A. The Board of Directors of the Health Insurance High Risk Pool shall select a case manager or managers through a competitive bidding process, to provide case management services for the Pool. The Board shall evaluate the bids submitted under this subsection based on criteria established by the Board, which criteria shall include, but not be limited to, the following:

1. 1. The case manager or managers' proven ability to handle large group accident and health insurance case management and its understanding of health care delivery systems;
2. 2. The cost savings attributed to the case manager or managers' services; and
3. 3. An estimate of total charges for providing case management services to the Pool.

C. A case manager's duties shall include:

1. 1. Assessing, planning, implementing, coordinating, monitoring and evaluating the options and services required to meet a member's health needs;
2. 2. Performance of utilization review, to include concurrent review of inpatient skilled and rehabilitation services, emergency room retrospective review for appropriateness, frequency, and/or chronic disease indicators;
3. 3. Authorization processes based upon nationally recognized criteria for elective inpatient and outpatient services;
4. 4. Multidisciplinary complex case management for high risk pregnancy, transplants, neonates, and other complex cases; and
5. 5. Providing other cost-containment measures as adopted by the Board.

D.

1. 1. The case manager shall be paid, as provided in the contract of the Pool, for direct and indirect expenses incurred in providing case management service for the Pool.
2. 2. As used in this subsection, the term "direct and indirect expenses" includes the portion of the printing expenses, case management expenses, management expenses, building overhead expenses and other actual operating and administrative expenses of the case manager which are approved by the Board as allocable to case management of the plan and included in the bid specifications.

E. The Health Insurance High Risk Pool may provide financial incentives to the case manager or managers based upon savings and outcomes attributed to such case manager or managers.Historical Data

Added by Laws 2002, SB 1233, c. 439, § 6, emerg. eff. July 1, 2002.