Enrolling Participants into the PACE Program

Size: px
Start display at page:

Download "Enrolling Participants into the PACE Program"

Transcription

1 Program of All-inclusive Care for the Elderly Enrolling Participants into the PACE Program Cindy Susee, APD PACE Policy Analyst February 2017

2 PACE Model PACE is a Medicare and Medicaid national program, currently in 31 states, that offers an array of health and wellness services in a consolidated all-inclusive service model. Medicare and Medicaid funds cover all medically necessary services. There are no co-pays or deductibles. Medicare recipients pay a monthly premium for the long-term care and drug benefits. Recipients can also pay privately for the PACE program if they do not qualify for Medicare or Medicaid.

3 PACE Model PACE services include but are not limited to: * Long-term Care * Primary Care * Laboratory Tests & Procedures * Emergency Medical Services * Hospital Care * Nursing Home Care * Palliative Care * Medication: Prescription & OTC * Medical Supplies * Medical Equipment * Adult Day Services * Transportation * In-Home Care * Dental Services * Mental Health Services * Social Services * Specialty Medical Care: Audiology/Optical/Podiatry * Therapeutic Services: Physical/Occupational/Speech/Recreational

4 PACE Eligibility and IDT The PACE Service Recipient is: 55 years old or older Living in a PACE service area Able to reside safely in the community At Nursing Home Level of Care (SPL 1-13) The PACE Interdisciplinary Team may include: Medical Doctors Registered Nurses Licensed Therapists Licensed Social Workers Therapeutic Aides Dieticians Other Relevant Healthcare Professionals

5 The PACE Participant & Care Team Together the Participant & Interdisciplinary Team: Develop a plan of care that is comprehensive and responsive to the individual s healthcare and social service needs. The PACE provider is responsible for meeting all of the healthcare and social service needs identified in the care plan.

6 PACE in Oregon The State of Oregon supports the expansion of the PACE program and PACE providers statewide. Currently, Providence ElderPlace is the only PACE provider in Oregon. Oregon PACE Service areas include Multnomah and Clatsop counties and parts of Washington, Tillamook and Clackamas Counties with over 1,200 participants.

7 ElderPlace Service Sites ElderPlace currently has 9 Health and Social Centers, including 3 that also offer housing. These Centers offer PACE participants comprehensive integrated care from an ElderPlace team of healthcare and social service professionals. If participants are unable to attend a Health and Social Center, their team will visit them at home. In addition to receiving healthcare services at the Center, participants have the opportunity to participate in social and recreational activities and include a nutritious lunch. Transportation is provided to and from ElderPlace Health and Social Centers and is available for medical appointments outside of the Center.

8 Referrals Prospective participants may be referred to Providence Intake Specialists at or (North Coast) Referrals may come from CMs, community sources (MDs) or others.

9 Marketing / Intake / Enrollment ElderPlace services can be provided in a Community Based Care, In-Home setting or a Nursing Facility (if participant is already enrolled in PACE). CM establishes financial eligibility and performs assessment. Providence s Intake Specialists provide information to prospective participants; screen for PACE eligibility; obtain signatures. Participant is enrolled by CM by the 1st of the month, unless s/he is new to Medicaid, in which case they may enroll weekly (on a Monday).

10 Enrollments Cont. If the participant is in a Medicare HMO (MedAdv.) or Medigap plan, they must disenroll from that plan. ElderPlace will call/and/or send an enrollment to the CM stating the participant has or will be enrolled into PACE. Once notified of the date of enrollment, CMs should make every effort to update the case coding and complete the pay-in letter within 5 days of the notification, or by the compute deadline. LTCCNs should be notified that services are discontinued as of the date of PACE enrollment. It is very important to do reassessments timely. Expired assessments end the capitation payment.

11 PACE vs MCO/CCO PACE enrollments need to have their Benefit Plans updated to reflect PACE enrollment prior to the start of the month being enrolled. PACE is a prospective payment. When a reassessment is not updated timely, PACE participants are automatically disenrolled from PACE and automatically enrolled into a MCO/CCO. To avoid MMIS issues, try to complete new enrollments and assessments for PACE participants as early in the month as possible to avoid any preventable timing issues with billing and enrollment.

12 Case Manager Responsibility CMs still need to do yearly redeterminations and assessments. Monthly K Waiver phone calls are not required, but regular monitoring is. CMs should contact the PEP Social Worker prior to reassessments to collaborate. Once the assessment is complete a copy needs to be sent to ElderPlace. ElderPlace conducts semi-annual care conferences (IDTs) lasting approximately 15 minutes each. CMs are highly encouraged to participate. Ask about conference availability. Narrate everything!

13 Facility Payment / Pay-In ElderPlace pays the facility (the 512 is not used for the facility payment). Participant pays Room & Board (R&B) directly to the facility and keeps PIF amount. EP can apply to become a participant s rep payee. Calculate pay-in on total income, minus R&B and PIF. Send the 541 (Notice of Responsibility). Advise that payment goes to the local branch office (payable to APD) and R&B goes to the facility.

14 Facility Payment / Pay-In Send 001N to the participant with instructions to sign and return to CM. Send EP the 001N (CAPS assessment), 003N (client details) and a copy of the pay-in letter. For In-home, also include 546N and 598N. The 001N does not need to be signed by PEP or the facility. Copy of the pay-in letter goes in the participants file. The local office is responsible for tracking participants payments on a spreadsheet (not in SFMU). If a pay-in is not received, CMs should contact the participant. Then notify the EP SW asking if they can remind the participant that they are required to make their monthly payment for services or they may be closed and lose their PACE services.

15 Pay-In Options Participants can have their bank issue an automatic check and mail them to OFS or do an online payment by clicking on this link and then PACE Pay-in: Questions about whether a payment has been received? Contact: APD.ClientReceipting@dhsoha.state.or.us OFS is working on sending out a monthly report of all PACE liability payments that have been received.

16 Pay-In Tracking A report for the online payment system goes out to Branches twice a month. When a payment is made for PACE (OFS or Local Office), the information needs to be added to the narrative that a payment has been received. Currently, each Local Office/Branch/County keeps track of Pay-In payments for each participant.

