Current through Register Vol. 35, No. 18, September 24, 2024
Transition of care refers to movement of an eligible
recipient or a manage care organization (MCO) member from one health care
practitioner or setting to another as their condition and health care needs
change. The MCO shall have the resources, the policies and the procedures in
place to actively assist the member with their transition of care.
A. Care coordination will be offered to
members who are:
(1) transitioning from a
nursing facility or out-of-home placement to the community;
(2) moving from a higher level of care to a
lower level of care (LOC);
(3)
turning 21 years of age;
(4)
changing MCOs while hospitalized;
(5) changing MCOs during major organ and
tissue transplantation services; and
(6) changing MCOs while receiving outpatient
treatments for significant medical conditions. A member shall continue to
receive medically necessary services in an uninterrupted manner during
transitions of care.
B.
The following is a list of HSD's general MCO requirements for transition of
care.
(1) The MCO shall establish policies and
procedures to ensure that each member is contacted in a timely manner and is
appropriately assessed by its MCO, using the HSD prescribed timeframes,
processes and tools to identify their needs.
(2) The MCO shall have policies and
procedures covering the transition of an eligible recipient into a MCO, which
shall include:
(a) member and provider
educational information about the MCO;
(b) self-care and the optimization of
treatment; and
(c) the review and
update of existing courses of the member's treatment.
(3) The MCO shall not transition a member to
another provider for continuing services, unless the current provider is not a
contracted provider.
(4) The MCO
shall facilitate a seamless transition into a new service, a new provider, or
both, in a care plan developed by the MCO without disruption in the member's
services.
(5) When a member of a
MCO is transitioning to another MCO, the receiving MCO shall immediately
contact the member's relinquishing MCO and request the transfer of "transition
of care data" as specified by HSD. If a MCO is contacted by another MCO
requesting the transfer of "transition of care data" for a transitioning
member, then upon verification of such a transition, the relinquishing MCO
shall provide such data in the timeframe and format specified by HSD to the
receiving MCO, and both MCOs shall facilitate a seamless transition for the
member.
(6) The receiving MCO will
ensure that its newly transitioning member is held harmless by their provider
for the costs of medically necessary covered services, except for applicable
cost sharing.
(7) For a medical
assistance division (MAD) medically necessary covered service provided by a
contracted provider, the MCO shall provide continuation of such services from
that provider, but may require prior authorization for the continuation of such
services from that provider beyond 30 calendar days. The receiving MCO may
initiate a provider change only as specified in the MCO agreement with
HSD.
(8) The receiving MCO shall
continue providing services previously authorized by HSD, its contractor or
designee, in the member's approved community benefit care plan, behavioral
health treatment plan or service plan without regard to whether such a service
is provided by contracted or non-contracted provider. The receiving MCO shall
not reduce approved services until the member's care coordinator conducts a
comprehensive needs assessment (CNA).
C. Transplant services, durable medical
equipment and prescription drugs:
(1) If an
eligible recipient has received HSD approval, either through fee-for-service
(FFS) or any other HSD contractor, the receiving MCO shall reimburse the HSD
approved providers if a donor organ becomes available during the first 30
calendar days of the member's MCO enrollment.
(2) If a member was approved by a MCO for
transplant services, HSD shall reimburse the MCO approved providers if a donor
organ becomes available during the first 30 calendar days of the eligible
recipient's FFS enrollment. The MCO provider who delivers these services will
be eligible for FFS enrollment if the provider is willing.
(3) If a member received approval from their
MCO for durable medical equipment (DME) costing $2,000 or more, and prior to
the delivery of the DME item, was disenrolled from the MCO, the relinquishing
MCO shall pay for the item.
(4) If
an eligible recipient received FFS approval for a DME costing $2,000 or more,
and prior to the delivery of the DME item, they are enrolled in a MCO, HSD
shall pay for the item. The DME provider will be eligible for FFS provider
enrollment if the provider is willing.
(5) If a FFS eligible recipient enrolls in a
MCO, the receiving MCO shall pay for prescribed drug refills for the first 30
calendar days or until the MCO makes other arrangements.
