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 develop and implement a transition plan that outlines how the MCP will effectively address the unique care coordination issues of members in their first three months of MCP membership and how the various MCP departments will coordinate and share information regarding these new members. The transition plan must include at a minimum: i. 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 Appendix C Aged, Blind or Disabled (ABD) population Page 13 sub-recipient agencies [e.g., the Ohio Department of Mental Health (ODMH), the Ohio Department of Mental Retardation and Developmental Disabilities (ODMR/DD), the Ohio Department of Alcohol and Drug Addiction Services (ODADAS) and the Ohio Department of Aging (ODA)]; 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, home health care services, private duty nursing (PDN), scheduled lab/radiology tests, necessary durable medical equipment, supplies and needed/approved transportation arrangements. ii. Strategies for how each new member will obtain care therapies from appropriate sources of care as an MCP member. The MCP’s strategies must include at a minimum: a. Allowing their new members that are transitioning from Medicaid fee-for-service to receive services from out-of-panel providers if the member or provider contacts the MCP to discuss the scheduled health services in advance of the service date and one of the following applies: i. The member has appointments within the initial three months of the MCP membership with a primary care provider_or specialty physician that was scheduled prior to the effective date of the MCP membership; ii. The member is in her third trimester of pregnancy and has an established relationship with an obstetrician and/or delivery hospital; iii. The member has been scheduled for an inpatient or outpatient surgery and has been prior-approved and/or precertified pursuant to OAC rule 5101:3-2-40 (surgical procedures would also include follow-up care as appropriate); iv. The member is receiving ongoing chemotherapy or radiation treatment; or
Appears in 1 contract
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 develop and implement must:
i. Develop a transition plan that outlines how the MCP will effectively address the unique care coordination issues of for members in their first three months of MCP membership and how the various MCP departments will coordinate and share information regarding these new members. The transition plan must include that includes at a minimum:: Appendix C
i. ii. An effective outreach process to identify each new member’s '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 Appendix C Aged, Blind or Disabled (ABD) population Page 13 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) and the Ohio Department of Aging (ODA)];
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 services, private duty nursing (PDN)care, scheduled lab/radiology tests, necessary necessary/approved durable medical equipment, supplies and needed/approved transportation arrangements.
iiiii. Strategies for how each new member will obtain care therapies from appropriate sources of care as an MCP membermember including reported scheduled health services as described in Section 28.i.(ii-iv) of this Appendix.
iv. The MCP’s strategies must include at a minimum:
a. Allowing Allow their new members that are transitioning from Medicaid fee-for-service to receive services from out-of-panel providers if the member or provider contacts members contact the MCP to discuss the scheduled health services in advance of the service date and one of the following applies:
i. a. The member has appointments within the initial three months of the MCP membership with a primary care provider_or physician or specialty physician physicians that was were scheduled prior to the effective date of the MCP membership;
ii. 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 obstetrician and/or delivery hospital;
iii. d. The member has been scheduled for an inpatient or inpatient/outpatient surgery and has been prior-approved and/or precertified pursuant to OAC rule 5101:3-2-40 (surgical procedures would also include follow-up care as appropriate);
iv. e. The member is receiving ongoing chemotherapy or radiation treatment; or;
f. The member has been released from the hospital within the last thirty (30) days and is following a treatment plan;
g. The member has been pre-certified to receive durable medical equipment (DME) which has not yet been received.
v. Reimburse out-of-panel providers that agree to provide the transition services identified in section 28.i.section ii at 100% of the current Medicaid fee-for-service provider rate for the service(s).
vi. Document the provision of transition services as follows:
a. As expeditiously as the situation warrants, contact the provider's offices via telephone to confirm that the service(s) meets the above criteria.
b. For services that meet the above criteria, inform the provider that the MCP is sending a form for signature to document that they accept/do not accept the terms for the provision of the services and copy the member on the form.
c. If the provider agrees to the terms, notify the member and provider of the MCP's authorization and ensure that the MCP's claims processing system will not deny the claim payment because the provider is out-of-panel. MCPs must include their non-contracting provider materials as outlined in Appendix G.4.e with the provider notice.
d. If the provider does not agree to the terms, notify the member and assist the member with locating a provider as expeditiously as the member's condition warrants. Appendix C
e. Use the ODJFS-specified model language for the provider and member notices.
f. Maintain documentation of all member and/or provider contacts relating to such out-of-panel services, including but not limited to telephone calls and letters.
vii. Not require prior-authorization of any prescription drug that does not require prior authorization by Medicaid fee-for-service for the initial three months of a member's MCP membership. Additionally, all atypical anti-psychotic drugs must be exempted from prior authorization requirements for all MCP ABD members through December 2007, after which time ODJFS will re-evaluate the continuation of this pharmacy utilization strategy.
