Special Case Managed Members
Policy/Procedure Number: MCUP3039 (previously UP100339)Lead Department: Health ServicesPolicy/Procedure Title: Special Case Managed Members?External Policy ? Internal PolicyOriginal Date: 04/25/1994Next Review Date:03/11/2021Last Review Date:03/11/2020Applies to:? Medi-Cal? EmployeesReviewing Entities:? IQI? P & T? QUAC? OPerations? Executive? Compliance? DepartmentApproving Entities:? BOARD? COMPLIANCE? FINANCE? PAC? CEO? COO? Credentialing? DEPT. DIRECTOR/OFFICERApproval Signature: Robert Moore, MD, MPH, MBAApproval Date: 03/11/2020RELATED POLICIES: MCUP3041 – TAR Review ProcessMCCP2024 – Whole Child Model for California Children’s Services (CCS)MCUP3104 – Major Organ TransplantsMCUP3020 – Hospice Service GuidelinesMCUP3103 – Coordination of Care for Members in Foster CareMCUP3033 – Out of Area Emergency AdmissionsMCUP3051 – Long Term Care SSI RegulationCGA024 – Medi-Cal Member Grievance SystemIMPACTED DEPTS: Health ServicesMember ServicesClaimsDEFINITIONS: N/AATTACHMENTS: N/APURPOSE:To define criteria for members who meet special case managed status.POLICY / PROCEDURE: Special case managed members are those whose service needs are such that inclusion in the Partnership HealthPlan of California (PHC) capitated case management system would be inappropriate. Assignment to special case managed status may be based on the member’s medical condition, prime insurance, demographics or administrative eligibility status. As of January 1, 2019, PHC assumed responsibility for authorizing and coordinating care for California Children’s Services (CCS) eligible conditions under the Whole Child Model (WCM). To maximize the patient-provider relationship and to best coordinate care, these members are assigned to a medical home. The provider identified as the child’s medical home is responsible for managing the child’s primary care needs and coordinating specialty services. WCM/CCS children do not require a Referral Authorization Form (RAF) to see a specialist. Services for special case managed members will be paid on a fee-for-service basis based upon prevailing PHC rates. The Treatment Authorization Request (TAR) system will be in place for all PHC services that require the use of a TAR. Generally, members become eligible for special case managed status either due to a specific clinical condition or due to a specific administrative service category.PHC Special Member DesignationSpecial Member TypeCriteriaDefault1New MemberUpon becoming eligible to PHC, new members will have up to 30 calendar days to select a primary care provider (PCP). During the interim, the member will not be assigned to a PCP or a case managed pool unless the member has selected a PCP in advance. Default2Member no longer eligible for a Health Services (HS) special member designation.Members who no longer qualify for Health Services special member status such as CCS, LTC or HP 5 are placed in Default 2 for one month if the member cannot be relinked, family-linked or assigned based on claims data.Default4Members who no longer have prime insurance status (HP 12, 20, 21, 24)Members who no longer qualify for prime insurance coverage status are placed in Default 4 for one month if the member cannot be relinked, family linked or assigned based on claims data.HP 1Emergency & Pregnancy Only OBRA Aid codesThe member is assigned the first day of the month the member becomes eligible for limited services (OBRA) related to pregnancy and/or emergency treatment. Members have aid code 58, 5F, 5G, 5N, C1, C3, C5, C7, C9, or D8. Dialysis may be covered, TAR required. The member is removed on the first day of the month following loss of OBRA status. OBRA aid codes apply to Solano, Napa and Yolo Counties only.HealthWCM0001 - 0004CCS Members Who Do Not Have a Medical HomeIf a WCM child has not been assigned to a medical home, they will be assigned as follows:HEALTHWCM 0001- Solano, Marin and Sonoma CountiesHEALTHWCM 0002- Lake, Mendocino and Northern Region CountiesHEALTHWCM 0003- Napa CountyHEALTHWCM 0004- Yolo CountyKaiser prime members assign to Kaiser MH and place on S members with other health coverage are placed in HealthWCM and placed on review.HP 3HP 3 cont’dAcquired Immune Deficiency Syndrome (AIDS)Members approved when the 2008 CDC criteria for AIDS is met. Effective date is the day of PHC notification.For Kaiser members, PHC does not remove from Kaiser assignment, however, a change in affiliation is made. The affiliation will change on the first day of the month if PHC is notified by the 15th day of the previous month. If PHC is notified after the 15th day of the month the affiliation will commence on the first day of the month after the next month. cont’dException: Kaiser prime members that meet the HIV criteria are not moved to the Kaiser HIV affiliation until the member’s Kaiser prime insurance is no longer active. Assignment to the Kaiser HIV affiliation would occur the month following PHC’s notification of the termination of the