Common use of Care Management Program Clause in Contracts

Care Management Program. The Contractor is responsible for ensuring by the contract start date that an EOHHS approved care management strategy and plan is in place, which addresses the preventive and chronic healthcare needs of its members, inclusive of behavioral health social services and supports and other social determinants that impact member health outcomes. The care management strategy and plan for members with significant health and social needs that are at high risk of poor health outcomes, including, but not limited to, adults with complex health needs, Children with Special Health Care Needs, other children with potentially care management service’s needs, individuals receiving home and community-based services or children with high need, HIV/AIDS, mental illness, addiction issues or those recently discharged from correctional facilities. The care management plan will describe the care management program including but not limited to the policies, procedures, practices and criteria for conducting the Health Risk Assessment and conducting providing care coordination and Intensive Care Management Services that comply with the requirements contained in ATTACHMENT G. The Care Management strategy and plan is subject to the approval of EOHHS. The Contractor will submit the Care Management strategy and plan to EOHHS thirty (30) days prior to the contract commencement date. The Contractor will implement processes to assess, monitor and evaluate the services to all care management subpopulations described in the care management strategy and plan, including but not limited to, defining any of the ongoing special conditions for focus of the care management program that requires a course of treatment, the frequency of ongoing care monitoring, and the number of members and their projected Medicaid eligibility category, type of disability, chronic condition, race, ethnicity, gender and age. In reference to HIV case management, for all Medicaid members, HIV positive; HIV negative; HIV medical; and HIV non-medical case management services will be considered an in-plan benefit. The Contractor will ensure that it has a robust provider network to meet the needs of the community. The Contractor will provide reporting on these services to EOHHS, at a frequency determined by EOHHS. The Contractor will ensure that all of its contracted providers for this service as in compliance with EOHHS’s HIV Targeted Care/Case Management (TCM) Provider Manual and accompanying HIV TCM Toolbox. The Contractor will also be responsible for monitoring and reporting on quality metrics in reference to these programs. The Contractor will submit evidence of compliance to this requirement. The Contractor will designate a Program Coordinator (and/or Care Manager). The Program Coordinator/Care Manager will be a licensed professional who will assure that the Health Risk Assessment and appropriate care management activities are completed for each member; for performance of this role the Program Coordinator/Care Manager must be currently licensed by the State as one of the following: licensed independent clinical social worker, bachelor’s or master’s prepared registered nurse, or psychologist. The responsibilities of the Program Coordinator/Care Manager as outlined will be inclusive of behavioral health services; the Care Manager will assure that behavioral health services are provided in compliance with EOHHS Care Management protocols and in active coordination with other services provided by the Contractor. The Program Coordinator/Care Manager will ensure that the component elements of care management are completed on a timely basis. The Health Risk Assessment must be completed within ninety (90) days of the member’s enrollment with the Contractor. In such event where the Contractor is unable to complete the Health Risk Assessment on a timely basis, the Contractor must be able to provide documented evidence that it made a bona fide effort to conduct the Health Risk Assessment. In the initial start-up period, the Health Plan has one-hundred and eighty (180) days to conduct the Health Risk Assessment of members who become eligible at the beginning of the contract. The Contractor will maintain records to identify care coordination and Intensive Care Management activities. For all members receiving intensive care management, records will include the resulting Intensive Care Management Plan or documentation of why such a plan is not needed. In accordance with 42 CFR 438.208(c)(3), care management plans are to be evaluated and updated as needed while active, but no less frequently than every twelve (12) months or when the member’s circumstances or needs change significantly, or at the request of the member. For members with special health care needs, the Contractor will: • Approve care plans in a timely manner, if the approval is required by the Contractor; and • Develop care plans in accordance with state quality assurance and utilization review standards. Care management is to be performed by Health Plan staff or agents located in the State of Rhode Island. Rhode Island staff will be key for their ability to work closely with local resources. Face- to-face meetings will be conducted where appropriate; to best coordinate the services and supports needed to meet the needs of members, including behavioral health needs, social supports and services and out-of-plan services. The Program Coordinator (and/or Care Manager) and all their needed support staff will be located in Rhode Island. EOHHS considers interactive communications between Primary Care Providers, behavioral health providers and other Specialists to be an important program objective to ensure that members receive the right care in the right setting. The Contractor is encouraged to promote interactive communication methods or systems that enable timely exchange of member information between collaborating providers. The Contractor will have a care management system that employs and/or collaborates with community and provider-based care coordinators and care managers to arrange, assure delivery of, monitor and evaluate basic and comprehensive care, treatment and services to a member. Members needing care coordination or care management will be identified through the health risk assessment, evaluation of claims data, provider referral or other mechanisms as appropriate. The Contractor will inform members how to contact their case manager.