Appears in 1 contract
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 develop and implement a transition plan that outlines how the MCP will effectively address the unique care coordination issues of members in their first three months of MCP membership and how the various MCP departments will coordinate and share information regarding these new members. The transition plan must include at a minimum:
i. 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 Appendix C Aged, Blind or Disabled (ABD) population Page 13 sub-recipient agencies [e.g., the Ohio Department of Mental Health (ODMH), the Ohio Department of Mental Retardation and Developmental Disabilities (ODMR/DD), the Ohio Department of Alcohol and Drug Addiction Services (ODADAS) and the Ohio Department of Aging (ODA)];
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, home health care services, private duty nursing (PDN), scheduled lab/radiology tests, necessary durable medical equipment, supplies and needed/approved transportation arrangements.
ii. Strategies for how each new member will obtain care therapies from appropriate sources of care as an MCP member. The MCP’s strategies must include at a minimum:
a. Allowing their new members that are transitioning from Medicaid fee-for-service to receive services from out-of-panel providers if the member or provider contacts the MCP to discuss the scheduled health services in advance of the service date and one of the following applies:
i. The member has appointments within the initial three months of the MCP membership with a primary care provider_or provider or specialty physician that was scheduled prior to the effective date of the MCP membership;
ii. The member is in her third trimester of pregnancy and has an established relationship with an obstetrician and/or delivery hospital;
iii. The member has been scheduled for an inpatient or outpatient oroutpatient surgery and has been prior-approved and/or precertified pursuant to OAC rule 5101:3-2-40 (surgical procedures would also include follow-up care as appropriate);
iv. The member is receiving ongoing chemotherapy or radiation treatment; or
v. The member has been released from the hospital within thirty (30) days prior to MCP enrollment and is following a treatment plan. If contacted by the member, the MCP must contact the provider’s office as expeditiously as the situation warrants to confirm that the service(s) meets the above criteria.
b. Allowing their new members that are transitioning from Medicaid fee-for-service to continue receiving home care services (i.e., nursing, aide, and skilled therapy services) and private duty nursing (PDN) services if the member or provider contacts the MCP to discuss the health services in advance of the service date. These services must be covered from the date of the member or provider contact at the current service level, and with the current provider, whether a panel or out-of-panel provider, until the MCP conducts a medical necessity review and renders an authorization decision pursuant to OAC rule 5101:3-26-03.
1. As soon as the MCP becomes aware of the member’s current home care services, the MCP must initiate contact with the current provider and member as applicable to ensure continuity of care and coordinate a transfer of services to a panel provider, if appropriate.
c. Honoring any current fee-for-service prior authorization to allow their new members that are transitioning from Medicaid fee-for-service to receive services from the authorized provider, whether a panel or out-of-panel provider, for the following approved services:
i. an organ, bone marrow, or hematapoietic stem cell transplant pursuant to OAC rule 5101:3-2-07.1;
ii. dental services that have not yet been received;
iii. vision services that have not yet been received;
iv. durable medical equipment (DME) that has not yet been received. Ongoing DME services and supplies are to be covered by the MCP as previously-authorized until the MCP conducts a medical necessity review and renders an authorization decision pursuant to OAC rule 5101:3-26-03.1.
v. private duty nursing (PDN) services. PDN services must be covered at the previously-authorized service level until the MCP conducts a medical necessity review and renders an authorization decision pursuant to OAC rule 5101:3-26-03.
