Transition of Fee-For-Service Members Sample Clauses

Transition of Fee-For-Service Members. Providing care coordination for prescheduled health services and existing care treatment plans, is critical for members transitioning from Medicaid fee-for service (FFS) to managed care. Therefore, MCPs must:

Transition of Fee-For-Service Members. Providing care coordination, access to preventive and specialized care, case management, member services, and education with minimal disruption to members’ established relationships with providers and existing care treatment plans is critical for members transitioning from Medicaid fee-for-service to managed care. MCPs must: i. Develop a transition plan that outlines how the MCP will effectively address the unique care coordination issues for members in their first three months of MCP membership that includes at a minimum: Appendix C ii. An effective outreach process to identify each new member’s existing and/or potential health care needs that results in a new member profile that includes, but is not limited to identification of: a. Health care needs, including those services received through state sub-recipient agencies [e.g., the Ohio Department of Mental Health (ODMH), the Ohio Department of Mental Retardation and Developmental Disabilities (ODMR/DD), and the Ohio Department of Alcohol and Drug Addiction Services (ODADAS); b. Existing sources of care (i.e., primary physicians, specialists, case manager(s), ancillary and other care givers); and c. Current care therapies for all aspects of health care services, including scheduled health care appointments, planned and/or approved surgeries (inpatient or outpatient), ancillary or medical therapies, prescribed drugs, approved home health care, scheduled lab/radiology tests, necessary/approved durable medical equipment, supplies and needed/approved transportation arrangements. iii. Strategies for how each new member will obtain care therapies from appropriate sources of care as an MCP member including reported scheduled health services as described in Section 28.i.(ii-iv) of this Appendix. iv. Allow their new members that are transitioning from Medicaid fee-for- service to receive services from out-of-panel providers if the members contact the MCP to discuss the scheduled health services in advance of the service date and one of the following applies: a. The member has appointments within the initial three months of the MCP membership with a primary physician or specialty physicians that were scheduled prior to the effective date of the MCP membership; b. The member has been approved to receive an organ, bone marrow, or hematapoietic stem cell transplant pursuant to OAC rule 5101:3-2-07.1; Appendix C c. The member is in her third trimester of pregnancy and has an established relationship with an obstetricia...