17 Coding If there is an open in-home liability on SFMU, close it. If there is an open 512, close it the day before enrollment into PEP. Example: 512 close day Sept. 14, 2015; Oregon Access/UCMS PACE enrollment begin date = Sept. 15, 2015 If the participant is moving, change the address, phone and possible living situation in ORACCESS Person Details. This is important as failing to do so may cancel enrollment (FIPS codes must match).

18 Coding - CAPS End the current Benefit a day prior to the PAC Benefit date of enrollment and start a PAC Benefit using the date of enrollment. Then add PEP as the provider by searching using the name Providence ElderPlace. Provider number will be #

19 Coding CMS Go to the Benefits Overview Medical tab. Choose SUPL, date of enrollment and change/add case descriptors with enrollment begin date: Change: APD Case Descriptor (service) to PAC Add: NID as case descriptor Remove: CBF, if appropriate Integrate by using the Mainframe Icon on the title bar and choosing CMS Note: If a PACE participant is admitted to a NF, PEP is responsible for the payment to the NF as long as the client remains enrolled. Do not set up a POC for EP participants.

20 Enrollment Checklist

21 Disenrollment Voluntary disenrollment: May be initiated by the participant at any time without cause. Involuntary disenrollment: May occur if Participant fails to pay client contribution (pay in or service contribution); or Engages in disruptive or threatening behavior (must be approved by CO); or No longer meets eligibility criteria. Participant must be given reasonable notice.

22 Disenrollment If a PACE participant wishes to disenroll, the CM should narrate the conversation and contact the ElderPlace social worker. They will talk with the participant to determine the reason for their request and will then notify the worker to disenroll. Disenrollment generally takes effect on the last day of the month in which the paperwork was completed. CM should then discuss waivered service options with the participant to be effective the first of the following month.

23 Disenrollment If a CM closes a participants Medicaid Eligibility they will be disenrolled from PACE. What is the protocol for CM disenrolling in regard to Fed Guidelines and 30 day notice? According to the 3 way agreement (CMS, DHS and EP), a 30 day notice of intent to disenroll must be sent. DHS contract states DHS will notify PEP when a participants fails to pay their share of the PACE costs. PACE participant will be disenrolled effective the last day of the full calendar month after EP provides a 30 day notice of Disenrollmnent to the PACE participant.

24 Grievance Process Grievances are handled internally by the PACE organization. Appeals are also handled by the PACE organization. If an appeal is denied, the participant may request an Administrative Hearing with the State.

25 Administrative Hearing If a PACE participant disagrees with a decision to approve, deny, reduce or close a benefit or service they may ask for an Administrative Hearing. When the participant requests a hearing, either verbally or in writing, the CM is to fill out top portion of form If the hearing request is made face to face, ask the participant to sign the 0443; however it is not required. Admin Hearing Protocols can be found at: %20Request%20PROTOCOLS%20SEPTEMBER% pdf

26 Collaboration and Communication PACE is a partnership, not just between participants and the program, but with the Local Offices, Providence ElderPlace and Central Office. We all share the same goal of enhancing the quality of life for Oregon s aging population!

27 PACE

28 Courtesy Assessments CM visits consumer and completes a 4 ADL assessment. No client details are needed. Narrative is written for clarification as to why the courtesy assessment was done and date completed. Fax 002N to ElderPlace contact ElderPlace distributes a list to branches on PACE private pay participants. An annual assessment is completed.

29 Deeming 42 CFR (b) Furthermore, the State Administering Agency (SAA) may deem a participant who no longer meets the State Medicaid nursing facility level of care requirements to continue to be eligible for the PACE program if, in the absence of continued coverage under the program, the SAA determines the participant reasonably would be expected to meet the nursing facility level of care requirement in the next six months. The SAA must establish the criteria to use in making the determination of deemed continued eligibility and the criteria used to make the determination of continued eligibility must be specified in the program agreement. These criteria must be applied in reviewing the participant s medical record and plan of care. The SAA, in consultation with the PACE organization, may make a determination of deemed continued eligibility based on review of the participant s medical record and plan of care.

30 Risk Assessment Everyone consumer receives a risk assessment. However, if the individual is PACE, the assessment is performed by ElderPlace.

31 Paid Family Caregiver (PFCG) Caregiver and setting identified by the participant is credentialed for caregiver reimbursement by PEP. Independent credentialed caregiver is compensated by PEP to provide personal ADL and IADL care to a designated participant. PFCG will receive payment when criminal background, Medicare and Medicaid Fraud Check and contractual agreements are complete. PFCG is reimbursed monthly equivalent to ACH Medicaid rate structure.

32 MAGI Clients If an individual is on MAGI, they are eligible for PACE. Use the work-around D4 case. When using D4 work-around, you don t use any KPS coding. If they have no income, APD pays the R&B monthly via 437 with a B8 code. There is no client liability for a MAGI individual.

33 Direct/Indirect For PACE participants, CMs don t need to do direct/indirect case management contacts, since PACE isn t a K-plan.

34 In Home Maintenance Allowance OAR (4)(c) The Department provides for the calculation of any applicable spend-down liability and for post-eligibility treatment of income for Medicaid participants in the same manner as the Department treats spend-down liability and posteligibility income for individuals receiving Medicaid home and community-based services (OAR ).

35 PACE & Moving Costs If PACE enrolled, PEP will assist with visiting homes and planning the move. In terms of the actual moving, it depends on whether the person qualified for special needs whether PEP would cover the cost. Either way, PEP will assist in coordinating unless there is involved family to help.

36 Special Needs To be eligible for a special need item, clients must have no other available resources in the community or in their natural support system to meet the need. To be eligible for a special need item, clients must not be eligible for the item through Medicare, Medicaid or any other medical coverage.

37 Behavioral Support Services ElderPlace has their own internal Health Team for behavioral supports.

38 Social Worker Contact Social Worker contacts change as do Case Managers. Please let PEP know when there is a change of caseloads within your Branch. If you are needing to know who the Social Worker is for your participant, please contact the PACE site Social Worker.

