Medically Frail Determination Clause Samples

Medically Frail Determination. The Contractor shall utilize the Milliman Medical Underwriting Guidelines (“Milliman Guidelines”) to determine a medically frail designation, a HIP member may be designated as medically frail at any time during the member’s twelve (12) month benefit period, provided such designation is supported by the Milliman Guidelines. In accordance with Section 7.2.3, the Contractor shall conduct an initial health needs screening of all new members within ninety (90) calendar days of a new member’s enrollment in the Contractor’s plan. The initial health needs screening shall be followed by a detailed comprehensive health assessment conducted by a health care professional in order to gather applicable information to compare against the Medical Underwriting Guidelines. The comprehensive health assessment may include a full review of important relevant clinical information such as the provider’s assessment of conditions and the severity of illness, treatment history and outcomes, other diseases, illnesses, and health conditions as well a review of the member’s available claims, including pharmacy claims. The Contractors shall apply the Milliman Guidelines to either the information obtained in the initial health needs screening and comprehensive health assessment, or the member’s claims history to generate debit points for the member. The member would qualify as medically frail based on the member’s qualifying conditions and related risk scores as follows:  150 debit points for combined indicated medical, behavioral health and substance abuse conditions;  75 debit points for indicated behavioral health conditions;  75 debit points for indicated substance abuse conditions; or  Needs assistances with one of the activities of daily living. Either the member, provider or the Contractor may initiate a medically frail assessment during the member’s benefit period. The Contractor shall establish a process to allow members to self-identify as medically frail to the Contractor. If requested by the member, the Contractor shall conduct a medically frail assessment in accordance with this Section 3.3.2.2 within thirty (30) days of the member’s self-identification. If the results of applying the Milliman Guidelines supports a medically frail designation, the Contractor shall document and support the decision. Documentation may include, but is not limited to (i) output files from the Milliman Renewal MUGs tool indicating the number of debit points the member accumulated; (ii) compl...
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