1400, MCO Service Coordination

Revision 19-13; Effective November 5, 2019

Managed care organizations (MCOs) are required to contact all members upon enrollment and at least annually thereafter. The MCO service coordinator must contact the member at least once telephonically and at least once face-to-face per year if a member receives long term services and supports (LTSS), has a history of behavioral health issues or substance use disorders (SUD) or is dual eligible. The MCO service coordinator must visit with the member face-to-face at least twice a year if the member receives the STAR+PLUS Home and Community Based Services (HCBS) program or has a complex medical condition. The MCO service coordinator must meet with the member face-to-face at a minimum of four times per year if a member resides in a nursing facility (NF).

All applicants or members of LTSS receive service coordination from the MCO. Service coordination is intended to bring together acute care and LTSS. Service coordination includes development of an individual service plan (ISP) with the individual, family members and provider, as well as authorization of LTSS for the member. MCO service coordination is responsible for working with the applicant or member and his or her acute care and LTSS providers to ensure all of an applicant’s or member's medically and functionally necessary services are provided. This includes referring and assisting the applicant or member in obtaining appointments with specialists, participating in discharge planning for applicants or members in hospitals or the NF, referring members to community organizations for services, and assistance not covered by Medicaid. Service coordination requirements for members receiving the STAR+PLUS HCBS program can be found in Section 3000, STAR+PLUS HCBS Program Eligibility and Services, Section 8000, Specific STAR+PLUS HCBS Program Services, Section 5000, Automation and Payment Issues in STAR+PLUS, and Appendices. Service coordination requirements for members receiving Medicaid state plan LTSS can be found in the Uniform Managed Care Contract (UMCC).

The following sections detail MCO service coordinator responsibilities for applicants or members in certain facilities or programs.