Kaiser prime insurance.HP 4Not in use for the Medi-Cal program.HP 5Continuity of Care, Transplants, and Sonoma Members approved CONTINUITY of CARE:The PHC Medical Director has the discretion to place members with complex medical conditions into special member status because of the member’s need for continuity of care. Criteria for inclusion as a special member, for continuity of care, is based upon:1.The member’s eligibility to PHC should be relatively recent. The member requires ongoing care from out-of-area specialist(s) for appropriate management of his (her) complex medical conditions and discontinuation of this care from the out-of-area specialist(s) would be detrimental for the member’s health. Referrals to specialty care by an in-plan PCP does not meet the member’s health care needs.The out-of-area specialist accepts the additional responsibility of Primary Care Provider.Transgender member or member with gender dysphoria requiring primary care with clinician with expertise in this area.The member’s need for special member status under Health Plan 5 is generally required for 12 months or less.Member will be removed when the member’s needs for continuity of care have been met.Sonoma Members Approved for House CallsSonoma Members approved for House Calls (a St. Joseph’s System Provider Group) House Calls is a provider group that provides care for home bound patients.TRANSPLANTSSOLID ORGAN TRANSPLANTS:Member is approved upon notification from a Medi-Cal designated transplant facility that the member has completed the evaluation process and is currently listed and waiting a solid organ transplant. Exception: See HP 38. Members on dialysis awaiting a kidney will stay in HP 38 until transplanted. Heart transplant recipients are granted HP 5 for plan lifetime.BONE MARROW TRANSPLANT:Member is approved upon notification from a Medi-Cal designated transplant facility that the member has completed the evaluation process, a donor match has been found and is currently listed and waiting transplant.Member becomes eligible for assignment to a PCP one year after receiving the transplant but may qualify for continued HP 5 based on continuity of care criteria above.HP 6HospiceMembers are approved the day the member signs the hospice election form and continues in this category as long as their care is provided by a hospice program.HP 7Foster Care (FC) and Special Needs (DDS) children.All foster care (FC) and other special needs.California Department of Developmental Services (DDS) members in or out of county that have one of the following aid codes: 03, 04, 06, 07, 2P, 2R, 2S, 2T, AND 2U, 40, 42, 43, 45, 46, 49, 4A, 4F, 4G, 4H, 4K, 4L, 4M, 4N, 4S, 4T, 4U (eff. 11/01/15), 4W and 5K) (Special needs DDS A/C 6W and 6V). Solano, Napa or Yolo county FC members assigned to PCP prior to September 1, 2011 remain assigned to a PCP and have the option to move to a special member status. HP 8Out of AreaMembers are approved the day the member establishes residence out-of-county for a 3 month period. If the member is an inpatient in an out-of-county hospital, the member is eligible the day the member moved out of county. Exception: Members in an inpatient Drug/Rehab facility will be temporarily placed in HP 8 if the facility is out of the resident county.HP 9Long Term Care (LTC)AND Long Term Care Psychiatric PatientsLTC:Member approved the day of admission to SNF or LTC facility. Kaiser members, assignment remains to Kaiser for the month of admission and the following month. If at the end of this time frame the member remains in Skilled Nursing Facility (SNF) and meets PHC criteria for LTC, the member will then be taken out of Kaiser cap and placed into this category. Kaiser members with Kaiser prime insurance are not moved to HP 9. Kaiser Commercial members are moved to HP 24 the 3rd month following admission.Kaiser Senior Advantage members are placed in HP 24 3rd month following admission if member is not at a skilled level of care.Kaiser Senior Advantage members receiving skilled level of care are placed in HP 24 on the 101 day of placement or any time after the 3rd month of placement that they no longer qualify for a skilled level of care. LTC Psychiatric:The member is approved on the date the member is admitted to a long term care psychiatric facility. The member is removed on the first day of the month following discharge and is re-linked to the previously assigned PCP at this time. HP 10Retroactive MembersThe member is approved the first day of the month, the member becomes retroactively eligible with PHC. The member is removed and assigned to a PCP on the first day of the month after the retroactive period. HP 11DeceasedThe member is approved on the date of death plus one day.HP 12EFMP/Tricare/ ChampusThe member is approved on the first day of the month that PHC is notified that the member is Exceptional Family Member Program (EFMP)/Tricare/Champus eligible. The member is removed from HP 12 on the first day of the month following