Transition of Fee-For-Service Members Sample Clauses
The "Transition of Fee-For-Service Members" clause outlines the procedures and responsibilities involved when individuals who previously received healthcare services on a fee-for-service basis are moved to a different payment or care model, such as managed care. This clause typically details how member information is transferred, how continuity of care is maintained during the transition, and the timelines for completing the process. Its core function is to ensure a smooth and coordinated shift for members, minimizing disruptions in care and clarifying obligations for all parties involved.
Transition of Fee-For-Service Members. Providing care coordination for prescheduled health services and existing care treatment plans, is critical for members transitioning from Medicaid fee-for service (FFS) to managed care. Therefore, MCPs must:
Transition of Fee-For-Service Members. Providing care coordination, access to preventive and specialized care, case management, member services, and education with minimal disruption to members’ established relationships with providers and existing care treatment plans is critical for members transitioning from Medicaid fee-for-service to managed care. MCPs must develop and implement a transition plan that outlines how the MCP will effectively address the unique care coordination issues of members in their first three months of MCP membership and how the various MCP departments will coordinate and share information regarding these new members. The transition plan must include at a minimum:
i. An effective outreach process to identify each new member’s existing and/or potential health care needs that results in a new member profile that includes, but is not limited to identification of:
a. Health care needs, including those services received through state sub-recipient agencies [e.g., the Ohio Department of Mental Health (ODMH), the Ohio Department of Mental Retardation and Developmental Disabilities (ODMR/DD), the Ohio Department of Alcohol and Drug Addiction Services (ODADAS) and the Ohio Department of Aging (ODA)];
b. Existing sources of care (i.e., primary physicians, specialists, case manager(s), ancillary and other care givers); and
c. Current care therapies for all aspects of health care services, including scheduled health care appointments, planned and/or approved surgeries (inpatient or outpatient), ancillary or medical therapies, prescribed drugs, home health care services, private duty nursing (PDN), scheduled lab/radiology tests, necessary durable medical equipment, supplies and needed/approved transportation arrangements. Appendix C Aged, Blind or Disabled (ABD) population Page 13
ii. Strategies for how each new member will obtain care therapies from appropriate sources of care as an MCP member. The MCP’s strategies must include at a minimum:
a. Allowing their new members that are transitioning from Medicaid fee-for-service to receive services from out-of-panel providers if the member or provider contacts the MCP to discuss the scheduled health services in advance of the service date and one of the following applies:
i. The member has appointments within the initial three months of the MCP membership with a primary physician or specialty physicians that were scheduled prior to the effective date of the MCP membership;
ii. The member is in her third trimester of pregnancy and has an...