Evaluación medioambiental

Contractor shall continue to cover and ensure that all Medically Necessary services are provided to Members who must disenroll and receive the following services through the Medi-Cal FFS program until the date of disenrollment is effective.

A. Long Term Care (LTC)

Long-term care (LTC) is defined as care in a facility for longer than the month of admission plus one month. LTC services are not covered under this Contract. Contractor shall cover Medically Necessary nursing care provided from the time of admission and up to one month after the month of admission.

Contractor shall ensure that Members, other than Members requesting hospice services, in need of nursing facility services are placed in a health care facility that provides the level of care most appropriate to the

Member's medical needs. These health care facilities include Skilled Nursing Facilities, subacute facilities, pediatric subacute facilities, and Intermediate Care Facilities. Contractor shall base decisions on the appropriate level of care on the definitions set forth in Title 22 CCR Sections 51118, 51120, 51120.5, 51121, 51124.5, and 51124.6 and the criteria for admission set forth in Title 22 CCR Sections 51335, 51335.5, 51335.6, and 51334 and related sections of the Manual of Criteria for Medi-Cal Authorization referenced in Title 22 CCR Section 51003(e). Upon admission to an appropriate facility, Contractor shall assess the Member’s health care needs and estimate the potential length of stay of the Member. If the Member requires LTC in the facility for longer than the month of admission plus one month, Contractor shall submit a

disenrollment request for the Member to DHCS for approval. Contractor shall provide all Medically Necessary Covered Services to the Member until the disenrollment is effective.

An approved disenrollment request will become effective the first day of the second month following the month of the Member's admission to the facility, provided the Contractor submitted the disenrollment request at least 30 calendar days prior to that date. If the Contractor submitted the disenrollment request less than 30 calendar days prior to that date,

disenrollment will be effective the first day of the month that begins at least 30 calendar days after submission of the disenrollment request. Upon the disenrollment effective date, Contractor shall ensure the Member's orderly transfer from the Contractor to the Medi-Cal FFS program. This includes

Contract Number

Exhibit A, Attachment 11

CASE MANAGEMENT AND COORDINATION OF CARE

notifying the Member and his or her family or guardian of the

disenrollment; assuring the appropriate transfer of medical records from the Contractor to the Medi-Cal FFS provider; assuring that continuity of care is not interrupted; and, completion of all administrative work

necessary to assure a smooth transfer of responsibility for the health care of the Medi-Cal beneficiary.

Admission to a nursing facility of a Member who has elected hospice services as described in Title 22 CCR Section 51349, does not affect the Member's eligibility for enrollment under this Contract. Hospice services are Covered Services under this Contract and are not long term care services regardless of the Member's expected or actual length of stay in a nursing facility.

B. Major Organ Transplants

Except for kidney transplants, major organ transplant procedures that are Medi-Cal FFS benefits are not covered under the Contract. When a Member is identified as a potential major organ transplant candidate, Contractor shall refer the Member to a Medi-Cal approved transplant center. If the transplant center physician considers the Member to be a suitable candidate, the Contractor shall submit a Prior authorization Request to either the San Francisco Medi-Cal Field Office (for adults) or the California Children Services Program (for children) for approval. Contractor shall initiate disenrollment of the Member when all of the following has occurred: referral of the Member to the organ transplant facility; the facility's evaluation has concurred that the Member is a candidate for major organ transplant and, the major organ transplant is authorized by either DHCS' Medi-Cal Field Office (for adults) or the California Children Services Program (for children).

Contractor shall continue to provide all Medically Necessary Covered Services until the Member has been disenrolled from the plan.

Upon the disenrollment effective date, Contractor shall ensure continuity of care by transferring all of the Member's medical documentation to the transplant physician. The effective date of the disenrollment will be retroactive to the beginning of the month in which the Member was approved as a major organ transplant candidate. The request for reimbursement for services in the month during which the transplant is approved are to be sent by the provider directly to the Medi-Cal FFS fiscal intermediary. The capitation payment for the Member will be recovered from the Contractor by DHCS.

Contract Number

Exhibit A, Attachment 11

CASE MANAGEMENT AND COORDINATION OF CARE

If the Member is evaluated and determined not to be a candidate for a major organ transplant or DHCS denies authorization for a transplant, the Member will not be disenrolled. Contractor shall cover the cost of the evaluation performed by the Medi-Cal approved transplant center. 19. Immunization Registry Reporting

Contractor shall ensure that member-specific immunization information is periodically reported to an immunization registry(ies) established in the

Contractor’s Service Area(s) as part of the Statewide Immunization Information System. Reports shall be made following the Member’s initial health assessment and all other health care visits which result in an immunization being provided. Reporting shall be in accordance with all applicable State and Federal laws. 20. Erectile Dysfunction (ED) Drugs and Other ED Therapies

Erectile dysfunction drugs and other ED therapies are excluded from this Contract. These excluded drugs include all drugs used for the treatment of ED that are listed in the Medi-Cal Pharmacy Provider Manual in the Erectile

Dysfunction Treatment Drug listings. The drugs listed in the Medi-Cal Pharmacy Provider Manual are not reimbursed by the Medi-Cal Fee-For-Service program. Contractor shall assist Members requiring ED drugs or therapies in locating available treatment service sites and arranging for referral for appropriate

services. Contractor shall continue to cover and ensure the provision of primary care and other services unrelated to the ED drugs or ED therapies and

coordinate services between the primary care providers and the treatment programs.

21. Waiver Programs

DHCS administers a number of Medi-Cal Home and Community Based Services (HCBS) Waiver programs authorized under Section 1915(c) of the Social

Security Act. Contractor shall have procedures in place to identify Members who may benefit from the HCBS Waiver programs, and refer Members to the agency administrating the waiver program. These waiver programs include, but are not limited to, the nursing facility/acute hospital waiver. If the agency administering the waiver program concurs with Contractor’s assessment of the Member and there is available placement in the waiver program, the Member will receive HCBS waiver services while remaining enrolled with Contractor. Contractor shall continue comprehensive case management and shall continue to cover all

Medically Necessary Covered Services to the Member. If the Member does not meet the criteria for the HCBS Waiver Program, or if placement is not available,

Contract Number

Exhibit A, Attachment 11

CASE MANAGEMENT AND COORDINATION OF CARE

Contractor shall continue to case manage and provide all Medically Necessary covered Services to the Member.

Contract Number Exhibit A, Attachment 12

LOCAL HEALTH DEPARTMENT COORDINATION