39 PACE Resources Key contacts: Providence Intake Specialists at or for North Coast Jeannie Frederick, Marketing & Enrollment Manager at or Cindy Susee, PACE Analyst, APD at or PACE Oregon Toll-free:

DECISIONS ON SERVICE CASES MANDATORY WEBINAR Q & A 5/9/18

DECISIONS ON SERVICE CASES MANDATORY WEBINAR Q & A 5/9/18 Questions? With new intakes that are just having their CAPS done this month, should we also wait to service plan until the hours are adjusted? We still have not received our list of closure cases that

More information

All related UCare forms can be found, HERE, all DHS forms can be found HERE, all DHS Bulletins can be found HERE.

All related UCare forms can be found, HERE, all DHS forms can be found HERE, all DHS Bulletins can be found HERE. Minnesota Senior Health Options (MSHO) Care Coordination (CC) and Minnesota Senior Care Plus (MSC+) Community Case Management (CM) Requirements Updated 1.1.18 All Minnesota Senior Health Options (MSHO)

More information

CHAPTER 411 DIVISION 45 PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE)

CHAPTER 411 DIVISION 45 PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) CHAPTER 411 DIVISION 45 PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) 411-045-0000 Purpose (Adopted 1/1/2001) (1) The Program of All-inclusive Care for the Elderly (PACE) is a permanent provider

More information

Action Request Transmittal

Action Request Transmittal Aging and People with Disabilities Action Request Transmittal Nate Singer Number: APD-AR-15-028 Authorized signature Issue date: 4/28/2015 Topic: Long Term Care Due date: Subject: APD/AAA Service Coding

More information

DEPARTMENT OF HUMAN SERVICES AGING AND PEOPLE WITH DISABILITIES OREGON ADMINISTRATIVE RULES CHAPTER 411 DIVISION 33

DEPARTMENT OF HUMAN SERVICES AGING AND PEOPLE WITH DISABILITIES OREGON ADMINISTRATIVE RULES CHAPTER 411 DIVISION 33 DEPARTMENT OF HUMAN SERVICES AGING AND PEOPLE WITH DISABILITIES OREGON ADMINISTRATIVE RULES CHAPTER 411 DIVISION 33 IN-HOME CARE AGENCIES PROVIDING MEDICAID IN-HOME SERVICES 411-033-0000 Purpose and Scope

More information

Complete Senior Care Enrollment Agreement

Complete Senior Care Enrollment Agreement Complete Senior Care Enrollment Agreement I have received the Enrollment Handbook and a copy of the Provider Network and have had the opportunity to ask questions. Name: Address: (First) (Middle) (Last)

More information

Introduction. Introduction 9/14/2010. ALABAMA NURSING HOME ASSOCIATION ANNUAL CONVENTION & TRADE SHOW Birmingham, Alabama September 20 23, 2010

Introduction. Introduction 9/14/2010. ALABAMA NURSING HOME ASSOCIATION ANNUAL CONVENTION & TRADE SHOW Birmingham, Alabama September 20 23, 2010 ALABAMA NURSING HOME ASSOCIATION ANNUAL CONVENTION & TRADE SHOW Birmingham, Alabama September 20 23, 2010 1 Introduction CMS defines state long term care rebalancing as achieving a more equitable balance

More information

Reference Guide for Hospice Medicaid Services

Reference Guide for Hospice Medicaid Services Reference Guide for Hospice Medicaid Services for Florida s Statewide Medicaid Managed Care Plans (MMA & LTC) This reference guide is intended to provide general hospice information on Florida Medicaid.

More information

Long-Term Care Glossary

Long-Term Care Glossary Long-Term Care Glossary Adjudicated Claim Activities of Daily Living (ADL) A claim that has reached final disposition such that it is either paid or denied. Basic tasks individuals perform in the course

More information

Evidence of Coverage. Elderplan Advantage for Nursing Home Residents (HMO SNP) H3347_EP16115_SALIS_

Evidence of Coverage. Elderplan Advantage for Nursing Home Residents (HMO SNP) H3347_EP16115_SALIS_ 2018 Evidence of Coverage January 1, 2018 to December 31, 2018 H3347_EP16115_SALIS_01.25.2018 January 1 December 31, 2018 Evidence of Coverage: Your Medicare Health Benefits and Services and Prescription

More information

Maryland Medicaid Program. Aaron Larrimore Medicaid Department of Health and Mental Hygiene May 31, 2012

Maryland Medicaid Program. Aaron Larrimore Medicaid Department of Health and Mental Hygiene May 31, 2012 Maryland Medicaid Program Aaron Larrimore Medicaid Department of Health and Mental Hygiene May 31, 2012 1 Maryland Medicaid In Maryland, Medicaid is also called Medical Assistance or MA. MA is a joint

More information

Evidence of Coverage:

Evidence of Coverage: January 1 December 31, 2013 Evidence of Coverage: Your Medicare Health Benefits and Services as a Member of Health Net Aqua (PPO) This booklet gives you the details about your Medicare health care coverage

More information

UCare Connect + Medicare Care Coordination Requirement Grid Updated

UCare Connect + Medicare Care Coordination Requirement Grid Updated UCare Connect + Medicare Care Coordination Requirement Grid Updated 1.1.18 The assigned Care Coordinator (CC) must meet the required definition of a qualified professional. Care coordination services incorporate

More information

Tufts Health Plan Senior Care Options Care Model Training. Designed for Providers 2018

Tufts Health Plan Senior Care Options Care Model Training. Designed for Providers 2018 Tufts Health Plan Senior Care Options Care Model Training Designed for Providers 2018 1 Tufts Health Plan Senior Care Options (SCO) Overview Tufts Health Plan SCO is a benefit plan offered through a contract

More information

2018 Evidence of Coverage

2018 Evidence of Coverage Los Angeles, Riverside and San Bernardino Counties 2018 Evidence of Coverage SCAN Connections (HMO SNP) Y0057_SCAN_10165_2017F File & Use Accepted DHCS Approved 08232017 08/17 18C-EOC006 January 1 December