(6) If a MCO member is later determined to be
exempt from MCO enrollment, HSD will pay for prescription drug refills for the
first 30 calendar days of their FFS enrollment. The pharmacy provider will be
eligible for FFS enrollment if the provider is willing;
(7) If a FFS eligible recipient is later
enrolled in a MCO, the receiving MCO will honor all prior authorizations
granted by HSD or its contractors for the first 30 calendar days or until it
makes other arrangements for the transition of services. A provider who
delivered services approved by HSD or through its contractors shall be
reimbursed by the receiving MCO.
(8) If a MCO member is later determined to be
exempt from MCO enrollment, HSD will honor the relinquishing MCO's prior
authorizations for the first 30 calendar days or until other arrangements for
the transition of services have been made. The provider will be eligible for
FFS enrollment if the provider is willing.
D. Transition of care requirements for
pregnant individuals:
(1) When a member is in
their second or third trimester of pregnancy and is receiving medically
necessary covered prenatal care services prior to their enrollment in the MCO,
the receiving MCO will be responsible for providing continued access to their
prenatal care provider (whether a contracted or non-contracted provider)
through the 12-month postpartum period without any form of prior
approval.
(2) When a newly enrolled
member is in their first trimester of pregnancy and is receiving medically
necessary covered prenatal care services prior to their enrollment, the
receiving MCO shall be responsible for the costs of continuation of such
medically necessary prenatal care services, including prenatal care and
delivery, without any form of prior approval from the receiving MCO and without
regard to whether such services are being provided by a contracted or
non-contracted provider for up to 60 calendar days from their MCO enrollment or
until they may be reasonably transferred to a MCO contracted provider without
disruption in care, whichever is less.
(3) When a member is receiving services from
a contracted provider, their MCO shall be responsible for the costs of
continuation of medically necessary covered prenatal services from that
provider, without any form of prior approval, through the 12-month postpartum
period.
(4) When a member is
receiving services from a non-contracted provider, their MCO will be
responsible for the costs of continuation of medically necessary covered
prenatal services, delivery, through the 12-month postpartum period, without
any form of prior approval, until such time when their MCO determines it can
reasonably transfer them to a contracted provider without impeding service
delivery that might be harmful to their health.
E. Transition from institutional facility to
community:
(1) The MCO shall develop and
implement methods for identifying members who may have the ability, the desire,
or both, to transition from institutional care to their community, such methods
include, at a minimum:
(a) the utilization of
a CNA;
(b) the utilization of the
preadmission screening and annual resident review (PASRR);
(c) minimum data set (MDS);
(d) a provider referral including hospitals,
and residential treatment centers;
(e) an ombudsman referral;
(f) a family member referral;
(g) a change in medical status;
(h) the member's self-referral;
(i) community reintegration allocation
received;
(j) state agency
referral; and
(k) incarceration or
detention facility referral.
(2) When a member's transition assessment
indicates that they are a candidate for transition to the community, their MCO
care coordinator shall facilitate the development and completion of a
transition plan, which shall remain in place for a minimum of 60 calendar days
from the decision to pursue transition or until the transition has occurred and
a new care plan is in place. The transition plan shall address the member's
transition needs including but not limited to:
(a) their physical and behavioral health
needs;
(b) the selection of
providers in their community;
(c)
continuation of MAP eligibility;
(d) their housing needs;
(e) their financial needs;
(f) their interpersonal skills; and
(g) their safety.
(3) The MCO shall conduct an additional
assessment within 75 calendar days of the member's transition to their
community to determine if the transition was successful and identify any
remaining needs of the member.
F. Transition from the New Mexico health
insurance exchange:
(1) The receiving MCO must
minimize the disruption of the newly enrolled member's care and ensure they
have uninterrupted access to medically necessary services when transitioning
between a MCO and their New Mexico health insurance exchange qualified health
plan coverage.
(2) At a minimum,
the receiving MCO shall establish transition guidelines for the following
populations:
(a) pregnant members, including
the 12-month postpartum period;
(b)
members with complex medical conditions;
(c) members receiving ongoing services or who
are hospitalized at the time of transition; and
(d) members who received prior authorization
for services from their qualified health plan.
(3) The receiving MCO is expected to
coordinate services and provide phase-in and phase-out time periods for each of
these populations, and to maintain written policies and procedures to address
these coverage transitions.