Full Delegation Model. In the Full Delegation Model, the CONTRACTOR is permitted to delegate the full set of Care Coordination functions to a Contract Provider (the delegate) for an attributable membership, and retains oversight and monitoring functions. The CONTRACTOR is only permitted to fully delegate Care Coordination when Care Coordination is included as part of a VBP arrangement(s) that outlines a payment arrangement for the full delegation of Care Coordination and other requirements associated with improving quality and health outcomes. The CONTRACTOR shall clearly define the terms of the VBP payment and Care Coordination delegation in order to fully delegate Care Coordination to the delegate for the attributed membership. The CONTRACTOR shall ensure the additional Care Coordination delegation requirements in VBP arrangements are met as described in the VBP delivery system improvement target in Attachment 2.A. The CONTRACTOR’s Care Coordination program description shall describe the CONTRACTOR’s roles and responsibilities in attributing membership and providing oversight and monitoring for its Full Delegation model. In establishing its Full Delegation model, the CONTRACTOR shall comply with the requirements in the Managed Care Policy Manual. Shared Functions Model In the Shared Functions Model, when offered, the CONTRACTOR retains some Care Coordination functions and allows other Care Coordination activities to be conducted by a delegated individual or entity. It does not require a VBP arrangement (although it may at the discretion of the CONTRACTOR and the delegated individual or entity). Potential shared Care Coordination functions may include the following: Conducting HRAs; Conducting CNAs; Conducting periodic touch points with Members as needed either in-person or telephonically; Coordinating referrals and linking Members to community services; Locating and engaging with Members categorized as CCL0; and Other functions as prior approved by HCA. The CONTRACTOR shall develop written agreements with individuals and entities that specify shared Care Coordination functions, reporting responsibilities, and a mutually-agreed upon reimbursement rate for shared functions of Care Coordination. The CONTRACTOR shall make good faith efforts to contract with tribal organizations (I/T/Us) for shared Care Coordination functions. The CONTRACTOR shall maintain all oversight and monitoring responsibilities for shared Care Coordination functions with the individuals and entities. The CONTRACTOR shall have written procedures for monitoring and review of shared Care Coordination functions, including how entities and individuals are evaluated for readiness to perform shared Care Coordination functions, how the CONTRACTOR will formally monitor entities and individuals for compliance with shared Care Coordination functions, and how the CONTRACTOR will ensure the quality of Care Coordination for Members served under these arrangements. The CONTRACTOR’s Care Coordination program description shall describe the CONTRACTOR’s roles and responsibilities providing oversight and monitoring for its Shared Functions Model. When offered, the CONTRACTOR shall ensure individuals and entities providing shared Care Coordination have a clear understanding of the delineated roles and responsibilities in its Shared Functions Model of Care Coordination to avoid duplication and gaps in Care Coordination. The CONTRACTOR shall share its Care Coordination policies and procedures with individuals and entities providing shared Care Coordination. The CONTRACTOR shall be responsible for including Member outcomes from the Shared Functions Model in applicable HCA required reports, including but not limited to reporting performance and tracking measures as outlined in Section 4.12 of this Agreement. The CONTRACTOR shall validate the reports from individuals and entities performing delegated Care Coordination functions and include the information in report submissions to HCA. The CONTRACTOR shall provide HCA with the details of the reimbursement agreement for each Shared Functions Model, including provider identification number, effective dates, and payment methodology and amount for the shared functions of Care Coordination. The CONTRACTOR shall submit all payments to individuals and entities performing shared functions of Care Coordination as Encounters (per Section 4.10 of this Agreement) for each Member served by the individual or entity.
Appears in 3 contracts
Sources: Medicaid Managed Care Services Agreement, Medicaid Managed Care Services Agreement, Medicaid Managed Care Services Agreement