At Risk of Developing Another Chronic Condition. Risk of a second chronic condition is defined by a minimum predictive risk score of 1.5. The predictive risk score of 1.5 means a beneficiary’s expected future medical expenditures is expected to be 50% greater than the base reference group, the Washington SSI disability population. The Washington risk score is based on the Chronic Illness & Disability Payment System and Medicaid- Rx risk groupers developed by Xxxx Xxxxxxx and Xxxx Xxxxxx at the University of California, San Diego, with risk weights normalized for the Washington Medicaid population. Diagnoses, prescriptions, age, and gender from the beneficiary’s medical claims and eligibility history for the past 15 months (24 months for children) are analyzed, a risk score is calculated and chronic conditions checked across all categorically needy populations, and a clinical indicator (Y=qualifies; N=does not qualify) is loaded into the Washington Medicaid Management Information System (MMIS).
At Risk of Developing Another Chronic Condition. Risk of a second chronic condition is defined by a minimum predictive risk score of 1.5. The predictive risk score of 1.5 means a beneficiary’s expected future medical expenditures is expected to be 50% greater than the base reference group, the Washington SSI disability population. The Washington risk score is based on the Chronic Illness & Disability Payment System and Medicaid-Rx risk groupers developed by Xxxx Xxxxxxx and Xxxx Xxxxxx at the University of California, San Diego, with risk weights normalized for the Washington Medicaid population. Diagnoses, prescriptions, age, and gender from the beneficiary’s medical claims and eligibility history for the past 15 months (24 months for children) are analyzed, a risk score is calculated and chronic conditions checked across all categorically needy populations, and a clinical indicator (Y=qualifies; N=does not qualify) is loaded into the Washington Medicaid Management Information System (MMIS). Potentially eligible beneficiaries with insufficient claims history may be referred to the program by contacting the Washington Health Care Authority (HCA). A tool has been developed to manually calculate risk. This tool will be on the health home website and distributed to the designated providers. Once a provider has determined a beneficiary is eligible by manually calculating their risk that information will be sent to HCA for further analysis. If the beneficiary is eligible, he or she will be enrolled into a health home.
