risk patients where possible.
(a) Identification of in-network providers with appropriate clinical expertise or any alternative therapies including specific drugs when transitioning care;
(b) Clear process(es) to communicate Enrollee’s continued treatment using a specific therapy, specific drug or a specific provider when no equivalent is available in-network;
(c) Where possible, advance notification and understanding of out-of-network provider status for treating and prescribing physicians; and
(d) A process to allow incoming Enrollees access to Contractor’s formulary information prior to enrollment. It is not the intention of the Exchange to require that Contractor's transition plans for At-Risk Enrollees impose any obligations on contractor which are not otherwise required under applicable State Law or by other provisions of this Agreement
Supporting At-Risk Enrollees Requiring Transition. Contractor shall have an evaluation and transition plan in place for the Enrollees of the Exchange with existing health coverage including, but not limited to, those members transferring from Major Risk Medical Insurance Program, Pre-Existing Condition Insurance Plan, AIDS Drug Assistance Program, or other individuals under active care for complex conditions and who require therapeutic provider and formulary transitions. It is the intention of the Exchange to work with Contractors and State partners to facilitate early identification of at-risk patients where possible.
(a) Identification of in-network providers with appropriate clinical expertise or any alternative therapies including specific drugs when transitioning care;
(b) Clear process(es) to communicate Enrollee’s continued treatment using a specific therapy, specific drug or a specific provider when no equivalent is available in-network;
(c) Where possible, advance notification and understanding of out-of-network provider status for treating and prescribing physicians; and
(d) A process to allow incoming Enrollees access to Contractor’s formulary information prior to enrollment.
Supporting At-Risk Enrollees Requiring Transition. Contractor shall have an evaluation and transition plan in place for the Enrollees of the Exchange with existing health coverage including, but not limited to, those members transferring from Major Risk Medical Insurance Program, Pre-Existing Condition Insurance Plan, AIDS Drug Assistance Program, or other individuals under active care for complex conditions and who require therapeutic provider and formulary transitions . It is the intention of the Exchange to work with Contractors and State partners to facilitate early identification of at-risk patients where possible.
(a) Identification of in-network providers with appropriate clinical expertise or any alternative therapies including specific drugs when transitioning care;
(b) Clear process(es) to communicate Enrollee’s continued treatment using a specific therapy, specific drug or a specific provider when no equivalent is available in-network;
(c) Where possible, advance notification and understanding of out-of-network provider status for treating and prescribing physicians; and
(d) A process to allow incoming Enrollees access to Contractor’s formulary information prior to enrollment. Covered California – Final Health Plan Contract Attachments, May 6,20117, 2013 Attachment 7-13
(a) Methods to identify and target At-Risk Enrollees;
(b) Description of Contractor’s predictive analytic capabilities to assist in identifying At Risk Plan Enrollees who would benefit from early, proactive intervention;
(c) Communication plan for known At-Risk Enrollees to receive information prior to provider visit;
(d) Process to update At-Risk Enrollee medical history in the Contractor maintained Plan Enrollee health profile;
(e) Mechanisms to evaluate access within provider network, on an ongoing basis, to ensure that an adequate network is in place to support a proactive intervention and care management program for At-Risk Enrollees;
(f) Care and network strategies that focuses on supporting a proactive approach to at-risk Plan Enrollee intervention and care management. Contractor agrees to provide the Exchange with a documented plan and include “tools” and strategies to supplement and/or expand care management and provider network capabilities, including an expansion and/or reconfiguration of specialties or health care professionals to meet clinical needs of At Risk Enrollees.
(g) Strategies or “tools” not otherwise described in Section 5.02 may include but are not limited to the following:
(i) Enrollment of At-Risk Enroll...
Supporting At-Risk Enrollees Requiring Transition. Contractor shall have an evaluation and transition plan in place for the Enrollees of the Exchange with existing health coverage including, but not limited to, those members transferring from Major Risk Medical Insurance Program, Pre-Existing Condition Insurance Plan, AIDS Drug Assistance Program, or other individuals under active care for complex conditions and who require therapeutic provider and formulary transitions.
(a) Identification of In-network providers with appropriate clinical expertise or any alternative therapies including specific drugs when transitioning care;
(b) Clear process to communicate Enrollee’s continued treatment using a specific therapy, specific drug or a specific provider when no equivalent is available in- network;
Supporting At-Risk Enrollees Requiring Transition. Contractor shall have an evaluation and transition plan in place for the Enrollees of the Exchange with existing health coverage including, but not limited to, those members transferring from Major Risk Medical Insurance Program, Pre-Existing Condition Insurance Plan, AIDS Drug Assistance Program, or other individuals under active care for complex conditions and who require therapeutic provider and formulary transitions. It is the intention of the Exchange to work with Contractors and State partners to facilitate early identification of at-risk patients where possible.
(a) Identification of in-network providers with appropriate clinical expertise or any alternative therapies including specific drugs when transitioning care;
(b) Clear process(es) to communicate Enrollee’s continued treatment using a specific therapy, specific drug or a specific provider when no equivalent is available in-network;