1. As soon as the MCP becomes aware of the member’s current fee-for-service authorization approval, the MCP must initiate contact with the authorized provider and member as applicable to ensure continuity of care. The MCP must implement a plan to meet the member’s immediate and ongoing medical needs and, with the exception of organ, bone marrow, or hematapoietic stem cell transplants, coordinate the transfer of services to a panel provider, if appropriate. When an MCP medical necessity review results in a decision to reduce, suspend, or terminate services previously authorized by fee-for-service Medicaid, the MCP must notify the member of their state hearing rights no less than 15 calendar days prior to the effective date of the MCP’s proposed action, per rule 5101:3-26-08.4 of the Administrative Code.
d. Reimbursing out-of-panel providers that agree to provide the transition services at 100% of the current Medicaid fee-for-service provider rate for the service(s) identified in Section 29.h.ii.(a., b., and c.) of this appendix.
e. Documenting the provision of transition services identified in Section 29.h.ii.(a., b., and c.) of this appendix as follows:
i. For non-panel providers, notification to the provider confirming the provider’s agreement/disagreement to provide the service and accept 100% of the current Medicaid fee-for-service rate as payment. If the provider agrees, the distribution of the MCP’s materials as outlined in Appendix G.4.e.
ii. Notification to the member of the non-panel provider’s agreement /disagreement to provide the service. If the provider disagrees, notification to the member of the MCP’s availability to assist with locating a provider as expeditiously as the member’s health condition warrants.
iii. For panel providers, notification to the provider and member confirming the MCP’s responsibility to cover the service. MCPs must use the ODJFS-specified model language for the provider and member notices and maintain documentation of all member and/or provider contacts relating to such services.
f. Implementing a drug transition of care process that prevents drug access problems for new members that are transitioning from Medicaid fee-for-service (FFS). Such a process would involve the MCP covering at least one prescription fill or refill without prior authorization (PA) of any covered prescription drug not requiring PA by FFS. For new members that are transitioning from FFS who utilize ongoing medications for chronic conditions the MCP must educate the member about how to continue to access drugs for their chronic condition before the MCP may implement PA requirements for that member’s specific ongoing medication. The MCP’s process for covering the prescription fill or refill without PA must be based on one of the following approaches:
i. the MCP covers without PA all prescriptions written within the two months prior to the effective date of MCP enrollment that do not require PA by Medicaid fee-for-service; or
ii. the MCP covers without PA for at least the initial 30 days of the member’s MCP membership all prescriptions that do not require PA by Medicaid fee-for-service. For any new member transitioning from FFS who utilizes ongoing medications for chronic conditions the MCP may require subsequent PA for those drugs once the MCP has educated the member about the importance of working with their physician to discuss initiating a PA request to continue the current medication and the option of using alternative medications that may be available without PA. Written member notices must use ODJFS-specified model language and be ODJFS-approved. Verbal member education may be done in place of written education but must contain the same information as a written notice and must follow a call script that contains ODJFS-specified model language and be ODJFS-approved. For those new members who are not utilizing ongoing medications for chronic conditions, no additional drug PA education is required beyond the MCP’s general new member education that includes what drugs require MCP PA. MCPs must receive ODJFS approval prior to implementing their transition of care drug PA process. An MCP’s proposal must document how the MCP will:
i. implement one of the above options to ensure that members transitioning from FFS receive at least one prescription fill or refill without PA of any covered prescription drug not requiring PA by FFS; and
ii. identify new members that are transitioning from FFS who utilize ongoing medications for chronic conditions and provide timely education to the member about how to continue to access drugs for their chronic condition before the MCP will implement PA requirements for that member’s specific ongoing medication. MCPs who have not received ODJFS approval for their transition of care drug PA process must not require PA of any prescription drug that does not require PA by Medicaid fee-for-service for the initial three months of a member’s MCP membership.
g. Covering antipsychotic medications for new members as well as current members as stipulated in Appendix G(3)(a)(i).
