Coordination of Care (a) The MA Dual SNP is responsible for coordinating the delivery of all benefits covered by both Medicare and Medicaid for Dual Eligible Members and Other Dual SNP Members who are eligible for LTSS including when benefits are delivered via Medicaid fee-for-service, making reasonable efforts to coordinate Medicare Advantage benefits provided by the MA Dual SNP with LTSS provided through Texas Health and Human Services Commission and the STAR+PLUS HMOs. Coordination of Care must include the following for these members:
(1) identify providers of covered Medicaid LTSS in the Texas service areas identified in Attachment A, Proposed MA Product Service Areas;
(2) help access needed Medicaid LTSS, to the extent they are available to the member;
(3) help coordinate the delivery of Medicaid LTSS and Medicare benefits and services; and
(4) provide training to its Network Providers regarding Medicaid LTSS so that they may help members receive needed LTSS that are not covered by Medicare. The MA Dual SNP must inform Network Providers of the Medicare benefits and Medicaid LTSS available to Dual Eligible Members and Other Dual SNP Members.
(b) The MA Dual SNP’s Coordination of Care efforts for LTSS may include protocols for working with STAR+PLUS service coordinators or HHSC caseworkers, as well as protocols for reciprocal referral and communication of data and clinical information regarding Dual Eligible Members with the coordinators and caseworkers.
(c) MA Dual SNPs that are not designated as HIDE-SNPs by CMS must provide timely notification of all admissions to a hospital and SNF to the STAR+PLUS MCO via a secure file transfer. The file shall be organized and populated in accordance with the template provided by HHSC. For the purposes of this section, timely notification is defined as no later than two business days from which the MA Dual SNP becomes aware that a High Risk Dual Eligible Member has been admitted. If the MA Dual SNP delegates responsibility for information sharing to its contracted hospitals and SNFs, the MA Dual SNP will require its contracted hospitals and SNFs meet the same information sharing requirements on admissions as required of the MA Dual SNP by this Agreement. The MA Dual SNP retains ultimate responsibility for compliance with the information sharing requirements in this Agreement.
(d) The MA Dual SNP is responsible for the coordination of both Medicare and Medicaid benefits, regardless of whether a Dual Eligible Member is enrolled with the MA Dual SNP’s companion Health Plan for Medicaid.
(e) The MA Dual SNP must provide HHSC with the name of the contact person at the MA Dual SNP who must be responsible for the coordination of care for dual eligible members. The MA Dual SNP must provide the following information to the HHSC designated point of contact referenced in Section 9.06: the MA Dual SNP coordination of care contact person’s name, telephone number, and e-mail address.
(f) The MA Dual SNP must also establish a contact person with each STAR+PLUS MCO and provide the same information required in (d) to each STAR+PLUS MCO.
Continuity of Care OMPP is committed to providing continuity of care for members as they transition between various IHCP programs and the Contractor’s enrollment. The Contractor shall have mechanisms in place to ensure the continuity of care and coordination of medically necessary health care services for its Hoosier Healthwise members. The State emphasizes several critically important areas where the Contractor shall address continuity of care. Critical continuity of care areas include, but are not limited to: Transitions for members receiving HIV, Hepatitis C and/or behavioral health services, especially for those members who have received prior authorization from their previous MCE or through fee-for-service; Transitions for members who are pregnant; A member’s transition into the Hoosier Healthwise program from traditional fee-for- service or HIP; A member’s transition between MCEs, particularly during an inpatient stay; A member’s transition between IHCP programs, Members exiting the Hoosier Healthwise program to receive excluded services; A member’s exiting the Hoosier Healthwise program to receive excluded services; A member’s transition to a new PMP; A member’s transition to private insurance or Marketplace coverage; and A member’s transition to no coverage. In situations such as a member or PMP disenrollment, the Contractor shall facilitate care coordination with other MCEs or other PMPs. When receiving members from another MCE or fee-for-service, the Contractor shall honor the previous care authorizations for a minimum of thirty (30) calendar days from the member’s date of enrollment with the Contractor. Contractor shall establish policies and procedures for identifying outstanding prior authorization decisions at the time of the member’s enrollment in their plan. For purposes of clarification, the date of member enrollment for purposes of the prior authorization time frames set forth in this section begin on the date the Contractor receives the member’s fully eligible file from the State. Additionally, when a member transitions to another source of coverage, the Contractor shall be responsible for providing the receiving entity with information on any current service authorizations, utilization data and other applicable clinical information such as disease management, case management or care management notes. This process shall be overseen by the Transition Coordination Manager. The Contractor will be responsible for care coordination after the member has disenrolled from the Contractor whenever the member disenrollment occurs during an inpatient stay. In these cases, the Contractor will remain financially responsible for the hospital DRG payment and any outlier payments (without a capitation payment) until the member is discharged from the hospital or the member’s eligibility in Medicaid terminates. The Contractor shall coordinate discharge plans with the member’s new MCE. See Section 3.7.5 for additional requirements regarding continuity of care for behavioral health services. The Hoosier Healthwise MCE Policies and Procedures Manual describes the Contractor’s continuity and coordination of care responsibilities in more detail.
Contractor Designation of Trade Secrets or Otherwise Confidential Information If the Contractor considers any portion of materials to be trade secret under section 688.002 or 812.081, F.S., or otherwise confidential under Florida or federal law, the Contractor must clearly designate that portion of the materials as trade secret or otherwise confidential when submitted to the Department. The Contractor will be responsible for responding to and resolving all claims for access to Contract-related materials it has designated trade secret or otherwise confidential.
