Subsection 144-101-II-91.03 - MEMBER ELIGIBILITY FOR COMMUNITY CARE TEAM SERVICESCCT services are for Members who are high-risk and/or high-cost and whose health care needs are more intense than can be managed solely by a primary care provider. CCTs will request qualifying Members be added to their panels.
To be eligible for CCT services, the Member must:
1. Be diagnosed with two (2) or more chronic conditions (91.03-1) and meet one of the general eligibility requirements (91.03-3); or2. Be diagnosed with one (1) chronic condition (91.03-1), be at risk for another chronic condition (91.03-2), and meet one of the general eligibility requirements (91.03-3). All diagnoses related to eligibility must be documented in the Member's EHR.
91.03-1Chronic Conditions1. a mental health condition (excluding Serious and Persistent Mental Illness and Serious Emotional disturbance, as defined in MBM, Section 92, Behavioral Health Homes;2. a substance use disorder;6. overweight or obese as evidenced by a body mass index over 25 for an adult or the 85th percentile for a child;7. Chronic Obstructive Pulmonary Disease (COPD);10. developmental and intellectual disorders;11. circulatory congenital abnormalities;13. acquired brain injury;14. seizure disorders; and91.03-2At Risk for Another Chronic ConditionA Member is deemed to be at risk for another chronic condition if the Member has been diagnosed with or has any of the following:
1. a mental health condition (excluding Serious and Persistent Mental Illness and Serious Emotional disturbance, as defined in MBM, Section 92, Behavioral Health Homes);2. a substance use disorder;6. overweight or obese as evidenced by a body mass index over 25 for an adult or the 85th percentile for a child;10. developmental and intellectual disorders; 11. congenital or acquired circulatory abnormalities;16. intravenous drug use;17. history of incarceration;18. history of or current substance use; or19. family history or genetic predisposition for developing a chronic condition.91.03-3General Eligibility RequirementsMembers shall also meet one of the following additional requirements for CCT eligibility and document the qualifying reason(s) for eligibility:
1.Hospital Admissionsa. Two or more admissions in past three months; orb. Three or more admissions in past 12 months2.ED Utilizationa. Two or more ED visits in past three months; orb. Three or more ED visits in past 12 months3. Members identified by the Department as high-risk or high-cost through Department-provided risk stratification and population health management data or by direct referral from the Department or its authorized agent.4. Members transitioning from institutional settings and at increased risk of poor outcomes (e.g. release from incarceration).5. Members identified by CCT risk-stratification as:a. at risk for deteriorating health status, as defined by a validated risk prediction score; and/orb. high-risk or high-cost by severity of illness, high social service needs that interfere with care, and service utilization; and/orc. having higher hospital costs, ED use, readmissions, utilization and/or escalation of services than what is expected for their clinical risk group.6.Polypharmacy: Members using 5 or more chronic medications and/or on multiple high-risk medications (e.g., insulin, warfarin, etc.), as defined by evidence-based or expert opinion. C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-91, subsec. 144-101-II-91.03