Common use of Plan of Care Clause in Contracts

Plan of Care. The Care Manager will authorize and coordinate the provision of Covered Services rendered under this Agreement and as may be referenced in the Provider Handbook. Provider shall adhere to the Plan of Care established for Enrollees. Except in the case where a Enrollee's health or safety is in jeopardy, where such transfer to another Provider may be immediate, Provider shall refer and cooperate with the transfer of Enrollees for Covered Services only to Providers designated, specifically approved or under contract with ILS Community Network and Managed Care Plan. The Provider, in the event of a transitioning Enrollee, including in the event of the termination of this Agreement, shall cooperate in all respects with Providers of other Managed Care Plans to assure maximum health outcomes for Enrollees. In the event that Provider renders a Enrollee non-covered services or refers a Enrollee to an out-of-network provider without pre-authorization from ILS Community Network or Managed Care Plan, Provider shall prior to the provision of such non-covered services or such out-of- network referral, inform the Enrollee in writing: (1) of the services to be provided or referral to be made; (2) that ILS Community Network and Managed Care Plan will not pay (or may pay a reduced benefit in the case of ILS Community Network and Managed Care Plan's point of service (POS) and/or preferred provider organization (PPO) products) or be liable financially for such non-covered service or out-of network referral and (3) that Enrollee will be responsible financially for non-covered service(s) and/or out-of-network referral(s) that are requested by the Enrollee. Provider acknowledges and agrees that the failure to inform Xxxxxxxx(s) in accordance with this paragraph may result in financial liability to Provider for the cost of such non-covered or non-authorized service(s). The Provisions of this Section shall not prohibit a Enrollee from receiving inpatient services in a contracted hospital if such services are determined by the Managed Care Plan to be medically necessary Covered Services. This Agreement shall not prohibit a Provider from discussing treatment or non-treatment options with Enrollees that may not reflect the Managed Care Plan's position or may not be covered by the Managed Care Plan; and shall not prohibit a Provider from acting within the lawful scope of practice, from advising or advocating on behalf of a Enrollee for the Enrollee's health status, medical care, or treatment or non-treatment options, including any alternative treatments that might be self-administered; and shall not prohibit a Provider from advocating on behalf of the enrollee in any grievance system or UM process, or individual authorization process to obtain necessary services.

Plan of Care. For all enrollees, a person-centered Plan of Care will be developed by the STAR+PLUS MMP Service Coordinator, with the enrollee, his/her caregiver and/or family supports, PCP, and other members of the Service Coordination Team (see section A.iv below), that addresses all the health and social needs of the enrollee, as identified in the comprehensive health risk assessment. The Plan of Care Manager will authorize contain the enrollee’s health history; a summary of current, short-term, and coordinate long-term health and social needs, concerns, and goals; and a list of required services, their frequency, and a description of who will provide such services. If an enrollee is found to be eligible for HCBS waiver services as a result of the provision of Covered Services rendered under this Agreement and as may be HCBS assessment referenced in section A.ii above, the Provider HandbookService Coordinator will work with the enrollee to develop an Individual Service Plan (ISP). Provider HCBS waiver service planning includes: 1) determining the individual's needs, goals, and preferences; 2) determining service levels; 3) maintaining costs and cost ceilings; 4) reviewing services; and 5) obtaining approval for planned services. The ISP will be incorporated into the enrollee’s overall Plan of Care. Each enrollee’s Plan of Care must also include, as applicable and consistent with enrollee preferences, coordination with the enrollee’s family and community support systems, including Independent Living Centers, Area Agencies on Aging (AAAs), and Local Authorities, as applicable. The Plan of Care shall adhere be agreed to and signed by the enrollee or the enrollee’s LAR to indicate agreement with the plan. The Plan of Care shall allow for financial management services and promote self-determination and may include information about accessing services outside of Demonstration covered services, such as affordable, integrated housing. For all enrollees, the STAR+PLUS MMP must ensure that the Plan of Care established for Enrollees. Except in the case where a Enrollee's health or safety is in jeopardyplace within 90 days of enrollment, where such transfer or upon receipt of all necessary eligibility information from the State, whichever is later. Continuous monitoring of the Plan of Care will occur, and any gaps in services will be addressed in an integrated manner by the STAR+PLUS MMP, including any necessary revisions to another Provider may be immediate, Provider shall refer and cooperate with the transfer of Enrollees for Covered Services only to Providers designated, specifically approved or under contract with ILS Community Network and Managed Care Planplan. The Provider, Plan of Care expires annually and must be updated each year regardless of any mid- year revisions made based on an enrollee’s needs. Each STAR+PLUS MMP is required to conduct an annual reassessment and update the Plan of Care prior to the expiration date. All services under the current Plan of Care would continue in the event of a transitioning Enrollee, including in the event of the termination of this Agreement, shall cooperate in all respects with Providers of other Managed Care Plans to assure maximum health outcomes for Enrollees. In the event that Provider renders a Enrollee non-covered services or refers a Enrollee to an out-of-network provider without pre-authorization from ILS Community Network or Managed Care Plan, Provider shall prior to the provision of such non-covered services or such out-of- network referral, inform the Enrollee in writing: (1) of the services to be provided or referral to be made; (2) that ILS Community Network and Managed Care Plan will not pay (or may pay a reduced benefit in the case of ILS Community Network and Managed Care Plan's point of service (POS) and/or preferred provider organization (PPO) products) or be liable financially for such non-covered service or out-of network referral and (3) that Enrollee will be responsible financially for non-covered service(s) and/or out-of-network referral(s) that are requested by the Enrollee. Provider acknowledges and agrees that the failure to inform Xxxxxxxx(s) in accordance with this paragraph may result in financial liability to Provider for the cost of such non-covered or non-authorized service(s). The Provisions of this Section shall not prohibit a Enrollee from receiving inpatient services in a contracted hospital if such services are determined by the Managed Care Plan to be medically necessary Covered Services. This Agreement shall not prohibit a Provider from discussing treatment or non-treatment options with Enrollees that may not reflect the Managed Care Plan's position or may not be covered by the Managed Care Plan; and shall not prohibit a Provider from acting within the lawful scope of practice, from advising or advocating on behalf of a Enrollee for the Enrollee's health status, medical care, or treatment or non-treatment options, including any alternative treatments that might be self-administered; and shall not prohibit a Provider from advocating on behalf of the enrollee in any grievance system or UM process, or individual authorization process to obtain necessary servicesexpiration.