DCS Comprehensive Health Plan

Transition of Members

Statement/Purpose

This policy establishes requirements for members transitioning into and/or exiting the Department of Child Safety Comprehensive Health Plan (DCS CHP).

Definitions

Enrollment Transition Information (ETI): Member specific information the Relinquishing Contractor must complete and transmit to the Receiving Contractor or Fee-For-Service (FFS) Program for those members requiring coordination of services as a result of transitioning to another Contractor or FFS Program.

Member Transition: The process during which members change from one Contractor or Fee-For-Service (FFS) Program to another.

Prior Authorization: A process by which the health plan, authorizes, in advance, the delivery of covered services based on factors including but not limited to medical necessity, cost effectiveness, compliance with this Article and any applicable contract provisions. Prior Authorization (PA) is not a guarantee of payment as specified in A.A.C. R9-22-101.

Policy

Enrollment Transition Information (ETI) - Member specific information the Relinquishing Contractor must complete and transmit to the Receiving Contractor or Fee-For-Service (FFS) Program for those members requiring coordination of services as a result of transitioning to another Contractor or FFS Program.

Member Transition - The process during which members change from one Contractor or Fee-For-Service (FFS) Program to another.

Prior Authorization - A process by which the health plan, authorizes, in advance, the delivery of covered services based on factors including but not limited to medical necessity, cost effectiveness, compliance with this Article and any applicable contract provisions. Prior Authorization (PA) is not a guarantee of payment as specified in A.A.C. R9-22-101.

Procedure

Transition Coordinator

Transition Coordinators are health plan staff members who possess the appropriate education and experience to effectively coordinate and oversee all transition issues, responsibilities, and activities.

The role of the transition coordinator includes:

• Ensuring that transition activities are accomplished in accordance with AHCCCS and health plan policies and procedures;

• Acting as an advocate for members leaving and joining DCS CHP;

• Facilitating communication between health plans and AHCCCS;

• Assisting Primary Care Providers (PCPs), internal health plan departments, and other participating healthcare providers with the coordination of care for transitioning members;

• Ensuring that continuity and quality of care for transitioning members is maintained during health plan transitions; and

• Participating in AHCCCS/health plan transition coordinators’ planning meetings.

Transition Requirements for Relinquishing Health Plan

As the relinquishing health plan, DCS CHP and its contracted MCO ensure that all relevant information regarding the member’s transition is provided to the receiving AHCCCS health plan or FFS program. Due to the special nature of DCS CHP’s member population, an AHCCCS mandated ETI Form is generated and transmitted to the receiving health plan, for all members exiting DCS CHP regardless of the medical complexity of the child, no later than 10 business days from receipt of enrollment change notification. If DCS CHP and the contracted MCO fail to transmit required documentation to the receiving health plan within the established timeframe, DCS CHP is responsible for covering the member’s health care for up to 30 days after the transition from DCS CHP.

DCS CHP and its contracted MCO are responsible for the transfer of pertinent medical records, as outlined in AHCCCS AMPM 520, and arranges for the timely notification to members, subcontractors or other providers, as appropriate during times of transition.

DCS CHP and its contracted MCO resolve pending grievances and notifies the receiving plan of their status.

As children reach the age of 18 years, they are no longer eligible for health care coverage through DCS CHP. DCS CHP requires the contracted MCO to engage in transition age services and coordination which include:

• Transition age services that focus on assisting the member with gaining skills to function as a self-sufficient adult;

• Coordination of behavioral health services which include but are not limited to SMI evaluation at seventeen and a half years of age, and the coordination of services to the adult provider and SMI health plan;

  • Adult system of care team is invited to the CFT and involved in other coordination activities.

• Coordination planning to meet the needs of members with special health care conditions including members with CRS designation;

• Coordination between child and anticipated adult physical and behavioral health providers and other stakeholders.

Transition Requirements for Receiving Health Plan

As the receiving health plan, DCS CHP and the contracted MCO ensure that all members receive the appropriate care coordination.

Members are provided with new membership information on entry into the health plan, in a timely manner including access to the Member Handbook, assignment to a Primary Care Provider, Primary Dental Provider or dental home as well as Behavioral health home.

A Transition Coordinator reviews all incoming ETI Forms for ongoing services, medical diagnoses, special circumstances and previously approved prior authorizations. Previously approved prior authorizations from relinquishing health plans are entered for a minimum period of 30 days from the date of the member’s transition so services are not interrupted.

