Special Case Managed Members

Policy/Procedure Number: MCUP3039 (previously UP100339) / Lead Department: Health Services
Policy/Procedure Title: Special Case Managed Members / ☒ External Policy
☐ Internal Policy
Original Date: 04/25/1994 / Next Review Date: 03/13/2020
Last Review Date: 03/13/2019
Applies to: / ☒ Medi-Cal / ☐ Employees
Policy/Procedure Number: MCUP3039 (previously UP100339) / Lead Department: Health Services
Policy/Procedure Title: Special Case Managed Members / ☒External Policy
☐ Internal Policy
Original Date: 04/25/1994 / Next Review Date:03/13/2020
Last Review Date:03/13/2019
Applies to: / ☒ Medi-Cal / ☐ Employees
Reviewing Entities: / ☒ IQI / ☐ P & T / ☒ QUAC
☐ OPerations / ☐ Executive / ☐ Compliance / ☐ Department
Approving Entities: / ☐ BOARD / ☐ COMPLIANCE / ☐ FINANCE / ☒ PAC
☒ CEO / ☐ COO / ☐ Credentialing / ☐ DEPT. DIRECTOR/OFFICER
Approval Signature: Robert Moore, MD, MPH, MBA / Approval Date: 03/13/2019

RELATED POLICIES:
MCUP3041 – TAR Review Process
MCCP2024 – Whole Child Model for California Children’s Services (CCS)
MCUP3104 – Major Organ Transplants
MCUP3020 – Hospice Service Guidelines
MCUP3103 – Coordination of Care for Members in Foster Care
MCUP3033 – Out of Area Emergency Admissions
MCUP3051 – Long Term Care Admissions
CGA024 – Medi-Cal Member Grievance System

IMPACTED DEPTS:
Health Services
Member Services
Claims

DEFINITIONS:

N/A

ATTACHMENTS:
N/A

PURPOSE:

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.

Kaiser prime members assign to Kaiser MH and place on review.
CCS members with other health coverage are placed in HealthWCM and placed on review.

Not in use for the Medi-Cal program.

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.

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.

Have a Pope Valley, Potter Valley, or a Sea Ranch address or
Qualify for special member status due to a state fair hearing decision, or
County expansion

The member has an appointment with a physician for primary care services other than the member’s assigned PCP, and
The 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.)

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.

Exception: Medi-Medi members can be assigned to Kaiser with or without Kaiser Prime with Kaiser approval.

Other Considerations
When 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 Chart