More information

UCare Connect Care Coordination Requirement Grid Updated effective

UCare Connect Care Coordination Requirement Grid Updated effective UCare Connect Care Coordination Requirement Grid Updated 8.1.18 effective 9.1.18 The assigned Care Coordinator (CC) must meet the required definition of a qualified professional. Care coordination services

More information

WHAT IS PACE? A TRAINING GUIDE FOR OUTREACH & REFERRAL ORGANIZATIONS

WHAT IS PACE? A TRAINING GUIDE FOR OUTREACH & REFERRAL ORGANIZATIONS PACE is a health plan exclusively for individuals over 55 years of age. Our programs have been operating for over 40 years and are located throughout California. PACE is for individuals who are living

More information

Provider Certification Standards Adult Day Care

Provider Certification Standards Adult Day Care Provider Certification Standards Adult Day Care December 2015 1 Definitions: Activities of Daily Living (ADL s)- Includes but is not limited to the following personal care activities: bathing, dressing,

More information

RESPITE CARE LEGACY HOSPICE

RESPITE CARE LEGACY HOSPICE RESPITE CARE LEGACY HOSPICE THE BASICS OF RESPITE CARE WHAT IS RESPITE? Short-term inpatient care provided only when necessary to relieve the family members or other persons caring for the individual at

More information

Annual Notice of Changes for 2016

Annual Notice of Changes for 2016 Health Alliance Medicare PPO 10 (PPO) offered by Health Alliance Connect, Inc. Annual Notice of Changes for 2016 You are currently enrolled as a member of Health Alliance Medicare PPO 10. Next year, there

More information

DEPARTMENT OF HUMAN SERVICES AGING AND PEOPLE WITH DISABILITIES OREGON ADMINISTRATIVE RULES CHAPTER 411 DIVISION 40 MEDICAID HOME DELIVERED MEALS

DEPARTMENT OF HUMAN SERVICES AGING AND PEOPLE WITH DISABILITIES OREGON ADMINISTRATIVE RULES CHAPTER 411 DIVISION 40 MEDICAID HOME DELIVERED MEALS DEPARTMENT OF HUMAN SERVICES AGING AND PEOPLE WITH DISABILITIES OREGON ADMINISTRATIVE RULES CHAPTER 411 DIVISION 40 MEDICAID HOME DELIVERED MEALS 411-040-0000 Purpose and Scope (Amended 06/04/2014) (1)

More information

10.0 Medicare Advantage Programs

10.0 Medicare Advantage Programs 10.0 Medicare Advantage Programs This section is intended for providers who participate in Medicare Advantage programs, including Medicare Blue PPO. In addition to every other provision of the Participating

More information

Chapter 15. Medicare Advantage Compliance

Chapter 15. Medicare Advantage Compliance Chapter 15. Medicare Advantage Compliance 15.1 Introduction 3 15.2 Medical Record Documentation Requirements 8 15.2.1 Overview... 8 15.2.2 Documentation Requirements... 8 15.2.3 CMS Signature and Credentials

More information

STRATEGIES FOR INCORPORATING PACE INTO STATE INTEGRATED CARE INITIATIVES

STRATEGIES FOR INCORPORATING PACE INTO STATE INTEGRATED CARE INITIATIVES NATIONAL PACE ASSOCIATION STRATEGIES FOR INCORPORATING PACE INTO STATE INTEGRATED CARE INITIATIVES A Toolkit for States MARCH, 2014 WWW.NPAONLINE.ORG 703-535-1565 STRATEGIES FOR INCORPORATING PACE INTO

More information

Archived SECTION 13 - BENEFITS AND LIMITATIONS. Section 13 - Benefits and Limitations

Archived SECTION 13 - BENEFITS AND LIMITATIONS. Section 13 - Benefits and Limitations SECTION 13 - BENEFITS AND LIMITATIONS 13.1 BENEFITS AND LIMITATIONS...4 13.1.A AUTHORIZATION...4 13.1.B DEFINITION...4 13.1.C PROVIDER PARTICIPATION REQUIREMENTS...4 13.1.C(1) Hospice-Nursing Facility

More information

Medicare Supplement Plans

Medicare Supplement Plans KPShealth plans P R O V I D E R N E T W O R K If you have questions about any of our Medicare Supplement plans or about the application process, please feel free to contact us at 360-478-6786, or toll

More information

ADMISSION CONSENTS. 1. Yes No Automobile Medical or No Fault insurance due to an accident?

ADMISSION CONSENTS. 1. Yes No Automobile Medical or No Fault insurance due to an accident? Patient Name: I.D. Number: Section A: Identifying Proper Payor ADMISSION CONSENTS Are services provided to you by Hospice reimbursements through health insurance other than Medicare due to one of the following

More information

No other type of Medicare plan offers these services.

No other type of Medicare plan offers these services. No other type of Medicare plan offers these services. A personal touch With UPMC for Life Options, you get all the benefits of Original Medicare (Parts A and B), plus prescription drug coverage, extra

More information

Table of Contents. 1.0 Description of the Procedure, Product, or Service Definitions Hospice Terminal illness...