Timely process of a transition is not delayed because of missing or incomplete information. If notification of a transition is received prior to receipt of the relinquishing health plan’s ETI Form, care coordination efforts begin immediately upon notification.

Members transitioning to DCS CHP are provided with health plan information, emergency numbers and instructions on how to obtain health care services.

The MCO care management team reaches out to caregivers to assist them in scheduling their EPSDT and dental preventative visits within the first 30 days of entering out-of- home care.

The MCO care management team coordinates care for members with special health care needs with the relinquishing health plan in order to have continuity of services. Members with special health care needs are provided, at minimum a 90 day transition period, if they have an established PCP who is not a contracted network provider, in order to transition to an identified alternative network PCP. The MCO provides assistance, if needed in locating a network PCP.

The DCS CHP Resource Liaisons also reach out to members and serve as a resource for caregivers, providing information on dental, medical and behavioral services, as well as transportation and pharmacy information.

Previously approved prior authorizations are extended for a minimum of 30 days from the date of the member entering care.

Members in active treatment (chemotherapy, pregnancy, previously scheduled surgery etc.) with a non-participating provider are allowed to continue receiving treatment from that provider for the duration of their treatment.

All members entering the DCS CHP health plan are referred by the custodial guardian for an Integrated Rapid Response Assessment. This assessment consists of a behavioral health assessment as well as a physical health screening, to be completed within 72 hours of the referral. The evaluation informs and begins the coordination process for the member and is another mechanism used to maintain the continuity of or initiate necessary services for the newly enrolled member.

Transition to Arizona Long Term Care System ALTCS/EPD/DDD

If a member is referred to and approved for Arizona Long Term Care System (ALTCS) enrollment, DCS CHP and its contracted MCO coordinates the transition with the assigned ALTCS plan to ensure applicable protocols are followed for any special circumstances of the member, and that continuity and Quality of Care (QOC) is maintained during and after the transition.

Transition During a Hospitalization

If a member is enrolled in the health plan during a hospitalization, the relinquishing Medicaid health plan is responsible for the coverage of the admission. However, the contracted MCO’s concurrent review staff follow the member on entry into the plan and coordinate with the inpatient facility to ensure a smooth transition.

Transition for Youth Aging out of DCS Care

Youth in DCS care remain with DCS CHP until 18 years of age. DCS CHP’s contracted MCO conducts enhanced care coordination and transition activities to assist Transition Age Youth with significant behavioral health conditions for SMI eligibility and transition to adult services.

All children enrolled in DCS CHP are eligible for age-appropriate transition to adulthood services. DCS CHP supports clinical practice and behavioral health service delivery that is individualized, strengths-based, recovery-oriented, and culturally sensitive in meeting the needs of youth, adolescents, and their families.

Transition for Justice Involved Youth

Youth in detention may have their Medicaid coverage suspended if they are detained on a criminal complaint, however, Medicaid coverage is not suspended in cases where youth are detained on a non-criminal matter such as a violation of probation. DCS CHP’s contracted MCO conducts a justice reach-in program to identify members with chronic and/or complex physical or behavioral health care needs, including substance use disorder. Justice reach-in includes pre and post release coordination of services for these members to ensure that there is successful transition of services from the justice facility to the community or other level of care as appropriate. DCS CHP receives notice, from its contracted MCO, of members who are detained. The DCS CHP System of Care team, together with the contracted MCO System of Care team and the assigned justice liaison, coordinate to facilitate the smooth transition of services for its justice involved youth.

Reporting

Internal monitoring and audits are conducted and reported at the Quality Management/Process Improvement (QM/PI) and/or Medical Management quarterly meetings.

Coordination Meetings

DCS CHP and its Contracted MCO participate in monthly Transition Age Youth (TAY) Rounds to provide care coordination for transition age youth with significant behavioral health issues and potential SMI designation. Through these coordination meetings and subsequent care coordination efforts, DCS CHP monitors the availability and implementation of Evidenced-Based Practices for transition aged youth.

DCS CHP and its Contracted MCO participate in a weekly staffing where members in a state of transition are discussed; this could include new members to DCS CHP or members with a planned transition from DCS CHP enrollment. This staffing includes members with complex health care needs including youth who are hospitalized for physical or behavioral health treatment, members receiving treatment in behavioral health levels of care in need of transition/discharge planning as well as members who may be receiving treatment in an out of state facility. DCS CHP in conjunction with its contracted MCO provide care coordination with all stakeholders to ensure timely and appropriate services are received.