Current through Register Vol. 35, No. 18, September 24, 2024
A.
General requirements:
(1) Care
coordination services are provided and coordinated with the eligible recipient
member and his or her family, as appropriate. Care coordination involves, but
is not limited to, the following: planning treatment strategies; developing
treatment and service plans; monitoring outcomes and resource use; coordinating
visits with primary care and specialists providers; organizing care to avoid
duplication of services; sharing information among medical and behavioral care
professionals and the member's family; facilitating access to services; and
actively managing transitions of care, including participation in hospital
discharge planning. Managed care organizations (MCOs) may delegate care
coordination functions through a full delegation model or a shared functions
model, while retaining oversight of all care coordination activities.
(a) Full delegation model allows the MCO to
delegate the full set of care coordination functions to a provider/health
system (delegate) through a value-based purchasing (VBP) arrangement.
(b) Shared functions model allows the MCO to
delegate some care coordination functions such as conducting health risk
assessments, conducting comprehensive needs assessments, conducting periodic
touch points, coordinating referrals to community services, and locating and
engaging difficult to engage medicaid members.
(2) Every member has the right to refuse to
participate in care coordination. In the event the member refuses this service,
the managed care organization (MCO) or MCO delegate will document the refusal
in the member's file and report it to HSD. The member remains enrolled with the
MCO with no reduction in the availability of services.
(3) If a native American member requests
assignment to a native American care coordinator, the MCO or MCO delegate must
employ or contract with a native American care coordinator or contract with a
community health representative (CHR) to serve as the care
coordinator.
(4) Individuals with
special health care needs (ISHCN) require a broad range of primary, specialized
medical, behavioral health and related services. ISHCN are individuals who
have, or are at an increased risk for, a chronic physical, developmental,
behavioral, neurobiological or emotional condition and who require health and
related services of a type or amount beyond that required by other members.
ISHCN have ongoing health conditions, high or complex service utilization, and
low to severe functional limitations. The primary purpose of the definition is
to identify these members so that the MCO or MCO delegate shall facilitate
access to appropriate services through its care coordination process and comply
with provisions of 42 CFR Section 438.208.
B.
Health risk assessment (HRA):
The MCO or MCO delegate shall conduct a HSD approved health risk assessment
(HRA) either by telephone, in person or as otherwise approved by HSD. The HRA
is conducted for the purpose of:
(1)
introducing the MCO or MCO delegate to the member;
(2) obtaining basic health and demographic
information about the member; and
(3) confirming the need for a comprehensive
needs assessment (CNA); and
(4)
determining the need for a nursing facility (NF) level of care (LOC)
assessment, as applicable. Requirements for health risk assessments are defined
in the HSD managed care policy manual (section 04 care coordination).
C.
Assignment to care
coordination levels two and three: The MCO or MCO delegate shall conduct
a HSD approved CNA to assess the member's medical, behavioral health, and long
term care needs and determine the care coordination level. Requirements for
care coordination level two and three determinations are defined in the HSD
managed care policy manual (section 04 care coordination).
D.
Increase in the level of care
coordination services: The requirements establishing a need for a CNA
for a higher level of care coordination determination are defined in the HSD
managed care policy manual (section 04 care coordination).
E.
Comprehensive care plan
requirements: The MCO or MCO delegate shall develop a comprehensive care
plan (CCP) for members in care coordination levels two and three. Requirements
for CCP development are defined in the HSD managed care policy manual (section
04 care coordination).
F.
On-going reporting: The MCO or MCO delegate shall require that the
following information about the member's care is shared amongst medical,
behavioral health, and long-term care providers:
(1) drug therapy;
(2) laboratory and radiology
results;
(3) sentinel events, such
as hospitalization, emergencies, or incarceration;
(4) discharge from a psychiatric hospital, a
residential treatment service, treatment foster care, other behavioral health
services, or release from incarceration; and
(5) all LOC transitions.
