The Care Manager evaluates whether the member meets the definition of “chronically ill” in accordance with 42 CFR § 422.102(f), including:

– The member must require intensive care management.

• • History of frequent outpatient services or specialty care
  • Evidence of poor disease control or medication adherence and/or, social or behavioral factors impacting health outcomes.
  • Multiple specialists/providers requiring coordination
  • Multiple chronic conditions requiring coordination
  • Worsening or exacerbation of chronic conditions in last 12 months
  • Mulitple or recurrent hospitalizations in the last 12 months
  • Multiple or recent ED visits in the last 12 months
  • Complex medication management
  • Frequent monitoring or follow-up
  • Complex Care transitions
  • Difficulty navigating the healthcare system
  • Transportation/access barriers affecting care
  • Significant social or functional barriers
  • Repeated missed appointments
  • Need for coordination among medical, behavioral, pharmacy, and community services
  • HRA findings indicating substantial care-coordination needs

– The member must be at high risk for unplanned hospitalization/ adverse health outcomes.

• • History of frequent hospitalizations or ED visits in the last 12 months
  • Worsening or exacerbation of chronic conditions in the last 12 months
  • Recent significant change in health status
  • Increased risk for disease related complications
  • Complex medical treatment needs
  • Recent functional decline
  • Increased risk for readmission
  • Significant cognitive concerns affecting healthcare mangement
  • Recurrent exacerbations
  • Uncontrolled chronic conditions
  • Frequent provider utilization

-The member must have a documented and active diagnosis for a qualifying chronic condition.

• • The chronic condition must be life threatening or significantly limit the overall health or function of the member.
  • Chronic conditions- https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422

Determinations are individualized and not uniformly applied to all members, in compliance with CMS guidance

Meeting eligibility criteria does not automatically qualify a member for all SSBCI services. Each requested benefit must be supported by an identified need and a reasonable expectation of improving or maintaining health or overall function.