Sunflower Will Cap Case Management Services

Below is official communication from Sunflower Health sent on September 9 to service providers.

“Sunflower Health Plan has received requests from Targeted Case Management providers for units above the TCM benefit limit. Sunflower intends to enforce the state-established limit of 240 units per year but will review exception requests for consumers with the most complex needs. Sunflower will note denial reasons in the TCM PA system. 

TCMs are encouraged to contact the member’s care coordinator in advance of exceeding unit limits. Regardless of the TCM unit level, all medically necessary services remain available to Sunflower members. Sunflower assures members that they will maintain their TCM and case management services.

Sunflower Resources for Members and TCMs, other providers

Sunflower Health Plan provides care coordination for its members with I/DD and provides services to members, providers and caregivers through LifeShare’s Rapid Crisis Response System (RCRS) and Pathways program. These services are not intended to duplicate or replace the services that TCMs provide.

Additionally, persons with I/DD who participate in the Health Home Program receive case management through Sunflower’s Health Home Partners network and their TCM partners.

Please do not hesitate to call Sunflower Health Plan, or specifically your Sunflower provider relations representative, if you would like to know more about these resources.”

If you have questions about this bulletin or other provider resources, please contact our Customer Service Center in Lenexa, Kansas, at 1-877-644-4623.

2 thoughts on “Sunflower Will Cap Case Management Services

  1. Cathy Pechin

    My thought on this is that I am having to contact my son’s TCM more often now that Sunflower is the MCO and the MCO seems to insist on going through the TCM even though I directly contact them. So, if they limit the hours, that should give the TCMs less time to devote to tracking issues with the MCO putting the TCMs in situation where they either donate the time or fail to address the issues with the MCO. How handy for the MCO. I cannot believe what is happening and it is obvious they are using some very dirty tactics to cut costs.

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  2. TCM Advocate

    The reason they give to the TCM’s is ridiculous…”Request Denied”… That’s it! No other explanation. TCM’s with the HCBS waiver already have about the lowest units for the year of any other waiver. Good grief, we either work for free, or tell the State we cannot provide services for the rest of the year? And this is a good thing, How? Only for those who are trying to save some $$.

    TCM’s don’t frivolously request extra units. For everyone that is requested there are several that the units may never be fully utilized in a year. They don’t see that these thing average out. It would take So much less paperwork, time, and money if the State would go back to contact billing for TCM’s. Then we could spend as much time as we needed on our high unit clients who’s teams desperately need the monitoring, encouragement, coordination, support and guidance that a TCM can provide. I don’t know of a TCM that is not completely dumbfounded at the way things have apparently not really been thought through. Of course, the really disturbing part is that maybe they have been thought through?… It’s really frustrating to see ourselves being put in a place where we are damned if we do, and damned if we don’t.

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