the date the member’s EFMP/Tricare/Champus eligibility ends.HP 13Newborn (mother not capitated)The member is approved on the date of birth. The member is removed on the first day of the third month following the date of birth.HP 14AdministrativeMembers placed in HP 14 for any of the reasons below:Have a Pope Valley, Potter Valley, or a Sea Ranch address orQualify for special member status due to a state fair hearing decision, or County expansion Members that exceed a 30 mile radius from the nearest PCPHP 15NO LONGER IN USE as of 9/1/03 Merged with HP 5HP 16Napa State HospitalThe member is approved on the date of admission to Napa State Hospital. The member is removed on the first day of the month following discharge from Napa State Hospital.HP 17Not in useHP 18Native Americans - Redding Rancheria Liberty siteNative American Indian – Redding Rancheria Liberty SiteAs of 9/1/2019:Healthrurl 0018 is used only for Native American Members and/or their family members receiving services at Redding Rancheria Liberty site. Assignment to Healthrurl 0018 requires Redding Rancheria approval.All other HP 18 i.e. Healthplan 0018, Healthnapa 0018 etc. are no longer used.HP 19HP 19 cont’dGeneral Member Service ANDPrenatal Care 28+ weeksGMSThe member is approved on the first day of the month of assignment to this category, at the discretion of the PHC Member Services Director, under the following circumstances:The member has an appointment with a physician for primary care services other than the member’s assigned PCP, andThe member was assigned to a PCP inappropriately due to an error in the assignment process.Other criteria making special member status appropriate (must be approved by the PHC Member Services Director and the Chief Medical Officer or physician designee.) cont’dThe member is removed when the member no longer qualifies, based on the criteria listed above. Prenatal CareThe member is approved the first of the month that PHC is notified of eligibility with PHC under the following conditions:The member is 28 weeks pregnant or more on the date of eligibility with PHC,The member has been regularly cared for by an obstetrical provider prior to eligibility with PHC, and;The member wishes to continue her care and requests during her pregnancy to continue with her established obstetrical provider for the duration of her pregnancy. The member is removed on the first day of the month following 60 calendar days from the delivery date.If the member is not made HP 19, the member would be required to change OB providers due to PCP and hospital linkages.HP 20Sonoma, Marin, Mendocino, and ShastaMedi-Medi members Effective the date member has Medicare Part A or Part B or both Part A and Part B status. Moved out of HP 20 the day they no longer have any Medicare status. Exception: Medi-Medi members can be assigned to Kaiser with or without Kaiser Prime with Kaiser approval.HP 21Continuous Insurance Premium Program (CIP)The member is approved on the first day of the month of notification that the member is eligible for CIP and the Health Services Department determines that the member’s medical condition warrants continued eligibility for this program. If the member is in HP 21, the member’s health insurance premium is paid by PHC. The HS Director monitors HP 21 members periodically. The member is removed on the first day of the month after the member no longer meets criteria for eligibility.HP 22Genetically Handicapped Persons Program (GHPP)The member is approved on the date PHC is notified from the state that the member has been included on the GHPP list. The member is removed on the first day of the month that the member is no longer eligible for GHPP. HP 23NO LONGER IN USE as of 9/1/03Merged with HP 9HP 24Other InsuranceThe member is approved on the first of the month of notification or identification that the member has other health insurance. The member is removed on the first day of the month that the other insurance ends. In this situation, since PHC is the “payer of last resort”, the other insurance is always the primary payer.Includes members who have prime insurance and are placed in an LTC. Also includes Kaiser prime members in counties that do not have a PHC contracted facility or live in a Kaiser excluded zip code.HP 25No longer in use HP 26Unmet Share of Cost (SOC)INELIGIBLE SHARE OF COST MEMBERS. When the member is in HP 26, the member is not eligible for services under PHC and PHC is not financially responsible for this member. When the member has met the share of cost, the member is removed from HP 26 and becomes eligible for HP 10 (retroactive eligibility). HP 27Long Term Care Resident with aid code 53, 55, D2 through D7 aid codes.The member is approved on the day the member is admitted to a long term care facility. The member is removed on the first day of the month that the member is discharged from the LTC facility or the member no longer has aid code 53. Aid codes 55 and D2 - D7 limited to LTC, ER, and