CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Delegated care coordination for perinatal members

Governs a new requirement for Managed Care Organizations in New Mexico to contract with Community Based Organizations and other local providers to deliver delegated care coordination for pregnant, postpartum, and infant Medicaid members under the state's Maternal and Infant Health initiative.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyDelegated care coordination for perinatal members

Policy CodePolicy N/A

Change TypeOperational requirement (new contracting mandate)

Effective DateN/A

Next Review DateN/A

Key ActionMCOs must contract with Community Based Organizations and other local providers to deliver delegated care coordination while retaining oversight responsibility.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~25%CARA members engaged

8% aboveInadequate prenatal care vs national avg

48/100kMaternal mortality (women >35)

4Named MCO contacts

Delegated Care Coordination — Operational Criteria

Delegated Care Coordination Operational Criteria

Operational requirements and intent for delegated care coordination:

MCOs must contract with Community Based Organizations (CBOs) and other local providers to deliver contractually required delegated care coordination for pregnant, postpartum, and infant members.

Contracted local resources include Indian Health Service, Tribal 638 and Urban Health Programs (I/T/U), primary care and specialty clinics, Patient Centered Medical Homes (PCMHs), Health Homes, Core Service Agencies (CSAs), School-Based Health Centers (SBHCs), Community Health Workers (CHWs), Community Health Representatives (CHRs), High Fidelity Wrap-Around (HFW) Teams, Paramedicine programs, community-based agencies, PCS agencies, Centers for Independent Living, and Tribal services.

Care coordination activities must include completion of Health Risk Assessments (HRA) and Comprehensive Needs Assessments (CNA) where indicated, referral assistance, and navigation of services.

MCOs retain oversight responsibility to ensure all contractual care coordination requirements are met even when functions are delegated.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyDelegated care coordination for perinatal members

Policy CodePolicy N/A

Change TypeOperational requirement (new contracting mandate)

Effective DateN/A

Next Review DateN/A

Key ActionMCOs must contract with Community Based Organizations and other local providers to deliver delegated care coordination while retaining oversight responsibility.

SourceLink

On This Page

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Contracting and Provider Requirements

Note

Delegated care coordination contracting requirement

Delegated care coordination is a required contracting arrangement. MCOs must establish contracts with Community Based Organizations (CBOs) and other local providers to deliver the contractually required care coordination services for pregnant and postpartum members and infants. These delegated partners may include, but are not limited to, Indian Health Service, Tribal 638 and Urban Health Programs (I/T/U), primary care and specialty clinics, Patient Centered Medical Homes (PCMHs), Health Homes, Core Service Agencies (CSAs), School-Based Health Centers (SBHCs), Community Health Workers (CHWs), Community Health Representatives (CHRs), High Fidelity Wrap-Around (HFW) Teams, Paramedicine programs, community-based agencies, Personal Care Services agencies, Centers for Independent Living, Tribal services, and other community partners. MCOs remain responsible for oversight to ensure all contractual care coordination requirements are met and for reimbursing delegated partners through mutually agreeable arrangements. For contracting opportunities and more information, contact the Turquoise Care Medicaid MCOs using the listed MCO contact information.

Affected parties: MCOs, CBOs, I/T/Us, PCMHs, CHWs, CHRs, HFW Teams, Paramedicine programs, PCS agencies, Centers for Independent Living, Tribal services

Key Definitions

Delegated care coordination definition

DefinitionDelegated care coordination is the contractual delegation by MCOs to community-based organizations and other providers to perform care coordination functions, with MCOs maintaining oversight.

PurposeIncrease engagement and expand face-to-face, community-driven solutions to improve health during pregnancy, postpartum, and for infants.

Scope of delegated partnersIncludes Indian Health Service, Tribal 638 and Urban Health Programs (I/T/U), primary care and specialty clinics, Patient Centered Medical Homes (PCMHs), Health Homes, Core Service Agencies (CSAs), School-Based Health Centers (SBHCs), Community Health Workers (CHWs), Community Health Representatives (CHRs), High Fidelity Wrap-Around (HFW) Teams, Paramedicine programs, community-based agencies, PCS agencies, Centers for Independent Living, and Tribal services.

MCO responsibilityMCOs retain oversight responsibility to ensure all contractual care coordination requirements are met even when functions are delegated.

Payment/contracting noteMCOs should reimburse delegated local providers in mutually agreeable arrangements and pursue contracting opportunities via the listed Turquoise Care Medicaid MCO contacts.

CARA population

PopulationMembers with a Comprehensive Care and Recovery Act (CARA) Plan of Safe Care who may require care coordination and supports.

Care focusPregnant, postpartum, and infant Medicaid members who need increased engagement and community-driven care coordination services.

Service approachCare coordination delivered by contracted CBOs and local providers working with MCO oversight to address health and social needs during pregnancy and postpartum periods.

Engagement goalIncrease face-to-face and community-driven solutions to improve member engagement and health outcomes.