| (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.
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| 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 |