pregnancy related services. These aid codes apply to Solano, Napa and Yolo County members.HP 28Long Term Care aid code not in LTC (13, 23, 63)Member with long term care (LTC) aid code, but not in LTC facility. Members that have Kaiser prime are placed in HP 24. HP 29DuplicatesThe member is approved on the day the member becomes eligible under more than one name or membership number. PHC pays for services under the valid member number.HP 30No longer in useHP 31No longer in use HP 32Holderman PatientsThe member is approved on the date of admission to Holderman facility. The member is removed on the first day of the month following discharge from the Holderman facility.HP 33No longer in use HP 34No longer in use HP 35No longer in use HP 36No longer in use HP 37No longer in use HP 38End Stage Renal Disease (ESRD)Members approved when the Medicare definition for ESRD is met. Effective date is the actual date of the first outpatient hemo/ peritoneal dialysis treatment. Exception: See HP 9HP 39Breast / Cervical CancerA member is placed in HP 39 when the member has Single aid code of: 0U, 0T, 0R or member has multiple aid codes and one of them is: 0U, 0T, 0R, 0P, 0N, 0WHP 40Continuity of Care due to large PCP contract termination?Used at the discretion of HS and Large Provider Term Workgroups.?As of 2/5/2020 only available for HEALTHYOLO 0040 & HEALTHRURL 0040HP 41Continuity of Care due to large PCP contract termination for WCM?Used at the discretion of HS and LG Provider Term Workgroups.?As of 2/5/2020 only available for HEALTHYOLO 0041 & HEALTHRURL0041Other ConsiderationsWhen conversion to special case managed status is approved, it will be done so for a time-limited or condition-limited (e.g., pregnancy) interval. After the interval has elapsed, the case will be reconsidered, and the member removed from special case managed status if circumstances warranting this status no longer exist.The Medical Director may review other cases where the circumstances of the clinical condition may warrant consideration of the status change by the HealthPlan. The Chief Medical Officer or Physician Designee will consult with other specialty physicians as needed to complete the review. Members or their physicians may request consideration for special case managed status. Member requests will be processed through Member Services and reviewed by the Health Services staff. Physicians must complete a Special Case Management Provider Request for Status Change form on behalf of their members. The HS staff will contact the providers as necessary to obtain medical documentation. Each case will be reviewed by the Chief Medical Officer or Physician Designee. Members may appeal the decision by the process in policy CGA-024 Medi-Cal Member Grievance System.Appeals submitted only for determination regarding HP 5 Continuity of Care status will go through the physician review process.The Health Services staff will notify the provider and the member of the decision. If the request is denied, the reasons will be outlined in the letter to the provider. If the request is approved, an alternate provider will be identified and notified concerning the PHC procedures for obtaining TAR services. The member will be encouraged to obtain all care from the alternate provider.The Health Services Department will encourage all special members to utilize the PHC network.The special member will receive a letter with his/her new ID card from the Member Services Department. The Member I.D. Card will reflect Partnership HealthPlan of California as PCP and an alternate provider, if indicated.Agencies/facilities will continue to provide the direct case management activities as mandated by state, federal and regulatory agencies.REFERENCES: Medi-Cal Aid Codes Master ChartDISTRIBUTION: PHC Department DirectorsPHC Provider ManualPOSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health ServicesREVISION DATES: Medi-Cal 03/01/95; 10/10/97 (name change only); 6/14/00; 8/15/00; 11/20/00; 03/07/01; 10/17/01; 11/11/03; 03/10/04; 02/08/05; 10/10/06; 11/19/08; 08/18/10, 06/19/13; 03/18/15; 03/16/16; 01/18/17; *02/14/18; 03/13/19; 03/11/20*Through 2017, Approval Date reflective of the Quality/Utilization Advisory Committee meeting date. Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date.PREVIOUSLY APPLIED TO:N/A*********************************In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with involvement from actively practicing health care providers and meets these provisions:Consistent with sound clinical principles and processesEvaluated and updated at least annuallyIf used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be disclosed to the provider and/or enrollee upon requestThe materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under PHC.PHC’s authorization requirements comply with the requirements for parity in mental health and substance use disorder benefits in 42 CFR 438.910. ................
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