2010-156 Health - AccessCare effective

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Exhibit 1 SCOPE OF WORK Section I -General Statement of Purpose and Intent The Community Care of North Carolina (CCNC) Program is designed to establish, support and maintain provider-network case management service agreements with local providers to develop organized health care delivery systems for enrolled populations that coordinate the full continuum of care with processes to favorably influence cost and quality of care. CCNC provides for the purchase of certain clinical, disease, and case management services for select recipients and is not a grant. The Program provides for the establishment of disease and care management support systems that implement quality improvement initiatives and test new approaches to population management. The Program offers a fee-for-service model with an enhanced case management fee. CCNC Networks coordinate the full continuum of care in concert with the primary care providers (medical homes) while achieving budget and performance goals and benchmarks. To qualify for payment under this contract, Networks must demonstrate the capacity to manage select populations by meeting the following project objectives: • Develop a care management plan to meet budget, utilization and performance targets; • Develop systems to manage enrollee care; • Promote disease management strategies, such as: referral processes; after hours protocols. and targeted management to focus on those in greatest need; • Implement quality improvement (QI) initiatives and participate in program-wide QI activities, such as asthma, diabetes, heart failure, hypertension, post myocardial infarction, emergency room utilization, and pharmacy; • Focus on high cost and high risk enrollees; • Develop strategies and quality improvement initiatives to include individuals simultaneously enrolled in both Medicare and Medicaid (the dually-eligible population); • Provide primary care, referral and authorization of services through a Network of providers; • Develop relationships and partnerships with community agencies to leverage community resources; • Participate in pharmacy initiatives to contain costs and improve quality; • Assure appropriate expenditure of the enhanced care management fees; and • Participate in new initiatives as they are identitied by the clinical directors or as mandated by the North Carolina General Assembly. Section 2 --General Statement of the Law Community Care of North Carolina is implemented by the Division of Medical Assistance and the Office of Rural Health and Community Care under Title XIX of the Social Security Act. This Contract shall be supplementary to the usual terms and conditions of participation in the Medicaid program. The Contractor agrees to abide by all applicable State and federal Medicaid laws, regulations, rules, policies, and procedures. 7