Table of Contents. 1.0 Description of the Procedure, Product, or Service Definitions Hospice Terminal illness... Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Definitions... 1 1.1.1 Hospice... 1 1.1.2 Terminal illness... 1 2.0 Eligibility Requirements... 1 2.1 Provisions... 1 2.1.1

More information

Evidence of Coverage

Evidence of Coverage January 1 December 31, 2017 Evidence of Coverage Your Medicare Health Benefits and Services as a Member of Kaiser Permanente Medicare Plus (Cost) This booklet gives you the details about your Medicare

More information

GAO MEDICARE AND MEDICAID. Consumer Protection Requirements Affecting Dual-Eligible Beneficiaries Vary across Programs, Payment Systems, and States

GAO MEDICARE AND MEDICAID. Consumer Protection Requirements Affecting Dual-Eligible Beneficiaries Vary across Programs, Payment Systems, and States GAO United States Government Accountability Office Report to Congressional Requesters December 2012 MEDICARE AND MEDICAID Consumer Protection Requirements Affecting Dual-Eligible Beneficiaries Vary across

More information

Mercy Care Advantage (HMO SNP) 2018 Evidence of Coverage Evidencia de Cobertura Visit/Viste

Mercy Care Advantage (HMO SNP) 2018 Evidence of Coverage Evidencia de Cobertura Visit/Viste Mercy Care Advantage (HMO SNP) 2018 Evidence of Coverage Evidencia de Cobertura 2018 Visit/Viste www.mercycareadvantage.com AZ-17-07-02 January 1 December 31, 2018 Evidence of Coverage: Your Medicare Health

More information

Member Handbook. Effective Date: January 1, Revised October 30, 2017

Member Handbook. Effective Date: January 1, Revised October 30, 2017 Member Handbook Effective Date: January 1, 2018 Revised October 30, 2017 2017 NH Healthy Families. All rights reserved. NH Healthy Families is underwritten by Granite State Health Plan, Inc. MED-NH-17-004

More information

Florida Medicaid Family Planning Waiver

Florida Medicaid Family Planning Waiver Florida Medicaid Family Planning Waiver 1115 Research and Demonstration Waiver #11-W-00135/4 Public Notice Document April 1, 2014 Posted on Agency Website http://ahca.myflorida.com/medicaid/family_planning/extension.shtml

More information

Select Topics in Implementing an Integrated Medicaid Managed Long-Term Care Program

Select Topics in Implementing an Integrated Medicaid Managed Long-Term Care Program Select Topics in Implementing an Integrated Medicaid Managed Long-Term Care Program TennCare Overview Tennessee s Medicaid Agency Tennessee s Medicaid Program Managed care demonstration implemented in

More information

65G Definitions. For the purposes of this chapter, the term: (1) Allocation Algorithm: The mathematical formula based upon statistically

65G Definitions. For the purposes of this chapter, the term: (1) Allocation Algorithm: The mathematical formula based upon statistically 65G-4.0213 Definitions. For the purposes of this chapter, the term: (1) Allocation Algorithm: The mathematical formula based upon statistically validated relationships between individual characteristics

More information

Chapter 30, Medicaid Hospice Program 07/19/13

Chapter 30, Medicaid Hospice Program 07/19/13 Chapter 30, Medicaid Hospice Program 07/19/13 30.4. Definitions. The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise.

More information

LTC User Guide for Nursing Facility Forms 3618/3619 and Minimum Data Set/ Long Term Care Medicaid Information (MDS/LTCMI)

LTC User Guide for Nursing Facility Forms 3618/3619 and Minimum Data Set/ Long Term Care Medicaid Information (MDS/LTCMI) LTC User Guide for Nursing Facility Forms 3618/3619 and Minimum Data Set/ Long Term Care Medicaid Information (MDS/LTCMI) v 2018 0614 Contents Learning Objectives...1 Sequencing of Documents...2 Admission

More information

Application for a 1915(c) Home and Community-Based Services Waiver

Application for a 1915(c) Home and Community-Based Services Waiver Application for a 1915(c) Home and Community-Based Services Waiver PURPOSE OF THE HCBS WAIVER PROGRAM Page 1 of 117 The Medicaid Home and Community-Based Services (HCBS) waiver program is authorized in

More information

Tufts Health Unify Member Handbook

Tufts Health Unify Member Handbook 2016 Tufts Health Unify Member Handbook H7419_5364 CMS Accepted Tufts Health Unify Member Handbook January 1, 2016 December 31, 2016 Your Health and Drug Coverage under the Tufts Health Unify Medicare-Medicaid

More information

WHAT ARE THE GOALS OF CHC?

WHAT ARE THE GOALS OF CHC? CHC Overview PHCA Conference September 27, 2017 Jennifer Burnett Deputy Secretary Kevin Hancock Chief of Staff Office of Long-Term Living Department of Human Services WHAT ARE THE GOALS OF CHC? 2 1 3 MANAGED

More information

MAKING IT HAPPEN. WHAT IS MEDI-CAL? A Booklet for Regional Center Clients and Families

MAKING IT HAPPEN. WHAT IS MEDI-CAL? A Booklet for Regional Center Clients and Families MAKING IT HAPPEN WHAT IS MEDI-CAL? A Booklet for Regional Center Clients and Families INTRODUCTION This booklet contains information about the Medi-Cal program. It provides a general overview of the program

More information

Fully Integrated Duals Advantage (FIDA) Provider Outreach and Education Event September 30, 2015

Fully Integrated Duals Advantage (FIDA) Provider Outreach and Education Event September 30, 2015 Fully Integrated Duals Advantage (FIDA) Provider Outreach and Education Event September 30, 2015 Joseph Shunk, Interim FIDA Project Director New York State Department of Health (DOH) Office of Health Insurance

More information

Long-Term Care Improvements under the Affordable Care Act (ACA)

Long-Term Care Improvements under the Affordable Care Act (ACA) Long-Term Care Improvements under the Affordable Care Act (ACA) South Carolina Health Care Implementation Coalition September 17, 2010 JoAnn Lamphere, DrPH Director, State Government Relations Health &

More information

Provider Training Frequently Asked Questions (FAQ) FIDA Education Provider Workgroup 6/1/15

Provider Training Frequently Asked Questions (FAQ) FIDA Education Provider Workgroup 6/1/15 Provider Training Frequently Asked Questions (FAQ) FIDA Education Provider Workgroup 6/1/15 This FAQ outlines the expectations and requirements for providers to take the New York State FIDA (Fully Integrated

More information

KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL. HCBS Autism Waiver

KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL. HCBS Autism Waiver KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL HCBS Autism Waiver Introduction Section 7000 7010 8100 8300 8400 BILLING INSTRUCTIONS HCBS Autism Waiver Billing Instructions... Submission of Claim...

