UCare Connect + Medicare Care Coordination Requirement Grid Updated

UCare Connect + Medicare Care Coordination Requirement Grid Updated 1.1.18 The assigned Care Coordinator (CC) must meet the required definition of a qualified professional. Care coordination services incorporate complex case management and consist of a comprehensive assessment of the member s condition, the determination of available benefits and resources, the development and implementation of an individualized care plan with performance goals, and monitoring and follow-up, as described in the grid below. Community Non-Waiver Members Community Waiver Members Institutionalized Members Initial Assignment Initial Contact with Member/ Unable to Reach or Refusal Upon receiving the monthly enrollment roster, the CC is required to: Look each member up in MN-ITS to determine the type of assessment. Contact the member within 30 Contact the member within 30 days days of enrollment date to of the enrollment date to complete a complete a Health Risk Health Risk Assessment (HRA). Assessment (HRA). The CC The CC makes a minimum of four makes a minimum of four attempts to contact the member. attempts to contact the member. Contact may be by letter (using the Contact may be by letter, (using Unable to Contact letter on the Unable to Contact letter on UCare s website- each letter counts UCare s website- each letter as one attempt), face-to-face, or by counts as one attempt), face-toface, phone on different days, at different or by phone, on different times. days, and at different times. Example: Example: Plan A-3 calls and a letter Plan A-3 calls and a letter Plan B-1 call and 3 letters Member records should show documentation of the 4 attempts Plan B-1 call and 3 letters Member records must show documentation of the 4 attempts that were made with the member. Contact the member and/or SNF staff to arrange a face-to-face visit within 30 days of the enrollment date. 1

Initial Assessment that were made. If the CC is unable to contact the member or the member refuses an assessment within the 30 days of enrollment date, or within 365 days from the last assessment, the CC is required to: Enter a refusal in MMIS. Add the member to the Monthly Activity Log as a refusal and return to UCare by the 20 th day of the following month. Complete a face-to-face HRA within 30 calendar days of the enrollment date using the UCare Connect + Medicare HRA form. When completing the HRA, all questions and sections must be acknowledged and completed, using not applicable as appropriate. Determine the HS code based on member need/risk and agreement to care coordination services. Track the HRA on the Monthly Activity Log and submit the log to UCare by the 20 th day of the If the CC is unable to contact the member or the member refuses an assessment within 30 days of the enrollment date, or within 365 days from the last assessment, the CC is required to: Enter a refusal in MMIS. Add the member to the Monthly Activity Log as a refusal and return to UCare by the 20 th day of the following month. Contact the Waiver CM and request a copy of the waiver assessment and signed POC. o Complete the CCDB assessment form by reviewing these documents with member via telephone or face-to-face. If unable to obtain the waiver assessment and POC, complete the CCDB assessment and the UCare Connect + Medicare low needs POC forms face-to-face within 30 days of the enrollment date. Send completed CCDB assessment Review the facility s MDS assessment and obtain copy of the signature page and POC for member s records. Document review of the assessment and other pertinent information on the Institutional Care Coordination Document (ICCD) form. Complete ICCD form in its entirety. Make a face-to face contact with the member. Document any discussion with the facility if modifications are needed to the POC. Enter the appropriate fields from the 2

following month. This includes returning to UCare any members who refused or are not appropriate for care coordination. Enter the HRA into MMIS by the 10 th day of the following month. If an HRA is requested by the member, the member s rep, or other party, it must be completed within 10 calendar days of the request. The assessment must be conducted faceto-face unless a telephonic HRA is approved by UCare. and POC to the PCP and Waiver CM. Track the HRA on the Monthly Activity Log and submit the log to UCare by the 20 th day of the following month. Return to UCare any member on a Waiver. Enter the HRA into MMIS by the 10 th day of the following month. ICCD form into MMIS. Track the HRA on the Monthly Activity Log and submit the log to UCare by the 20 th day of the following month. Return any institutionalized member to UCare. Product Change- this is when a member moves from Connect Regular or Expansion to Connect + Medicare, and vice versa. Entry of If there is a change in CC due to a product change, the existing (sending) CC is required to: Send a copy of the HRA and POC, and relevant case notes to the new (receiving) CC. The new (receiving) CC is required to: Provide the member with the name and telephone number of the new CC within 10 days of the assignment. This may be done by phone or letter (using the approved letter on UCare s website), and must be documented in the case record. Obtain and review the HRA and POC from the previous (sending) CC. Review the POC and update as necessary. If unable to obtain a completed HRA and POC that was completed within the last 365 days, or if there has been a change in condition, the CC is required to complete a new HRA and POC face-to-face. Enter the assessment into MMIS. Document all product change assessments on the Monthly Activity Log. 3