Appears in 1 contract
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 develop and implement a transition plan that outlines how the MCP will effectively address the unique care coordination issues of members in their first three months of MCP membership and how the various MCP departments will coordinate and share information regarding these new members. The transition plan must include at a minimum:
i. 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 Appendix C Aged, Blind or Disabled (ABD) population Page 13 sub-recipient agencies [e.g., the Ohio Department of Mental Health (ODMH), the Ohio Department of Mental Retardation and Developmental Disabilities (ODMR/DD), the Ohio Department of Alcohol and Drug Addiction Services (ODADAS) and the Ohio Department of Aging (ODA)];
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, home health care services, private duty nursing (PDN), scheduled lab/radiology tests, necessary durable medical equipment, supplies and needed/approved transportation arrangements.. Appendix C Aged, Blind or Disabled (ABD) population Page 13
ii. Strategies for how each new member will obtain care therapies from appropriate sources of care as an MCP member. The MCP’s strategies must include at a minimum:
a. Allowing their new members that are transitioning from Medicaid fee-for-service to receive services from out-of-panel providers if the member or provider contacts the MCP to discuss the scheduled health services in advance of the service date and one of the following applies:
i. The member has appointments within the initial three months of the MCP membership with a primary care provider_or physician or specialty physician physicians that was were scheduled prior to the effective date of the MCP membership;
ii. The member is in her third trimester of pregnancy and has an established relationship with an obstetrician and/or delivery hospital;
iii. The member has been scheduled for an inpatient or outpatient surgery and has been prior-approved and/or precertified pursuant to OAC rule 5101:3-2-40 (surgical procedures would also include follow-up care as appropriate);
iv. The member is receiving ongoing chemotherapy or radiation treatment; or
v. The member has been released from the hospital within thirty (30) days prior to MCP enrollment and is following a treatment plan. If contacted by the member, the MCP must contact the provider’s office as expeditiously as the situation warrants to confirm that the service(s) meets the above criteria.
b. Allowing their new members that are transitioning from Medicaid fee-for-service to continue receiving home care services (i.e., nursing, aide, and skilled therapy services) and private duty nursing (PDN) services if the member or provider contacts the MCP to discuss the health services in advance of the service date. These services must be covered from the date of the member or Appendix C Aged, Blind or Disabled (ABD) population Page 14
1. As soon as the MCP becomes aware of the member’s current home care services, the MCP must initiate contact with the current provider and member as applicable to ensure continuity of care and coordinate a transfer of services to a panel provider, if appropriate.
c. Honoring any current fee-for-service prior authorization to allow their new members that are transitioning from Medicaid fee-for- service to receive services from the authorized provider, whether a panel or out-of-panel provider, for the following approved services:
i. an organ, bone marrow, or hematapoietic stem cell transplant pursuant to OAC rule 5101:3-2-07.1;
ii. dental services that have not yet been received;
iii. vision services that have not yet been received;
iv. durable medical equipment (DME) that has not yet been received. Ongoing DME services and supplies are to be covered by the MCP as previously-authorized until the MCP conducts a medical necessity review and renders an authorization decision pursuant to OAC rule 5101:3-26-03.1.
v. private duty nursing (PDN) services. PDN services must be covered at the previously-authorized service level until the MCP conducts a medical necessity review and renders an authorization decision pursuant to OAC rule 5101:3-26-03.
1. As soon as the MCP becomes aware of the member’s current fee-for-service authorization approval, the MCP must initiate contact with the authorized provider and member as applicable to ensure continuity of care. The MCP must implement a plan to meet the member’s immediate and ongoing medical needs and, with the exception of organ, bone marrow, or hematapoietic stem cell transplants, coordinate the transfer of services to a panel provider, if appropriate. Appendix C Aged, Blind or Disabled (ABD) population Page 15 When an MCP medical necessity review results in a decision to reduce, suspend, or terminate services previously authorized by fee-for-service Medicaid, the MCP must notify the member of their state hearing rights no less than 15 calendar days prior to the effective date of the MCP’s proposed action, per rule 5101:3-26-08.4 of the Administrative Code.
d. Reimbursing out-of-panel providers that agree to provide the transition services at 100% of the current Medicaid fee-for-service provider rate for the service(s) identified in Section 29.h.ii.(a., b., and c.) of this appendix.
e. Documenting the provision of transition services identified in Section 29.h.ii.(a., b., and c.) of this appendix as follows:
i. For non-panel providers, notification to the provider confirming the provider’s agreement/disagreement to provide the service and accept 100% of the current Medicaid fee-for-service rate as payment. If the provider agrees, the distribution of the MCP’s materials as outlined in Appendix G.4.e.
ii. Notification to the member of the non-panel provider’s agreement /disagreement to provide the service. If the provider disagrees, notification to the member of the MCP’s availability to assist with locating a provider as expeditiously as the member’s health condition warrants.
