The adequacy of the Respondent’s description of how its respective disease management program will be incorporated into its overall Case Management approach to advance the CMS Plan’s goals. The extent to which the Respondent’s algorithm and risk stratification approach is well defined and describes the data sources that will be utilized and ensures that all children will receive Disease/Case Management. The extent to which the Respondent describes data sources that are incorporated into the risk stratification process that is used for new enrollees. The extent to which the Respondent’s approach includes the use of predictive modeling. The extent to which the Respondent’s approach includes innovative strategies for addressing the unique needs of highly resistant or difficult to serve populations. The adequacy of the Respondent’s description of evidence-based interventions in achieving improved outcomes and enhancing enrollee engagement. The efficacy of the Respondent’s approach in achieving cost savings, cost avoidance, emergency department diversion, increased utilization of ambulatory care settings, transitioning children out of institutional settings, and diverting institutionalization, etc. The extent to which the Respondent’s case management programs include at least the following components: Assessment; Plan of Care development; Diversion from or transition from institutional care as needed; Solution-oriented follow-up after emergency room or institutional care to identify opportunities for care improvement to prevent re-institutionalization; Identification of gaps in care including accessibility issues; Identification of service to support children in their homes; Symptom management; Medication support; Emotional support; Behavior change; Parent training regarding diagnoses, medications, symptoms; Arranging transportation; Communication with schools in the development of an Individual Education Plan, 504 plan or education plan; and Communication/education with providers, including the PCP/specialists. The extent to which the Respondent has described a methodology for evaluating the impact of the case management programs and provided results/data based on previous experience that supports the reduction of potentially preventable events.
Category Procedure Code Description Procedure/CPT Code Min Age Max Age Current Florida Medicaid Coverage Expanded Benefit Coverage (Units) Emergency and Planned Respite Respite Respite Care-in home Respite Care-out of home S9125-in-home H0045-out of home 0 21 yrs For model and DD waiver enrollees, this is covered via FFS For non-model and DD waiver enrollees, 200 hours a year for in home. 10 days of out of home. Behavioral Health Crisis Stabilization 0910 2 yrs 21 yrs As needed to divert hospitalization, emergency room visits, or prevent placement Modifications to divert institutional stay or home maintenance and home or environmental modifications including vehicle modifications Home maintenance and minor home/environmental modifications s5165 0 21 yrs Only in $5,000 3 years. Housing related supports/supplemental adaptive device or equipment Home helper catalog item 0 21 yrs Not covered 1 item a year.
Housing related supports/supplemental adaptive device or equipment hypoallergenic bedding 0 21 yrs $100 1x credit $100 1x credit Community Behavioral Health Self-Help/Peer H0038 0 21 yrs In lieu of Psychosocial Rehabilitation Mobile Crisis Crisis Intervention S9485; H2011 0 21 yrs As needed to divert hospitalization, emergency room visits, or prevent placement Healthy Behavior Reward Program healthy community reward program 0 21 yrs As outlined in health plan literature submitted in ITN reply Professional consultation between primary care provider and specialist or medical team conference without patient/family present case consultation or 99368 0 21 yrs Limited to 2 per year for team
Family Training family support and education S5110 0 21 yrs 12 visits a year. social determinant of health benefits counseling H2014 SE 0 21 yrs Not covered 3 sessions annually. Partial hospitalization Partial hospitalization H0035 or S9480 (Mental Health), H0015 (Substance Use Disorder), Use of Revenue codes (0172, 0173, 0175, 0176), 0 21 yrs Covered as needed in lieu of inpatient hospitalization Detoxification or withdrawal management in an ambulatory or residential setting Withdrawal management H0010, H0011, H0012, H0014, 0 21 yrs Covered as needed in lieu of inpatient hospital detoxification Drop-in Center Drop-in Center or H2031 16 21 yrs Covered as needed in lieu of clubhouses
Non-medical transport Transportation A0090, A0100, A0110, A0120, A0130, A0170, T2003 0 21 yrs Covered as needed for community integration Nutritional Counseling Nutritional Counseling, diet S9470 0 21 yrs Covered as medically necessary for children with diabetes, Phenylketonuria (PKU) and other metabolic conditions, eating disorders, Obesity, and children at risk of metabolic disorders under EPSDT For wellness counseling for at-risk children Supports for Wellness healthy living coaching 7 yrs 13 yrs 12 visits a year.
Education/Supports for Wellness Miscellaneous therapeutic and supplies, retail purchases, not otherwise classified; identify product in “remarks” T1999 Covered up to $200 per year Housing Supports Pest control Pest Control S5121 0 21 yrs Only available on Project Aids Care Waiver $25 a job/$150 a year. $500 max annually. Social Determinant of Health Financial Counseling Financial counseling T2013 SE 0 21 yrs Not covered 6 sessions annually.
Criteria #55– Provider Network Agreements/Contracts/Essential Providers Provider network agreements/contracts scoring templates are available for Respondents to download at: REMAINDER OF PAGE INTENTIONALLY LEFT BLANK Criteria #56 – Data reporting Respondent will describe its organizational commitment to providing the Department with real-time data dashboards and reporting, including hospital admission and discharge data and emergency room utilization. Reply: Evaluation Criteria: The extent to the Respondent provides examples of dashboards that will be regularly provided to the Department for a data-driven quality improvement cycle. The extent to the Respondent provides the following: An interactive internet-based performance dashboard for Department staff that provides visual displays of key Respondent and system performance measures relative to goals and benchmarks; The dashboard’s compatibility with modern mobile technology (e.g., computers, smart phones, tablets, iPads) that are accessible 24 hours a day, 7 days a week, via mobile technology for identified CMS staff; A secure internet-based portal or application available to identified and trained Department staff for generating standard and ad hoc reports; and Standard reports required under the ITN would be contained the identified portal. Score: This section is worth a maximum of 40 raw points with each of the above components being worth a maximum of 20 points each.