SECTION 353.421. Special Disease Management for Health Care MCOs

(a) For purposes of this rule, "Special Disease Management" means a program of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant.

(b) In order for a health care MCO to receive a contract from HHSC to provide special disease management services, the health care MCO must:

(1) Implement policies and procedures to ensure that members requiring special disease management services are identified and enrolled into a disease management program;

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

(3) Ensure that all members identified for special disease management are enrolled in and have the opportunity to opt out of special disease management services within 30 days while still maintaining access to all other covered services; and

(4) Show evidence of the ability to manage complex diseases in the Medicaid population. Such evidence shall be demonstrated by the health care MCO's compliance with this subchapter.

(c) Special disease management programs 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 special disease management participants 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 the differences between recommended prevention and treatment and actual care received by special disease management participants, information concerning the participant's adherence to a service plan and reports on changes in each participant's health status.

(d) Special disease management programs must have performance measures for particular diseases. HHSC will review the performance measures submitted by a special disease management program for comparability with the relevant performance measures in Texas Government Code §533.009, 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 §32.057, Human Resources Code, during a transition period for patients that move from one disease management program to another program.

Source Note: 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 5873