Common use of Transition of Care Requirements Clause in Contracts

Transition of Care Requirements. for Members who are Changing MyCare Ohio Plans. When the MCOP is informed by ODM, or its designee, of a member who is changing to a different MCOP, the disenrolling MCOP shall share, at a minimum, the current assessment and care plan, including the person-centered service plan, with the enrolling MCOP prior to the new enrollment effective date. a. Upon notification from a member and/or provider of a need to continue services, the MCOP shall allow a member transitioning from another MCOP to continue to receive services from network and out-of-network providers when the member could suffer detriment to their health or be at risk for hospitalization or institutionalization in the absence of continued services. Upon notification from ODM that an individual will be switching to a different MCOP or managed care plan (MCP), the disenrolling MCOP shall provide specific information related to the disenrolling member to the enrolling plan as specified by ODM. The MCOP may prior authorize these services or assist the member to access services through a network provider when any of the following occur: i. The member’s condition stabilizes and the MCOP can ensure no interruption to services; ii. The member chooses to change to a network provider; iii. The member’s needs change to warrant a change in service; or iv. Quality concerns are identified with the provider. b. The enrolling MCOP shall honor the disenrolling MCOP’s prior authorization for all new members until the enrolling MCOP is able to conduct a medical necessity review. The MCOP shall honor prior authorizations and continue services with network and out-of-network providers as specified by ODM.

Transition of Care Requirements. for Members who are Changing MyCare Ohio Plans. When the MCOP is notified through the HIPAA 834 files or informed by ODM, or its designee, through the consumer contact record, of a member who is changing to a different MCOP, the disenrolling MCOP shall share, at a minimum, the current assessment assessment, HRA, and care plan, including the person-centered service plan, with the enrolling MCOP prior to within five business days of notification of the new enrollment effective datepending change. a. Upon notification from a member and/or provider of a need to continue services, the MCOP shall allow a member transitioning from another MCOP to continue to receive services from network and out-of-network providers when the member could suffer detriment to their health or be at risk for hospitalization or institutionalization in the absence of continued services. Upon notification from ODM that an individual will be switching to a different MCOP or managed care plan organization (MCPMCO), the disenrolling MCOP shall provide specific information related to the disenrolling member to the enrolling plan as specified by ODM. The MCOP may prior authorize these services or assist the member to access services through a network provider when any of the following occur: i. The member’s condition stabilizes and the MCOP can ensure no interruption to services; ii. The member chooses to change to a network provider; iii. The member’s needs change to warrant a change in service; or iv. Quality concerns are identified with the provider. b. The enrolling MCOP shall honor the disenrolling MCOP’s prior authorization for all new members until the enrolling MCOP is able to conduct a medical necessity review. The MCOP shall honor prior authorizations and continue services with network and out-of-network providers as specified by ODM.

Transition of Care Requirements. for Members who are Changing MyCare Ohio Plans. When the MCOP is informed by ODM, or its designee, of a member who is changing to a different MCOP, the disenrolling MCOP shall share, at a minimum, the current assessment and care plan, including the person-centered waiver service plan, with the enrolling MCOP prior to the new enrollment effective date. a. Upon notification from a member and/or provider of a need to continue services, the MCOP shall allow a member transitioning from another MCOP to continue to receive services from network and out-of-network providers when the member could suffer detriment to their health or be at risk for hospitalization or institutionalization in the absence of continued services. Upon notification request from ODM that an individual will be switching to a different MCOP or managed care plan (MCP)the enrolling MCOP, the disenrolling MCOP shall provide specific information related to historical utilization and prior authorization data for the disenrolling disenrolled member to as expeditiously as the enrolling plan as specified by ODMsituation warrants. The MCOP may prior authorize these services or assist the member to access services through a network provider when any of the following occur: i. The member’s condition stabilizes and the MCOP can ensure no interruption to services; ii. The member chooses to change to a network provider; iii. The member’s needs change to warrant a change in service; or iv. Quality concerns are identified with the provider. b. The enrolling MCOP shall honor the disenrolling MCOP’s prior authorization for all new members until the enrolling MCOP is able to conduct a medical necessity review. The Effective January 1, 2019, the MCOP shall honor prior authorizations and continue services with network and out-of-network providers as specified by ODM.