Common use of Member Incentive Programs Clause in Contracts

Member Incentive Programs. Contractors shall establish member incentive programs to encourage appropriate utilization of health services and healthy behaviors. Member incentives may be financial or non- financial. The Contractor will determine its own methodology for providing incentives to members. For example, the Contractor may offer member incentives for:  Attending all prenatal visits;  Obtaining recommended preventive care;  Completing the expected number of EPSDT visits;  Complying with treatment in a disease management, care management or complex case management program;  Making healthy lifestyle decisions such as quitting smoking or losing weight; or  Completing a health screening. Except as provided herein, the Contractor may not offer gifts or incentives greater than $10.00 for each incentive and not to exceed $50.00 total per year per individual. The Contractor may petition OMPP, in the manner prescribed by OMPP, for authorization to offer items or incentives greater than $10.00 for each individual and $50.00 per year per individual if the items are intended to promote the delivery of certain preventive care services, as defined in 42 CFR 1003.101, Such incentives may not be disproportionate to the value of the preventive care service provided, as determined by OMPP. Petitions to provide enhanced incentives for preventive care shall be reviewed on a case-by-case basis, and OMPP shall retain full discretion in determining whether the enhanced incentives will be approved. In any member incentive program, the incentives shall be tied to appropriate utilization of health services and/or health-promoting behavior. For example, the member incentive programs can encourage responsible emergency room use or preventive care utilization. Contractors should develop member incentives designed to encourage appropriate utilization of health care services, increase adherence to keeping medical appointments and encourage the receipt of health care services in the appropriate treatment setting. Additionally, the Contractor shall comply with those requirements found in 42 CFR 1003.101, “Remuneration…(4) Incentives given to individuals to promote the delivery of preventive care services where the delivery of such services is not tied (directly or indirectly) to the provision of other services reimbursed in whole or in part by Medicare or an applicable State health care program. Such incentives may include the provision of preventive care, but may not include— (i) Cash or instruments convertible to cash; or (ii) An incentive the value of which is disproportionally large in relationship to the value of the preventive care service (i.e., either the value of the service itself or the future health care costs reasonably expected to be avoided as a result of the preventive care)…” Examples of appropriate rewards include:  Gift certificates for groceries;  Phone cards; or  Gifts such as diaper bags or new baby “welcome” kits. The Contractor shall obtain OMPP-approval prior to implementing its member incentive program and before making any changes thereto.

Member Incentive Programs. Contractors shall establish member incentive programs to encourage appropriate utilization of health services and healthy behaviors. Member incentives may be financial or non- financial. The Contractor will determine its own methodology for providing incentives to members. For example, the Contractor may offer member incentives for:  Attending all prenatal visits;  Obtaining recommended preventive care;  Completing the expected number of EPSDT visits;  Complying with treatment in a disease management, care management or complex case management program;  Making healthy lifestyle decisions such as quitting smoking or losing weight; or  Completing a health screening. 1. Except as provided herein, the Contractor may not offer gifts or incentives greater than $10.00 for each incentive and not to exceed $50.00 total per year per individual. The Contractor may petition OMPP, in the manner prescribed by OMPP, for authorization to offer items or incentives greater than $10.00 for each individual and $50.00 per year per individual if the items are intended to promote the delivery of certain preventive care services, as defined in 42 CFR 1003.101, . Such incentives may not be disproportionate to the value of the preventive care service provided, as determined by OMPP. Petitions to provide enhanced incentives for preventive care shall be reviewed on a case-by-case basis, and OMPP shall retain full discretion in determining whether the enhanced incentives will be approved. In any member incentive program, the incentives shall be tied to appropriate utilization of health services and/or health-promoting behavior. For example, the member incentive programs can encourage responsible emergency room use or preventive care utilization. Contractors should develop member incentives designed to encourage appropriate utilization of health care services, increase adherence to keeping medical appointments and encourage the receipt of health care services in the appropriate treatment setting. Additionally, the Contractor shall comply with those requirements found in 42 CFR 1003.101, “Remuneration…(4) Incentives given to individuals to promote the delivery of preventive care services where the delivery of such services is not tied (directly or indirectly) to the provision of other services reimbursed in whole or in part by Medicare or an applicable State health care program. Such incentives may include the provision of preventive care, but may not include— (i) Cash or instruments convertible to cash; or (ii) An incentive the value of which is disproportionally large in relationship to the value of the preventive care service (i.e., either the value of the service itself or the future health care costs reasonably expected to be avoided as a result of the preventive care)…” ” 2. Examples of appropriate rewards include:  Gift certificates for groceries;  Phone cards; or  Gifts such as diaper bags or new baby “welcome” kits. The Contractor shall obtain OMPP-approval prior to implementing its member incentive program and before making any changes thereto.