assessments on Monthly Activity Log Admission to a Nursing Facility from the Community Comprehensiv e Plan of Care (POC) Enter all assessments and refusals on the Monthly Activity Log. Submit the Monthly Activity Log to connectintake@ucare.org by the 20 th calendar day of the following month. If a member is admitted to a Nursing Facility and their stay is expected to be less than 90 days, keep the member open to care coordination. If it is expected that the member will be admitted for greater than 90 days, the CC is required to return the member to UCare via the Monthly Activity Log. UCare Responsibilities: Complete all Preadmission Screening and Resident Review (PASRR) activities. Notify the delegate when a PASRR is received. Care Coordinator s Responsibilities: Monitor the daily authorization report for admissions. Assist with transitions and complete a TOC log. Develop and implement a personcentered POC within 30 days of the initial or annual assessment date. This takes into account input N/A Members enrolled in UCare Connect + Medicare who are living in an institutional facility are generally not assigned to ongoing care coordination. However, if member circumstances dictate the need for care coordination assignment, the following will occur: UCare Responsibilities: Complete all Preadmission Screening and Resident Review (PASRR) activities (if not done prior to admission). Notify delegate when a PASRR is received. Care Coordinator s Responsibilities: Monitor the daily authorization Review a copy of the waiver POC if obtained from the waiver CM, and keep a copy in the member record. report for admissions. Assist with transitions and complete a TOC log. Review the POC from the NF if the member is open to care coordination. 4

from the member and/or family members, the member s authorized health care decision maker, Primary Care Physician (PCP), and other interdisciplinary care team members as applicable. The CC develops the personcentered POC using the Care Plan document found on UCare s website. The POC is based on the information collected through telephonic or face-to-face review of the comprehensive assessment with the member or legal guardian, and includes: Member problem list/needs. Discussion of service back-up plan. Prioritized member goals. Member driven interventions to address medical, social, behavioral, educational, and other service needs of the member. Member s strengths and services in place. Measurable outcomes (must be monitored and POC revised as Complete the UCare Connect + Medicare low needs POC form face-to-face within 30 days of assessment date if unable to obtain the waiver assessment and care plan. o Send completed POC to the PCP and Waiver CM. 5

Plan of Care Signature Page necessary) with a target achievement date identified by month/year. Fax a copy of the POC or a POC summary, to the member s PCP and specialist (as applicable) on an annual basis. Communicate updates and changes in the member s condition to the PCC as appropriate. Complete the Personal Risk Management Plan (PRMP) section of the POC when the member refuses services, and document PRMP discussion with member. Obtain a signature from the member or authorized representative on the POC on an annual basis to document that they have discussed their care plan with their CC. o The POC is not considered valid unless signed by the member or authorized representative. If CC is unable to receive the POC from the waiver CM, the CC is required to: Obtain a signature from the member/authorized representative on the UCare Connect + Medicare low needs POC to document that they have discussed their care plan with their CC. o The POC is not considered valid unless signed by the The CC is required to; Review the POC from the NF if the member is open to care coordination. 6

Ongoing Contact with Member and POC Updates Maintain ongoing contact or check-in with the member at a minimum of every 90 days (quarterly) to update the POC which includes documenting monitoring of progress or goal revisions (with date). Contact may be by phone or face-to-face (refer to contact attempt requirements in the unable to reach or refusal section). member/authorized representative. N/A for Community Waiver and Institutional Members. Return the member to UCare via the Monthly Activity Log if the following occur: The CC is unable to reach the member after 2 quarterly attempts. The member opens to a waiver or TCM/ACT services. The member becomes a longterm resident of a nursing facility. 7

Reassessment Complete a face-to-face HRA using the UCare Connect + Medicare HRA form within 365 days of the previous assessment or upon a change in condition. When completing the UCare Connect + Medicare Assessment/ HRA, all questions and sections must be completed or marked as not applicable. Enter the completed HRA in MMIS. Enter the reassessment on the Monthly Activity Log and return to UCare by the 20 th of the month. Update the Date Goal Achieved/Not Achieved column from the previous year s POC with a month and year documented and retain in member s file. Develop a new POC with ongoing and new goals within 30 days of the HRA. Send the POC or POC summary to the PCP and member/rep Contact the Waiver CM and request a copy of the waiver assessment and signed POC. o Complete the CCDB assessment form by reviewing these documents with member via telephone or face-to-face. If unable to obtain the waiver assessment and care plan, complete the CCDB assessment and the UCare Connect + Medicare low needs POC forms face-to-face within 365 days of the previous assessment. Send the completed CCDB assessment and POC to the PCP and Waiver CM. Track the CCDB on the Monthly Activity Log and submit the log to UCare by the 20 th day of the following month. Return to UCare any member on a Waiver. Enter the CCDB into MMIS by the 10 th day of the following month. Conduct a face-to-face reassessment at least once per year (within 365 days of the prior assessment). Review the comprehensive assessment on an annual basis and note this on the ICCD form. Obtain a copy of the nursing home s MDS (including signature page) and POC and keep it in the member s record. Enter the ICCD form into MMIS. Track the HRA on the Monthly Activity Log and return to UCare by the 20th th day of the following month. 8