iii. For panel providers, notification to the provider and member confirming the MCP’s responsibility to cover the service. MCPs must use the ODJFS-specified model language for the provider and member notices and maintain documentation of all member and/or provider contacts relating to such services.
f. Not requiring prior-authorization of any prescription drug that does not require prior authorization by Medicaid fee-for-service for the initial three months of a member’s MCP membership. Additionally, all atypical anti-psychotic drugs that do not require prior authorization by Medicaid fee-for-service must be exempted from prior authorization requirements for all MCP ABD members Appendix C Aged, Blind or Disabled (ABD) population Page 16 through December 2007, after which time ODJFS will re-evaluate the continuation of this pharmacy utilization strategy.
Appears in 1 contract
Samples: Ohio Medical Assistance Provider Agreement for Managed Care Plan (Molina Healthcare Inc)
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 develop and implement must:
i. Develop a transition plan that outlines how the MCP will effectively address the unique care coordination issues of for members in their first three months of MCP membership and how the various MCP departments will coordinate and share information regarding these new members. The transition plan must include that includes at a minimum:: Appendix C
i. 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 Appendix C Aged, Blind or Disabled (ABD) population Page 13 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) and the Ohio Department of Aging (ODA)];
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 services, private duty nursing (PDN)care, scheduled lab/radiology tests, necessary necessary/approved durable medical equipment, supplies and needed/approved transportation arrangements.
iiiii. Strategies for how each new member will obtain care therapies from appropriate sources of care as an MCP membermember including reported scheduled health services as described in Section 28.i.(ii-iv) of this Appendix.
iv. The MCP’s strategies must include at a minimum:
a. Allowing Allow their new members that are transitioning from Medicaid fee-for-for- service to receive services from out-of-panel providers if the member or provider contacts members contact the MCP to discuss the scheduled health services in advance of the service date and one of the following applies:
i. a. The member has appointments within the initial three months of the MCP membership with a primary care provider_or physician or specialty physician physicians that was were scheduled prior to the effective date of the MCP membership;
ii. 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 obstetrician and/or delivery hospital;
iii. d. The member has been scheduled for an inpatient or inpatient/outpatient surgery and has been prior-approved and/or precertified pursuant to OAC rule 5101:3-2-40 (surgical procedures would also include follow-follow- up care as appropriate);
iv. e. The member is receiving ongoing chemotherapy or radiation treatment; or;
f. The member has been released from the hospital within the last thirty (30) days and is following a treatment plan;
g. The member has been pre-certified to receive durable medical equipment (DME) which has not yet been received.
v. Reimburse out-of-panel providers that agree to provide the transition services identified in section 28.i.section ii at 100% of the current Medicaid fee-for-service provider rate for the service(s).
vi. Document the provision of transition services as follows:
a. As expeditiously as the situation warrants, contact the provider’s offices via telephone to confirm that the service(s) meets the above criteria.
b. For services that meet the above criteria, inform the provider that the MCP is sending a form for signature to document that they accept/do not accept the terms for the provision of the services and copy the member on the form.
c. If the provider agrees to the terms, notify the member and provider of the MCP’s authorization and ensure that the MCP’s claims processing system will not deny the claim payment because the provider is out-of-panel. MCPs must include their non-contracting provider materials as outlined in Appendix G.4.e with the provider notice.
d. If the provider does not agree to the terms, notify the member and assist the member with locating a provider as expeditiously as the member’s condition warrants. Appendix C
e. Use the ODJFS-specified model language for the provider and member notices.
f. Maintain documentation of all member and/or provider contacts relating to such out-of-panel services, including but not limited to telephone calls and letters.
vii. Not require prior-authorization of any prescription drug that does not require prior authorization by Medicaid fee-for-service for the initial three months of a member’s MCP membership. Additionally, all a typical anti- psychotic drugs, that do not require prior authorization by Medicaid fee-for-service, must be exempted from prior authorization requirements for all MCP ABD members through December 2007, after which time ODJFS will re-evaluate the continuation of this pharmacy utilization strategy.
Appears in 1 contract
Samples: Ohio Medical Assistance Provider Agreement for Managed Care Plan (Molina Healthcare Inc)
