1 Tex. Admin. Code § 353.421

Current through Register Vol. 49, No. 48, November 29, 2024

Section 353.421 - Special Disease Management for a Health Care Managed Care Organization

(a) Definitions. The following words and terms, when used in this section have the following meanings, unless the context clearly indicates otherwise.

(1) Active participation--One or more encounters in a calendar year, either face-to-face or by an approved telehealth modality, between the disease management staff of a health care managed care organization (MCO) and a member or the member's representative. In determining active participation, a member who is assessed and provided supports and services that address a chronic disease, but is not participating in the MCO's special disease management program as described in Texas Government Code § 540.0708 should not be counted as participating in the disease management program.

(2) High-risk member--A member at high-risk for non-adherence to the member's plan of care that addresses the member's disease or other chronic health condition, such as heart disease; chronic kidney disease and its medical complications; respiratory illness, including asthma; diabetes; end-stage renal disease; human immunodeficiency virus infection (HIV), or acquired immunodeficiency syndrome (AIDS). A high risk member has multiple or complex medical or behavioral health conditions, or both, with clinical instability undergoing active treatment and at risk of avoidable emergency room visits or hospitalizations.

(3) Special disease management--Coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant.

(b) A health care MCO must provide special disease management services. A health care MCO must:

(1) implement policies and procedures to ensure that a member who requires special disease management services are identified and enrolled into the MCO's special disease management program;

(2) develop and maintain screening and evaluation procedures for the early detection, prevention, treatment, or referral of a member at risk for or diagnosed with chronic conditions such as heart disease; chronic kidney disease and its medical complications; respiratory illness, including asthma; diabetes; HIV infection; or AIDS;

(3) ensure a member who is enrolled in the MCO's special disease management program has the opportunity to disenroll from the program within 30 days while still maintaining access to all other covered services;

(4) show evidence of the ability to manage complex diseases in the Medicaid population by demonstrating the health care MCO's ability to comply with this section; and

(5) include mechanisms to:

(A) identify:

(i) low active participation rates in the MCO's special disease management program; and

(ii) the reason for the low rates; and

(B) increase active participation in the disease management program for high-risk members.

(c) A special disease management program must include:

(1) patient self-management education;

(2) patient education regarding the role of the provider;

(3) evidence-supported models, standards of care in the medical community, and clinical outcomes;

(4) standardized protocols and participation criteria;

(5) physician-directed or physician-supervised care;

(6) implementation of interventions that address the continuum of care;

(7) mechanisms to modify or change interventions that have not been proven effective;

(8) mechanisms to monitor the impact of the special disease management program over time, including both the clinical and the financial impact;

(9) a system to track and monitor all members enrolled in a special disease management program for clinical, utilization, and cost measures;

(10) designated staff to implement and maintain the program and assist members in accessing program services;

(11) a system that enables providers to request specific special disease management interventions; and

(12) provider information, including:

(A) the differences between recommended prevention and treatment and actual care received by a member enrolled in a special disease management program;

(B) information concerning the member's adherence to a service plan; and

(C) reports on changes in each member's health status.

(d) A health care MCO's special disease management program must have performance measures for particular diseases. HHSC reviews the performance measures submitted by a special disease management program for comparability with the relevant performance measures in Texas Government Code § 540.0708, relating to contracts for disease management programs.

(e) A health care MCO implementing a special disease management program for chronic kidney disease and its medical complications that includes screening for and diagnosis and treatment of this disease and its medical complications, must, for the screening, diagnosis and treatment, use generally recognized clinical practice guidelines and laboratory assessments that identify chronic kidney disease on the basis of impaired kidney function or the presence of kidney damage.

(f) A health care MCO that develops and implements a special disease management program must coordinate participant care with a provider of a disease management program under Texas Human Resources Code § 32.057, during a transition period for patients that move from one disease management program to another program.

1 Tex. Admin. Code § 353.421

The provisions of this §353.421 adopted to be effective August 19, 2007, 32 TexReg 4964; Amended to be effective March 1, 2012, 37 TexReg 1283; Amended to be effective September 1, 2014, 39 TexReg 5879; Amended by Texas Register, Volume 49, Number 48, November 29, 2024, TexReg 9743, eff. 11/28/2024