Current through 2024-38, September 18, 2024
CCT services are for Members who are high-risk and/or
high-cost and whose health care needs are more intense than can be managed
solely by a primary care provider. CCTs will request qualifying Members be
added to their panels.
To be eligible for CCT services, the Member must:
1. Be diagnosed with two (2) or more chronic
conditions (91.03-1) and meet one of the general eligibility requirements
(91.03-3); or
2. Be diagnosed with
one (1) chronic condition (91.03-1), be at risk for another chronic condition
(91.03-2), and meet one of the general eligibility requirements (91.03-3).
All diagnoses related to eligibility must be documented
in the Member's EHR.
91.03-1
Chronic Conditions
1. a mental
health condition (excluding Serious and Persistent Mental Illness and Serious
Emotional disturbance, as defined in MBM, Section
92, Behavioral Health
Homes;
2. a substance use
disorder;
3. tobacco use;
4. diabetes;
5. heart disease;
6. overweight or obese as evidenced by a body
mass index over 25 for an adult or the 85th
percentile for a child;
7. Chronic
Obstructive Pulmonary Disease (COPD);
8. hypertension;
9. hyperlipidemia;
10. developmental and intellectual
disorders;
11. circulatory
congenital abnormalities;
12.
asthma;
13. acquired brain
injury;
14. seizure disorders;
and
15. HIV/AIDS.
91.03-2
At Risk for Another
Chronic Condition
A Member is deemed to be at risk for another chronic
condition if the Member has been diagnosed with or has any of the
following:
1. a mental health
condition (excluding Serious and Persistent Mental Illness and Serious
Emotional disturbance, as defined in MBM, Section
92, Behavioral Health
Homes);
2. a substance use
disorder;
3. tobacco use;
4. diabetes;
5. heart disease;
6. overweight or obese as evidenced by a body
mass index over 25 for an adult or the 85th
percentile for a child;
7. COPD;
8. hypertension;
9. hyperlipidemia;
10. developmental and intellectual disorders;
11. congenital or acquired
circulatory abnormalities;
12.
HIV/AIDs;
13. poor nutrition;
14. childhood trauma;
15. risky sex practices;
16. intravenous drug use;
17. history of incarceration;
18. history of or current substance use;
or
19. family history or genetic
predisposition for developing a chronic condition.
91.03-3
General Eligibility
Requirements
Members shall also meet one of the following additional
requirements for CCT eligibility and document the qualifying reason(s) for
eligibility:
1.
Hospital
Admissionsa. Two or more admissions in
past three months; or
b. Three or
more admissions in past 12 months
2.
ED Utilization
a. Two or more ED visits in past three
months; or
b. Three or more ED
visits in past 12 months
3. Members identified by the Department as
high-risk or high-cost through Department-provided risk stratification and
population health management data or by direct referral from the Department or
its authorized agent.
4. Members
transitioning from institutional settings and at increased risk of poor
outcomes (e.g. release from incarceration).
5. Members identified by CCT
risk-stratification as:
a. at risk for
deteriorating health status, as defined by a validated risk prediction score;
and/or
b. high-risk or high-cost by
severity of illness, high social service needs that interfere with care, and
service utilization; and/or
c.
having higher hospital costs, ED use, readmissions, utilization and/or
escalation of services than what is expected for their clinical risk
group.
6.
Polypharmacy: Members using 5 or more chronic medications and/or
on multiple high-risk medications (e.g., insulin, warfarin, etc.), as defined
by evidence-based or expert opinion.
