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KMAP BULLETIN: KanCare Transitional Care Requirements

Date: 11/30/18

MCO GENERAL BULLETIN 18243 (PDF)

MCO Transitional and Continuity of Care Management Requirements

Definition

Managed care organizations (MCOs) are required to provide transition of care management for all KanCare Enrollees. Specialized care coordination is required for Enrollees whose health care needs are changing for a variety of reasons, including:

  • Changing from one MCO to another
  • Hospital (such as State hospital, ICF-IID) to home or nursing facility
  • Nursing facility to home or home to nursing facility
  • Enrollee assignment to the Home and Community Based Services (HCBS) waiver
  • Enrollee assignment of chronic care management moved from one provider to another
  • Transition to or from KanCare eligibility
  • Transitions for children in Foster Care

For a full description, refer to the Kansas Transition of Care Policy on the Transition of Care page on the KanCare website.

Requirements for Specific Transitions Transition Between MCOs

To ensure the continuity of care during periods of Enrollee transition between MCOs, the following actions must be taken:

  • All MCOs must designate points of contact to aide in MCO-to-MCO outreach during these transitions.
  • “Receiving” MCOs must make outreach to the previous MCO to gather Enrollee provider information and Plans of Care (POCs), as necessary.
  • Receiving MCOs must utilize previous MCO encounter data provided by the State to determine previously utilized Enrollee providers and services.
  • Receiving MCOs must develop or attempt to develop contracts with previously utilized providers to ensure the continuity of care for Enrollees.
    • MCOs must make efforts to preserve existing relationships between providers and Enrollees in which the provider was a main source of Medicaid services for the Enrollee during the previous year.
  • Receiving MCOs must update all relevant documentation and planning. The “original” MCO will have 15 calendar days to provide the documentation.
  • To ensure that the current POC is in place, the POC of the original MCO will be honored for 90 days by the receiving MCO. Services should not change or reduce until after 90 days are over and the initial screening has occurred. This requirement may be waived at the Enrollee’s request. The MCO may include additional services at any time to benefit the Enrollee.
  • To ensure that the current authorization is in place, the original MCO will be honored without change by the receiving MCO until 90 days after the transfer of the Enrollee. This requirement may be waived at the Enrollee’s request. The MCO may include additional services at any time to benefit the Enrollee. This does not include patients who are being discharged from a facility. The inpatient authorization stops with the discharge.
  • Enrollees are entitled to see an established primary care physician (PCP) for six months after their transition, regardless if the provider is “in network” or not.
  • This policy timeframe takes precedence over the KanCare contract stipulations around needs assessment timeframes and Person-Centered Service Plan timeframes for members who transfer from other MCOs and already have a POC associated with their waiver. If the member changes waivers OR is a new KanCare member, the contract timeframes apply.

Transitions Between MCOs When Receiving MCO is New For MCOs that are new to KanCare, there are additional requirements for the first 90 days of their contract with the State of Kansas:

  • Providers who are already enrolled in KMAP and not yet contracted with the MCO will be paid as in network at 100% of the Medicaid fee-for-service (FFS) rate through the first 90 days after the MCO enters the KanCare program. If the provider has applied for credentialing or contracting, and the MCO is not timely due to internal delays with their provider networking process, then the MCO must extend the period during which the provider is deemed in network.
  • Providers who are not yet contracted or credentialed with one or more MCOs do not need to prior authorize (PA) every service during the KanCare transition. During the first 90 days for a new KanCare MCO, participating and nonparticipating providers alike should follow the plan’s service PA/notification policies for participating providers. Except as outlined in the paragraph above, at the end of the 90-day period, noncontracted providers must follow the MCOs regular noncontracted prior authorization procedures.

For all transitions specified above, MCOs must ensure that any sharing of Enrollee information is conducted with the consent of the Enrollee or designated representative and in accordance with State and Federal requirements.