within 30 calendar days of the HRA. Reassessments When The Member Is In the 90 Day Grace Period After MA Terms Medicaid Eligibility Renewals Advance Directives Transition of Care (TOC) If a member s Medical Assistance (MA) terms, the CC is required to monitor the member for up to 90 days. If their annual reassessment is due during the 90 day term window, the CC is required to: Complete the annual reassessment and maintain in the member s file. Enter the DHS form #3427 into MMIS when the member s MA is reinstated. Enter the assessment on the Monthly Activity Log. Review the UCare Connect eligibility renewal report, provided by UCare, on a monthly basis and remind members when they are at risk of losing Medicaid eligibility due to incomplete or unprocessed Medical Assistance paperwork. The UCare Retention Specialist reaches out to members to see if they need additional assistance with maintaining eligibility. Document on an annual basis that they addressed or discussed advance directives with the member, or; Document the reason why advance directives were not discussed. Assist with the member s planned and unplanned movement from one care setting (e.g., member s home, hospital, and skilled nursing facility) to another care setting. Each movement, when due to a change in the member s health status, is considered a separate transition. Conduct Transition of Care activities and document these activities on the Transitions of Care Log on UCare s website, according to the TOC Log instructions (also on UCare s website). Conduct a reassessment in the event of a care transition that would involve significant health changes, repeated or multiple falls, recurring hospital readmissions or emergency room visits. 9

Coordination with Local Agencies DTR Requirements- Medically Necessary If CC finds out about the transition(s) 15 days or more after the member has returned to their usual care setting, the CC is not required to complete a TOC log, however, the CC is required to: Follow-up with the member to discuss the care transition process, any changes to their health status and plan of care. Provide education about how to prevent readmission, and document this discussion in case notes. Refer to the TOC log instructions on the UCare website for additional instruction. The CC is required to make referrals and/or coordinate care with county social services and other community resources when a member is in need of: Pre-petition screening. Home and Community Based Services (HCBS). County case management for HCBS. Child protection. Court ordered treatment. Case management and service providers for people with DD. Mental Health Targeted Case Management (MH-TCM). Behavioral Health Home. Adult protection services. Assessment of medical barriers to employment. Relocation services. Nursing home, residential, or home care providers. State Medical Review Team or Social Security disability determination. Work with local agency staff or county attorney staff for members who are victims or perpetrators in criminal cases Assessment and evaluation related to judicial proceedings. Assertive Community Treatment (ACT), Intensive Residential Therapy Services (IRTS), or Adult Rehabilitative Mental Health Services (ARMHS.) UCare or one of its utilization review (UR) delegates must review all services that require a medical necessity review. UCare sends a denial, termination, or reduction (DTR) letter to the member any time services that require prior authorization and review of medical necessity according to UCare s prior authorization grid are denied, terminated, or reduced. A DTR of these services requires review and determination by a UCare Medical Director. 10

Services Transfer of Member Between MCO s Member Death Documentation Requirements Policies and Procedures Model of Care The current (sending) CC is required to: Complete the DHS #6037 Home and Community Based Services Case Management Transfer Form and send or fax the form to the new care coordination delegate (receiver) as soon as the enrollment with the new delegate is indicated on the enrollment roster, but no later than the 15 th calendar day of the month. Include the following supporting case documentation with (the DHS form #6037: o Current assessment(s). o POC. o Relevant case notes. The receiving CC is required to: Contact the transferred member within 10 calendar days of assignment, by letter or phone, to introduce the new CC. Review the DHS form #6037, assessments, and current POC with the member and document this review in the member s record. Identify when next assessment is due. Reassessments should be kept on schedule, based on the previous assessment date per MMIS. Complete a new face to face assessment and POC if unable to obtain a copy of the most recent assessment and POC from the previous CC. Notify UCare by completing the Death Notification form found on UCare s website. Complete the DHS #5181 form and send it to the county financial worker. If any of the care coordination requirements were attempted but not completed, the CC is required to document all attempts in the plan of care and/or progress notes. All UCare delegates are required to have policies and /or procedures that support all the above stated requirements. All CCs are required to attend initial Model of Care training within three months of hire. CCs may access this training via 11

Training WebEx contained on the provider page of UCare s website (Connect+Medicare MOC Training). Additionally, UCare will provide in-person Model of Care training to CCs at least annually during quarterly in-person training meetings and webinars. Delegates are required to submit an annual training roster, showing all CCs who attended MOC training, to the UCare Clinical Liaison by the fourth quarter of the year. 12