More information

FREQUENTLY ASKED RHO QUESTIONS- November 2013

FREQUENTLY ASKED RHO QUESTIONS- November 2013 ELIGIBILITY How will Medicaid Pending applicants be handled? Will they be approved by DHS and then transitioned to Neighborhood? Or will Neighborhood be handling the pending applicants? All eligibility

More information

Medicare and Medicaid

Medicare and Medicaid Medicare and Medicaid Medicare Medicare is a multi-part federal health insurance program managed by the federal government. A person applies for Medicare through the Social Security Administration, but

More information

Hospital Appeals. December 6, Adrienne Mims, MD MPH Medical Director, Medicare Quality Improvement

Hospital Appeals. December 6, Adrienne Mims, MD MPH Medical Director, Medicare Quality Improvement Hospital Appeals December 6, 2012 Adrienne Mims, MD MPH Medical Director, Medicare Quality Improvement Objectives Review process for appeals for termination of Medicare services in the hospital setting

More information

Passport Advantage (HMO SNP) Model of Care Training (Providers)

Passport Advantage (HMO SNP) Model of Care Training (Providers) Passport Advantage (HMO SNP) Model of Care Training (Providers) 2018 Passport Advantage (HMO SNP) is an HMO Special Needs plan with a Medicare contract and an agreement with the Kentucky Department for

More information

MassHealth Updates. Massachusetts Health Care Training Forum October 2017

MassHealth Updates. Massachusetts Health Care Training Forum October 2017 MassHealth Updates Massachusetts Health Care Training Forum October 2017 Agenda ACA-3 and Member Booklet Revision Notice of Birth (NOBs) Update SACA-2 and Senior Guide Revision Senior Care Options (SCO)

More information

FIDA. Care Management for ALL

FIDA. Care Management for ALL Care Management for ALL In 2011, Governor Andrew M. Cuomo established a Medicaid Redesign Team (MRT), which initiated significant reforms to the state s Medicaid program. This included a critical initiative

More information

The Alliance Health Plan. NC Innovations Individual and Family Guide

The Alliance Health Plan. NC Innovations Individual and Family Guide The Alliance Health Plan NC Innovations Individual and Family Guide Corporate Office 4600 Emperor Boulevard Durham, NC 27703 24 Hour Toll-Free Access and Information Line: (800) 510-9132 This handbook

More information

Home Health, Hospice, and Nursing Facility. Indiana Health Coverage Programs DXC Technology October 2017

Home Health, Hospice, and Nursing Facility. Indiana Health Coverage Programs DXC Technology October 2017 Home Health, Hospice, and Nursing Facility Indiana Health Coverage Programs DXC Technology October 2017 Agenda Billing Tips Home Health Hospice Nursing Facility Claim Form Update Helpful Tools Questions

More information

Elder Services/Programs

Elder Services/Programs Note: The following applies to Tufts Medicare Preferred HMO and Tufts Health Plan Senior Options members. Program Eligibility/Program Information Possible Services Standard State Home Respite Home Community

More information

Family Planning Waiver

Family Planning Waiver Family Planning Waiver 1115 Research and Demonstration Waiver #11-W-00135/4 Public Notice Document Public Notice Period May 1 30, 2017 5-Year Waiver Extension Request Florida Medicaid Florida Agency for

More information

HOSPICE CONTRACTING CHECKLIST FOR INPATIENT SERVICES, RESPITE CARE AND VENDOR AGREEMENTS

HOSPICE CONTRACTING CHECKLIST FOR INPATIENT SERVICES, RESPITE CARE AND VENDOR AGREEMENTS HOSPICE CONTRACTING CHECKLIST FOR INPATIENT SERVICES, RESPITE CARE AND VENDOR AGREEMENTS The following checklist can be used to verify that the regulatory requirements are addressed in hospice contracts

More information

Roles and Responsibilities of Hospitals and the Oregon Health Authority

Roles and Responsibilities of Hospitals and the Oregon Health Authority Roles and Responsibilities of Hospitals and the Oregon Health Authority Contents About the Hospital Presumptive (Temporary) Medical Process... 1 The hospital s role... 1 Qualified hospitals... 1 Who can

More information

Introducing Individual Customized Living Support (ICLS) Goals

Introducing Individual Customized Living Support (ICLS) Goals Introducing Individual Customized Living Support (ICLS) Aging and Adult Services, DHS March 13, 2014 3/13/2014 1 Goals Background and purpose of ICLS Delineate provider requirements Describe ICLS service

More information

65G Definitions. For the purposes of this chapter, the term: (1) Allocation Algorithm: The mathematical formula based upon statistically

65G Definitions. For the purposes of this chapter, the term: (1) Allocation Algorithm: The mathematical formula based upon statistically 65G-4.0213 Definitions. For the purposes of this chapter, the term: (1) Allocation Algorithm: The mathematical formula based upon statistically validated relationships between individual characteristics

More information

CMS OASIS Q&As: CATEGORY 2 - COMPREHENSIVE ASSESSMENT

CMS OASIS Q&As: CATEGORY 2 - COMPREHENSIVE ASSESSMENT CMS OASIS Q&As: CATEGORY 2 - COMPREHENSIVE ASSESSMENT Q1. When are we required to collect OASIS? [Q&A EDITED 06/14] A1. The Condition of Participation (CoP) published in January 1999 requires a comprehensive

More information

Exhibit A. Part 1 Statement of Work

Exhibit A. Part 1 Statement of Work Exhibit A Part 1 Statement of Work Contractor shall provide Basic Neurological services as described herein to Medicaid eligible Clients who are authorized to receive services at the Contractor s owned

More information

Medicare for Medicaid Advocates

Medicare for Medicaid Advocates Medicare for Medicaid Advocates July 24, 2013 Georgia Burke, National Senior Citizens Law Center Doug Goggin-Callahan, Medicare Rights Center The Medicare Rights Center is a national, not-forprofit consumer

More information

Annual Notice of Coverage

Annual Notice of Coverage CHRISTUS Health Plan Generations (HMO) Annual Notice of Coverage Finally, access to the doctor and hospital you know and trust. christushealthplan.org CHRISTUS Health Plan Generations (HMO) offered by

