Common use of Assignment of Risk Levels Clause in Contracts

Assignment of Risk Levels. The Contractor shall develop a Care Management program that addresses the varying needs and differing levels of Care Management needs for Members. Based on the Health Risk Screening, the Contractor’s Care Management program must provide for the completion of a detailed health risk assessment for Members, which includes an assessment of and assignment to risk stratification levels (e.g., low, medium, high) which determine the intensity of interventions and follow-up care that is required for each Member. The Contractor shall prioritize and assign Members to low, medium, or high levels based on the identified risk and level of need. Members who have high costs or potentially high costs or otherwise qualify, include but are not limited to pregnant women under twenty-one (21), high risk pregnancies, serious and persistent behavioral health conditions, and infants and toddlers with established risk for developmental delays, shall be assigned to the medium or high risk level and receive Care Management services. Members with less intensive needs will be assigned to the low risk level and shall have access to Care Management teams. The Care Manager must contact the Member via telephone or face-to-face interview to assess the Member’s Care Management needs. This detailed health risk assessment must evaluate the Member’s medical condition(s), including physical, behavioral, social and psychological needs. The goal of this assessment is to confirm the Member’s need for Care Management, identify the Member’s existing and /or potential health care needs, determine the types of services needed by the Member and begin the development of the treatment plan. The Contractor will determine the need for an onsite visit at the Member’s residence to complete this assessment. This detailed health risk assessment must occur within thirty (30) calendar days for Members newly assigned to the High or Medium risk levels as a result of the Health Risk Screening, referral and/or predictive modeling. The detailed health risk assessment must be reviewed by a qualified health professional appropriate for the Member’s health condition. The detailed health risk assessment shall address the following, at a minimum:

Assignment of Risk Levels. The Contractor shall develop a Care Management program that addresses the varying needs and differing levels of Care Management needs for Members. Based on the Health Risk Screening, the Contractor’s Care Management program must provide for the completion of a detailed health risk assessment for Members, which includes an assessment of and assignment to risk stratification levels (e.g., low, medium, high) which determine the intensity of interventions and follow-up care that is required for each Member. The Contractor shall prioritize and assign Members to low, medium, or high levels based on the identified risk and level of need. Members who have high costs or potentially high costs or otherwise qualify, include including but are not limited to pregnant women under twenty-one (21), high risk pregnanciesMembers with persistent and/or preventable inpatient readmissions, serious and persistent behavioral health Behavioral Health conditions, and infants and toddlers with established risk for developmental delays, shall be assigned to the medium or high risk level and receive Care Management services. Members with less intensive needs will be assigned to the low risk level and shall have access to Care Management teams. Contractor shall conduct predictive modeling upon initial Enrollment and at least monthly to identify and evaluate Member risk levels, which must incorporate the use of pharmacy utilization data. Contractor shall also consider Members for receiving Care Management through provider referral, State Agency referral, and Member self- referral. In addition, in consideration of the potential lack of complete claims or encounter data for the CHIP population prior to Enrollment with Contractor, particularly for Members new to CHIP, Contractor may use other analyses used to identify and stratify Members who may be in need of Care Management services. The Care Manager must may contact potentially medium- and high-risk Members and/or the Member Member’s guardian via telephone or face-to-face interview to assess administer the Member’s Care Management needsdetailed health risk assessment. This detailed health risk assessment must evaluate the Member’s medical condition(s), including physical, behavioral, social social, and psychological needs. The goal of this assessment is to confirm the Member’s need for Care Management, identify the Member’s existing and /or potential health care needs, determine the types of services needed by the Member Member, and begin the development of the Member’s treatment plan. The Contractor will determine the need for an onsite visit at the Member’s residence to complete this assessment. This detailed health risk assessment must occur within thirty (30) calendar days for Members newly assigned to the High identified as potentially high- or Medium medium-risk levels as a result of the Health Risk Screening, referral and/or predictive modeling. The detailed health risk assessment must be reviewed by a qualified health professional appropriate for the Member’s health condition. The detailed health risk assessment shall address the following, at a minimum:

Assignment of Risk Levels. The Contractor shall develop a Care Management program that addresses the varying needs and differing levels of Care Management needs for Members. Based on the Health Risk Screening, the Contractor’s Care Management program must provide for the completion of a detailed health risk assessment for Members, which includes an assessment of and assignment to risk stratification levels (e.g., low, medium, high) which determine the intensity of interventions and follow-up care that is required for each Member. The Contractor shall prioritize and assign Members to low, medium, or high levels based on the identified risk and level of need. Members who have high costs or potentially high costs or otherwise qualify, include but are not limited to Members with persistent and/or preventable inpatient readmissions, pregnant women under twenty-one (21), high risk pregnancies, serious and persistent behavioral health conditions, and infants and toddlers with established risk for developmental delays, shall be assigned to the medium or high risk level and receive Care Management services. Members being discharged from an acute inpatient psychiatric stay or PRTF shall be assigned to high risk level and receive Care Management services. Members with less intensive needs will be assigned to the low risk level and shall have access to Care Management teams. The Care Manager must contact the Member via telephone or face-to-face interview to assess the Member’s Care Management needs. This detailed health risk assessment must evaluate the Member’s medical condition(s), including physical, behavioral, social and psychological needs. The goal of this assessment is to confirm the Member’s need for Care Management, identify the Member’s existing and /or potential health care needs, determine the types of services needed by the Member and begin the development of the treatment plan. The Contractor will determine the need for an onsite visit at the Member’s residence to complete this assessment. This detailed health risk assessment must occur within thirty (30) calendar days for Members newly assigned to the High or Medium risk levels as a result of the Health Risk Screening, referral and/or predictive modeling. The detailed health risk assessment must be reviewed by a qualified health professional appropriate for the Member’s health condition. The detailed health risk assessment shall address the following, at a minimum: