Integration of Care. A. Project case managers are responsible for long-term care planning and at least annual assessments, for developing and carrying out strategies to coordinate and integrate the delivery of all acute and long-term care services to enrollees. B. For those persons enrolled in the contractor's Medicare Advantage plan (where applicable), the contractor must have protocols to ensure that all acute care services and long-term care services are coordinated. The enrollee's case manager must coordinate with the primary care physician, as well as the enrollee or other appropriate person, in the development of acute and long-term care plans. The contractor must ensure that all subcontractors, delivering services covered by the contract, agree to cooperate with the goal of an integrated and coordinated service delivery system for the enrollee. Amendment 001 Agreement Number XQ744 C. When contract enrollees elect to remain in the Medicare fee-for-service system, the contractor must establish protocols to ensure that services are coordinated to the maximum extent feasible. The case manager must actively pursue coordination with the enrollee's primary care physician and other care providers. D. In addition, the contractor will be responsible for the following activities to facilitate care coordination and continuity of care: 1. The contractor must implement a systematic process for generating or receiving referrals and with the enrollee's written consent, sharing clinical and treatment plan information, including management of medications. 2. The contractor must implement a systematic process for obtaining consent from enrollees or their representatives to share confidential medical and treatment-planning information with providers. 3. The contractor must implement a systematic process for coordinating care with organizations which are not part of the contractor's network of providers but are otherwise important to the health and well being of enrollees. 4. For enrollees in an assisted living or nursing facility, the contractor will ensure coordination with the medical, nursing, or administrative staff designated by the facility to ensure that the enrollees have timely and appropriate access to the contractor's providers and to coordinate care between those providers and the facility's providers. 5. The contractor must implement a systematic process for tracking the Medicaid eligibility redetermination dates on a monthly basis to ensure continuity of care without a break in eligibility. E. Pursuant to 42 CFR 438.208(b), the contractor must implement procedures to coordinate health care service for all enrollees that: 1. Ensure each enrollee has an ongoing source of primary care appropriate to his/her needs and a person or entity formally designated as primarily responsible for coordinating the health care services furnished to the enrollee. 2. Coordinate the services the contractor furnishes to the enrollee with services the enrollee receives from any other managed care entity during the same period of enrollment. 3. Share with other managed care organizations serving the enrollee with special health care needs the results of its identification and assessment of the enrollee's needs to prevent duplication of those activities. 4. Ensure in the process of coordinating care, each enrollee's privacy is protected in accordance with the privacy requirements in 45 CFR Part 160 and 164 Subparts A and E, to the extent that they are applicable.
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Integration of Care. A. Project case managers are responsible for long-term care planning and at least annual assessments, for developing and carrying out strategies to coordinate and integrate the delivery of all acute and long-term care services to enrollees.
B. For those persons enrolled in the contractor's ’s Medicare Advantage plan (where applicable), the contractor must have protocols to ensure that all acute care services and long-term care services are coordinated. The enrollee's ’s case manager must coordinate with the primary care physician, as well as the enrollee or other appropriate person, in the development of acute and long-term care plans. The contractor must ensure that all subcontractors, delivering services covered by the contract, agree to cooperate with the goal of an integrated and coordinated service delivery system for the enrollee. Amendment 001 Agreement Number XQ744.
C. When contract enrollees elect to remain in the Medicare fee-for-service system, the contractor must establish protocols to ensure that services are coordinated to the maximum extent feasible. The case manager must actively pursue coordination with the enrollee's ’s primary care physician and other care providers.
D. In ▇. ▇▇ addition, the contractor will be responsible for the following activities to facilitate care coordination and continuity of care:
1. The contractor must implement a systematic process for generating or receiving referrals and with the enrollee's ’s written consent, sharing clinical and treatment plan information, including management of medications.
2. The contractor must implement a systematic process for obtaining consent from enrollees or their representatives to share confidential medical and treatment-treatment planning information with providers.
3. The contractor must implement a systematic process for coordinating care with organizations which are not part of the contractor's ’s network of providers but are otherwise important to the health and well being of enrollees.
4. For enrollees in an assisted living or nursing facility, the contractor will ensure coordination with the medical, nursing, or administrative staff designated by the facility to ensure that the enrollees have timely and appropriate access to the contractor's ’s providers and to coordinate care between those providers and the facility's ’s providers.
5. The contractor must implement a systematic process for tracking the Medicaid eligibility redetermination dates on a monthly basis to ensure continuity of care without a break in eligibility.
E. Pursuant to 42 CFR 438.208(b), the contractor must implement procedures to coordinate health care service for all enrollees that:
1. Ensure each enrollee has an ongoing source of primary care appropriate to his/her needs and a person or entity formally designated as primarily responsible for coordinating the health care services furnished to the enrollee.
2. Coordinate the services the contractor furnishes to the enrollee with services the enrollee receives from any other managed care entity during the same period of enrollment.
3. Share with other managed care organizations serving the enrollee with special health care needs the results of its identification and assessment of the enrollee's needs to prevent duplication of those activities.
4. Ensure in the process of coordinating care, each enrollee's privacy is protected in accordance with the privacy requirements in 45 CFR Part 160 and 164 Subparts A and E, to the extent that they are applicable.
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