More information

Analysis Item 13: Oregon Health Authority Medicaid Management Information System Workgroup

Analysis Item 13: Oregon Health Authority Medicaid Management Information System Workgroup Analysis Item 13: Oregon Health Authority Medicaid Management Information System Workgroup Analyst: Linda Ames Request: Acknowledge receipt of a report on recommendations regarding the Medicaid Management

More information

PURPOSE CONTACT. DHS Financial Operations Division (651) or or fax (651) SIGNED

PURPOSE CONTACT. DHS Financial Operations Division (651) or or fax (651) SIGNED Bulletin NUMBER #17-32-08 DATE March 20, 2017 OF INTEREST TO County Directors SSTS Coordinators Social Services Supervisors and Staff Fiscal Supervisors ACTION/DUE DATE Please read information and prepare

More information

Medicaid RAC Audit Results

Medicaid RAC Audit Results Medicaid RAC Audit Results Clinical Audits: The RAC Clinical audit goal was to review supporting documentation for necessity of admission and continued stay in long term care for Medicaid residents. There

More information

PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS CSHCN SERVICES PROGRAM PROVIDER MANUAL

PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS CSHCN SERVICES PROGRAM PROVIDER MANUAL PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS CSHCN SERVICES PROGRAM PROVIDER MANUAL SEPTEMBER 2018 CSHCN PROVIDER PROCEDURES MANUAL SEPTEMBER 2018 PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS Table of Contents

More information

EVIDENCE OF COVERAGE Molina Medicare Options Plus HMO SNP

EVIDENCE OF COVERAGE Molina Medicare Options Plus HMO SNP Molina Medicare Options Plus HMO SNP Member Services CALL (800) 665-0898 Calls to this number are free. 7 days a week, 8 a.m. to 8 p.m., local time. Member Services also has free language interpreter services

More information

Mississippi Medicaid Hospice Services Provider Manual

Mississippi Medicaid Hospice Services Provider Manual Mississippi Medicaid Hospice Services Provider Manual Effective: January 2011 Revised: January 2017 Table of Contents I. Introduction II. Frequently Used Terms III. Getting Started Helpful Tips A. Before

More information

Medicare Program; Announcement of the Approval of the American Association for

Medicare Program; Announcement of the Approval of the American Association for This document is scheduled to be published in the Federal Register on 03/23/2018 and available online at https://federalregister.gov/d/2018-05892, and on FDsys.gov BILLING CODE 4120-01-P DEPARTMENT OF

More information

Special Needs BasicCare

Special Needs BasicCare Minnesota Disability Health Options (MnDHO) Special Needs BasicCare (SNBC) Special Needs Purchasing Deb Maruska Program Coordinator Susan Kennedy Project Coordinator Managed Care Programs for People with

More information

EVIDENCE OF COVERAGE. January 1 December 31, Your Medicare Health Benefits and Services as a Member of Cigna HealthSpring Advantage (PPO)

EVIDENCE OF COVERAGE. January 1 December 31, Your Medicare Health Benefits and Services as a Member of Cigna HealthSpring Advantage (PPO) January 1 December 31, 2018 EVIDENCE OF COVERAGE Your Medicare Health Benefits and Services as a Member of Cigna HealthSpring Advantage (PPO) This booklet gives you the details about your Medicare health

More information

Hospital Crosswalk. Medicare Hospital Requirements to 2012 Joint Commission Hospital Standards & EPs

Hospital Crosswalk. Medicare Hospital Requirements to 2012 Joint Commission Hospital Standards & EPs Hospital Crosswalk CFR Number Standards and Elements of Performance 482.11 TAG: A-0020 482.11 Condition of Participation: Compliance with Federal, State and Local Laws 482.11(a) TAG: A-0021 LD.04.01.01

More information

PAC Waiver. eqhealth Solutions PAC Waiver Authorization Process

PAC Waiver. eqhealth Solutions PAC Waiver Authorization Process PAC Waiver eqhealth Solutions PAC Waiver Authorization Process January 2015 1 Purpose of Presentation Upon completion of the webinar, participants will be able to: 1. Prepare and submit PAC Waiver Requests

More information

CHAPTER 411 DIVISION 48 CONTRACT REGISTERED NURSE SERVICE

CHAPTER 411 DIVISION 48 CONTRACT REGISTERED NURSE SERVICE CHAPTER 411 DIVISION 48 CONTRACT REGISTERED NURSE SERVICE 411-048-0000 Purpose The purpose of these rules is to establish Department of Human Services (DHS) standards and procedures for the Seniors and

More information

9/10/2013. The Session s Focus. Status of the NYS FIDA Initiative

9/10/2013. The Session s Focus. Status of the NYS FIDA Initiative Leading Age NY Financial Manager s Conference, September 10-12, 2013 The Otesaga Resort Hotel, Cooperstown NY Paul Tenan VCC, Inc. FIDA: An Overview and Update The Session s Focus Overview of CMS national

More information

Health in Handbook. a guide to Medicare rights & health in Pennsylvania #6009-8/07

Health in Handbook. a guide to Medicare rights & health in Pennsylvania #6009-8/07 Health in Handbook a guide to Medicare rights & health in Pennsylvania #6009-8/07 Tips for Staying Healthy works hard to make sure that the health care you receive is the best care possible. There are

More information

HAP Midwest MI Health Link Medicare-Medicaid Plan Member Handbook

HAP Midwest MI Health Link Medicare-Medicaid Plan Member Handbook H9712_2016 MMP Handbook Accepted 12/12/2015 HAP Midwest MI Health Link Medicare-Medicaid Plan 2016 Member Handbook Effective: January 1, 2016 1 If you have questions, please call HAP Midwest MI Health

More information

Division of Medical Assistance Programs Client and Provider Education

Division of Medical Assistance Programs Client and Provider Education DMAP Organization Chart... 1 Quick reference... 2 Main contact information... 2 DMAP mail codes... 2 E-mail addresses by topic... 2 Helpful telephone numbers... 2 Office of the State Medicaid Director...

