Sec. 10.67.04.04. Special Needs Populations

A. An MCO shall provide health care services to enrollees who are members of special needs populations.

B. Special needs populations consist of the following non-mutually exclusive populations:

(1) Children with special health care needs;

(2) Individuals with a physical disability;

(3) Individuals with a developmental disability;

(4) Pregnant and postpartum women;

(5) Individuals who are homeless;

(6) Individuals with HIV/AIDS; and

(7) Children in State-supervised care.

C. General Requirements for Special Needs Populations.

(1) An MCO shall demonstrate that its pediatric and adult primary care providers (PCPs) and specialists are clinically qualified based upon generally accepted community standards to provide or arrange for the provision of appropriate health care services to individuals who are members of a special needs population. The MCO shall submit to the Department referral protocols that demonstrate the conditions under which PCPs will make the arrangements for referrals to specialty care networks.

(2) Clinical qualifications are to be determined through the MCO's credentialing and recredentialing processes, including a review of the provider's medical education, special training, and work history and experience.

(3) Specialty and subspecialty providers shall:

(a) Have experience in treating individuals within a special needs population;

(b) Have experience in interdisciplinary medical management; and

(c) Understand the relationship between somatic and behavioral health care issues and interventions.

(4) The MCO shall demonstrate the use of a primary care system of care delivery which includes a comprehensive plan of care for an enrollee who is a member of a special needs population and which uses a coordinated and continuous case management approach, involving the enrollee and, as appropriate, the enrollee's family, guardian, or caregiver, in all aspects of care, including primary, acute, tertiary, and home care.

(5) To meet the commitment outlined in §C(4) of this regulation, an MCO shall:

(a) Provide case management services to adult and pediatric enrollees as appropriate;

(b) Have the capacity to perform home visits as part of the ongoing case management program and have the ability to respond to urgent care needs while in the enrollee's home;

(c) Ensure that, if warranted, a case manager is assigned to an enrollee at the time of the initial health screen by the MCO;

(d) Ensure that the PCP, who may also be the specialist, shall be the admitting or referring provider for all hospital admissions;

(e) Ensure that it will:

(i) Collaborate with inpatient facilities in facilitating preadmission and discharge planning, and

(ii) Communicate all post-discharge home and community arrangements to the enrollee, the PCP, and, as appropriate, the enrollee's family, guardian, and caregiver;

(f) Document the plan of care and treatment modalities provided to enrollees in special populations, assuring that the plan of care:

(i) Is updated at least annually, when the enrollee’s circumstances or needs change significantly, or at the enrollee’s request; and

(ii) Involves the enrollee and, as appropriate, the enrollee's family, guardian, and caregiver in care decisions; and

(g) Be familiar with community and social support providers for the special populations.

(6) An MCO shall make documented outreach efforts to contact and educate enrollees who fail to appear for appointments or who have been noncompliant with a regimen of care. These efforts may include, but may not be limited to, notification:

(a) By mail;

(b) By telephone;

(c) By email;

(d) By text messaging; and

(e) Through face-to-face contact.

(7) Referral to Local Health Department.

(a) An MCO shall make a written referral, or ensure that the enrollee's provider makes a written referral, to the local health department (LHD) for the county in which an enrollee resides, for assistance in bringing into care an enrollee for whom the MCO has been unsuccessful in its documented out-reach efforts pursuant to §C(6) of this regulation, within 10 business days of whichever first occurs:

(i) The third consecutive missed appointment; or

(ii) The MCO or the enrollee's provider identifies the enrollee's repeated noncompliance with a regimen of care.

(b) The MCO may not include information about an enrollee's HIV status on the form used to refer an enrollee to the local health department.

(8) An MCO shall subject its decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested, for an enrollee who is a member of special needs population to utilization review that includes review by a health care professional who has appropriate clinical expertise in treating the enrollee's condition or disease.

(9) An MCO shall identify a special needs coordinator, who shall:

(a) Serve as a point of contact for health care services information and referral for members of special needs populations;

(b) Be skilled in communications with, and sensitive to the unique needs of, members of special needs populations, their families, guardians, and caregivers;

(c) Participate on the MCO's consumer advisory board, pursuant to Regulation .12 of this chapter, as a representative of special needs populations;

(d) Serve as a resource to MCO providers and enrollees on the requirements of P.L. 101-330, Americans with Disabilities Act of 1990, 42 U.S.C. §12101 et seq.; and

(e) Maintain a log of each denial of treatment and the outcome of the utilization review conducted pursuant to §C(8) of this regulation.

(10) An MCO shall have mechanisms in place to allow enrollees with special health care needs to access a specialist directly as appropriate for the enrollee’s condition and identified needs.