Enrollee with Special Health Care Needs definition

Enrollee with Special Health Care Needs means an enrollee who has chronic and disabling condition as defined in WAC 000-000-000.
Sample 1
Enrollee with Special Health Care Needs means an enrollee who has: at least two chronic conditions; one chronic condition and be at risk for another chronic condition; or one serious and persistent mental health condition. Enrollees with chronic condition(s) scoring in the highest forty percent (40%) of dual eligibles or have a risk score of 1.5 or greater using the Predictive Risk Intelligence System (PRISM) risk scoring methods, are considered enrollees with special health care needs.
Sample 1Sample 2
Enrollee with Special Health Care Needs means an enrollee who has a chronic or disabling condition that meets all of the following conditions:
Sample 1Sample 2

Examples of Enrollee with Special Health Care Needs in a sentence

  • The Contractor shall not limit the number of referrals to specialists that a Network Provider may make for an Enrollee with Special Health Care Needs.

  • If an Enrollee with Special Health Care Needs is enrolled in a Prepaid Mental Health Plan or is enrolled in any of the Medicaid home and community-based waiver programs and is receiving case management services through that program, or is covered by one of the other Medicaid targeted case management programs, the Contractor’s care coordinator shall collaborate with the appropriate program person for that program.

  • If an Enrollee with Special Health Care Needs qualifies for any of the Medicaid Home and Community-based Waiver Programs and is receiving case management services through that program, or is covered by one of the other Medicaid targeted case management programs, the Contractor’s care coordinator shall collaborate with the appropriate program person for that program.

  • The Contractor shall not limit the number of referrals to specialists that a Provider may make for an Enrollee with Special Health Care Needs.

  • In the event that an Enrollee with Special Health Care Needs is unable to secure a new network provider within 3 business days, MFC-DC will arrange for covered services from an out- of-network provider at a level of service comparable to that received from a network provider until MFC-DC is able to arrange for such service from a network provider.


More Definitions of Enrollee with Special Health Care Needs

Enrollee with Special Health Care Needs means an enrollee having a chronic or disabling condition that meets all of the following conditions (WAC 388-538-050):
Sample 1

Related to Enrollee with Special Health Care Needs

  • Health care worker means a person other than a health care professional who provides medical, dental, or other health-related care or treatment under the direction of a health care professional with the authority to direct that individual's activities, including medical technicians, medical assistants, dental assistants, orderlies, aides, and individuals acting in similar capacities.

  • Health care plan means any contract, policy or other arrangement for benefits or services for medical or dental care or treatment under:

  • Community mental health program means all mental health

  • Licensed health care practitioner means a physician, as defined in Section 1861(r)(1) of the Social Security Act, a registered professional nurse, licensed social worker or other individual who meets requirements prescribed by the Secretary of the Treasury.

  • Medicare Provider Agreement means an agreement entered into between CMS or other such entity administering the Medicare program on behalf of CMS, and a health care provider or supplier under which the health care provider or supplier agrees to provide items and services for Medicare patients in accordance with the terms of the agreement and Medicare Regulations.

  • Designated mental health professional means a mental health

  • Qualified mental health professional means a licensed medical practitioner or any other person meeting the qualifications specified in OAR 309-019-0125.

  • Licensed health care professional means a person who possesses a professional medical license that is valid in Oregon. Examples include, but are not limited to, a registered nurse (RN), nurse practitioner (NP), licensed practical nurse (LPN), medical doctor (MD), osteopathic physician (DO), respiratory therapist (RT), physical therapist (PT), physician assistant (PA), or occupational therapist (OT).

  • Provider of health care means a physician or physician assistant licensed pursuant to chapter 630, 630A or 633 of NRS, perfusionist, dentist, licensed nurse, dispensing optician, optometrist, practitioner of respiratory care, registered physical therapist, podiatric physician, licensed psychologist, licensed audiologist, licensed speech-language pathologist, licensed hearing aid specialist, licensed marriage and family therapist, licensed clinical professional counselor, chiropractor, licensed dietitian or doctor of Oriental medicine in any form.

  • Health care practitioner means an individual licensed

  • Health care organization ’ means any person or en-

  • Health care system means any public or private entity whose function or purpose is the management of, processing of, enrollment of individuals for or payment for, in full or in part, health care services or health care data or health care information for its participants;

  • Licensed health care provider means a physician, physician assistant, chiropractor, advanced registered nurse practitioner, nurse, physical therapist, or athletic trainer licensed by a board.

  • Basic health plan means the plan described under chapter

  • Health carrier or "carrier" means a disability insurer

  • Health care entity means any health care provider, health plan or health care clearinghouse.

  • Managed health care system means: (a) Any health care

  • Medicare Advantage plan means a plan of coverage for health benefits under Medicare Part C as defined in 42 U.S.C. 1395w-28(b)(1), and includes:

  • Behavioral health provider means a person licensed under 34 chapter 18.57, 18.57A, 18.71, 18.71A, 18.83, 18.205, 18.225, or 18.79

  • Home Health Care Agency means an agency or organization which provides a program of home health care and which:

  • Community mental health center or "CMHC" means a facility offering a comprehensive array of community-based mental health services, including but not limited to, inpatient treatment, outpatient treatment, partial hospitalization, emergency care, consultation and education; and, certain services at the option of the center, including, but not limited to, prescreening, rehabilitation services, pre-care and aftercare, training programs, and research and evaluation.

  • Medicaid means the medical assistance programs administered by state agencies and approved by CMS pursuant to the terms of Title XIX of the Social Security Act, codified at 42 U.S.C. 1396 et seq.

  • Medicare means the “Health Insurance for the Aged Act,” Title XVIII of the Social Security Amendments of 1965, as then constituted or later amended.

  • Participating Retail Health Clinic means a Retail Health Clinic which has a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Basic health care services means in and out-of-area emergency services, inpatient hospital and

  • Licensed mental health professional or "LMHP" means a physician, licensed clinical psychologist, licensed professional counselor, licensed clinical social worker, licensed substance abuse treatment practitioner, licensed marriage and family therapist, certified psychiatric clinical nurse specialist, licensed behavior analyst, or licensed psychiatric/mental health nurse practitioner.