Common use of Transitions of Care Clause in Contracts

Transitions of Care. The CONTRACTOR shall identify and facilitate coordination of care for all Members during various transitions consistent with the requirements in the Managed Care Policy Manual. Examples of Member transitions of care include but are not limited to the following transitions: Justice-Involved Individuals from prisons, jails, and detention facilities into the community, including tribal communities and reservations for Native American Members; Between health care settings and levels of care; Between MCOs; Between FFS and the CONTRACTOR; Between the CONTRACTOR and the Health Insurance Exchange; Child Members transitioning in and out of state custody; Age-related transitions; and Members transitioning to the CONTRACTOR who are pregnant. The CONTRACTOR’s Care Coordination program description shall describe each type of transition and the CONTRACTOR’s protocols that ensure continuity of care and timely access to Covered services for its Members during the transition. The CONTRACTOR’s program description shall include the circumstances and time period in which the CONTRACTOR will allow Members to continue receiving services from Non-Contract Providers and honor existing service authorizations, unless otherwise set forth in this Section 4.4.11. For planned transitions, the CONTRACTOR shall conduct a transition of care assessment using the HCA-approved, standardized transition of care assessment tool and develop a transition plan, facilitated by the care coordinator with the Member and/or Member’s Representative, which shall remain in place until the transition has occurred and a new CCP is in place. For all transitions of care of CYFD-involved children and youth, the CONTRACTOR shall involve the assigned CYFD PPW for CPS involved children and youth in the development of the transition of care plan, and notify the assigned CYFD PPW for CPS within three (3) Business Days prior to transition in care. The CONTRACTOR shall ensure the continuity of care for CISC Members by allowing CISC Members to continue receiving services from Non-Contract Providers, honor existing service authorizations, and reimbursing Non-Contract Providers at the greater of CONTRACTOR’s Contract provider rate or Medicaid FFS rate.

Transitions of Care. The CONTRACTOR shall identify and facilitate coordination of care for all Members during various transitions consistent with the requirements in the Managed Care Policy Manual. Examples of Member transitions of care include but are not limited to the following transitions: Justice-Involved Individuals involved Members from prisons, jails, and detention facilities into the community, including tribal communities and reservations for Native American Members; Between health care settings and levels of care; Between MCOs; Between FFS and the CONTRACTOR; Between the CONTRACTOR and the Health Insurance Exchange; Child Members transitioning in and out of state custody; Age-related transitions; and Members transitioning to the CONTRACTOR who are pregnant. The CONTRACTOR’s Care Coordination program description shall describe each type of transition and the CONTRACTOR’s protocols that ensure continuity of care and timely access to Covered services for its Members during the transition. The CONTRACTOR’s program description shall include the circumstances and time period in which the CONTRACTOR will allow Members to continue receiving services from Non-Contract Providers and honor existing service authorizations, unless otherwise set forth in this Section 4.4.114.4.10. For planned transitions, the CONTRACTOR shall conduct a transition of care assessment using the HCAHSD-approved, standardized transition of care assessment tool and develop a transition plan, facilitated by the care coordinator with the Member and/or Member’s Representative, which shall remain in place until the transition has occurred and a new CCP is in place. For all transitions of care of CYFD-involved children and youth, the CONTRACTOR shall involve the assigned CYFD PPW for CPS involved children and youth in the development of the transition of care plan, and notify the assigned CYFD PPW for CPS within three (3) Business Days prior to transition in care. The CONTRACTOR shall ensure the continuity of care for CISC Members by allowing CISC Members to continue receiving services from Non-Contract Providers, honor existing service authorizations, and reimbursing Non-Contract Providers at the greater of CONTRACTOR’s Contract provider rate or Medicaid FFS rate.