More information

COMMCARE and Independence Waiver Renewals Aging, Attendant Care and OBRA Waiver Amendments Side-by-Side Comparison of Current and Revised Language

COMMCARE and Independence Waiver Renewals Aging, Attendant Care and OBRA Waiver Amendments Side-by-Side Comparison of Current and Revised Language Appendix and Waiver Section Current Language Revised Language Waiver Affected Commenter Name, Date Submitted and Comment Appendix A: Waiver Administration and Operation Appendix A-2-a. Medicaid Director

More information

KANSAS MEDICAL ASSISTANCE PROGRAM. Fee-for-Service Provider Manual. HCBS Frail Elderly

KANSAS MEDICAL ASSISTANCE PROGRAM. Fee-for-Service Provider Manual. HCBS Frail Elderly Fee-for-Service Provider Manual HCBS Frail Elderly Updated 02.2016 PART II Section BILLING INSTRUCTIONS Page 7000 HCBS FE Billing Instructions................. 7-1 7010 HCBS FE Specific Billing Information.............

More information

Participant Direction Option (PDO) Training Developed for the Statewide Medicaid Managed Care Long Term Care Plans

Participant Direction Option (PDO) Training Developed for the Statewide Medicaid Managed Care Long Term Care Plans Participant Direction Option (PDO) Training Developed for the Statewide Medicaid Managed Care Long Term Care Plans Presented by: Danielle Reatherford 1 Purpose The purpose of this presentation is to: Introduce

More information

Coordinated Care Initiative (CCI): Basics for Consumers

Coordinated Care Initiative (CCI): Basics for Consumers California s Protection & Advocacy System Toll-Free (800) 776-5746 Coordinated Care Initiative (CCI): Basics for Consumers September 2016, Pub #5535.01 January 28, 2014 Revised April 1, 2014 Updated September

More information

Family Planning Clinic

Family Planning Clinic PROVIDER TYPE SPECIFIC PACKET/CHECKLIST (Louisiana Medicaid Program) Family Planning Clinic (Enrollment packet is subject to change without notice) (PT71) 07/10 Family Planning Clinic CHECKLIST OF FORMS

More information

Wyoming Medicaid- Provider Services Updates. Provider Workshops Summer 2017

Wyoming Medicaid- Provider Services Updates. Provider Workshops Summer 2017 Wyoming Medicaid- Provider Services Updates Provider Workshops Summer 2017 Facilities Update TITLE 25- Involuntary Hospitalization Effective August 1, 2016- Wyoming Medicaid began processing Title 25 claims

More information

Insight into Hospice and PACE

Insight into Hospice and PACE Insight into Hospice and PACE Defining Hospice Care A form of palliative care designed to provide medical, spiritual and psychological care to individuals facing a life limiting illness. Focuses on caring,

More information

(f) Department means the New Hampshire department of health and human services.

(f) Department means the New Hampshire department of health and human services. Adopted Rule 6/16/10. Effective: 7/1/10 1 Adopt He-W 544.01 544.16, cited and to read as follows: CHAPTER He-W 500 MEDICAL ASSISTANCE PART He-W 544 HOSPICE SERVICES He-W 544.01 Definitions. (a) Agent means

More information

SSI Managed Care Expansion Overview

SSI Managed Care Expansion Overview Overview Milwaukee Mental Health Task Force November 14, 2017 Nicholas Di Meo, MPH Department of Health Services Office of the Secretary 1 Complex Care Vision and Strategy 2 Complex Care Vision and Strategy

More information

42 CFR 438 MMC Service Authorization and Appeals MMC/HIV SNP/HARP/MLTC/Medicaid Advantage/Medicaid Advantage Plus

42 CFR 438 MMC Service Authorization and Appeals MMC/HIV SNP/HARP/MLTC/Medicaid Advantage/Medicaid Advantage Plus of Health Office of Health Insurance Programs 42 CFR 438 MMC Service Authorization and Appeals MMC/HIV SNP/HARP/MLTC/Medicaid Advantage/Medicaid Advantage Plus Hope Goldhaber, Division of Health Plan Contracting

More information

Arkansas LTSS Reform Update

Arkansas LTSS Reform Update Arkansas LTSS Reform Update Division of Aging, Adult, and Behavioral Health Services (DAABH) Mark White, Deputy Director Division of Provider Services and Quality Assurance (DPSQA) Craig Cloud, Director

More information

[SKILLED NURSING FACILITY LETTERHEAD] (Must be issued for all SNF discharges) SKILLED NURSING FACILITY EXHAUSTION OF MEDICARE BENEFITS

[SKILLED NURSING FACILITY LETTERHEAD] (Must be issued for all SNF discharges) SKILLED NURSING FACILITY EXHAUSTION OF MEDICARE BENEFITS [SKILLED NURSING FACILITY LETTERHEAD] (Must be issued for all SNF discharges) SKILLED NURSING FACILITY EXHAUSTION OF MEDICARE BENEFITS (Hand deliver to HMSA 65C Plus Member one day prior to effective date

More information

Lessons Learned from MLTSS Implementation in Florida Where Have We Been and Where Are We Going?

Lessons Learned from MLTSS Implementation in Florida Where Have We Been and Where Are We Going? Lessons Learned from MLTSS Implementation in Florida Where Have We Been and Where Are We Going? David Rogers Assistant Deputy Secretary for Medicaid Operations Agency for Health Care Administration 2016

More information

Florida Medicaid. Definitions Policy. Agency for Health Care Administration. August 2017

Florida Medicaid. Definitions Policy. Agency for Health Care Administration. August 2017 Florida Medicaid Agency for Health Care Administration August 2017 August 2017 1.0 Introduction This policy contains definitions of commonly used terms that are applicable to all sections of Rule Division

More information

State of California Health and Human Services Agency Department of Health Care Services

State of California Health and Human Services Agency Department of Health Care Services State of California Health and Human Services Agency Department of Health Care Services TOBY DOUGLAS Director EDMUND G. BROWN JR. Governor DATE: OCTOBER 28, 2013 ALL PLAN LETTER 13-014 SUPERSEDES ALL PLAN

More information

Medicare Hospice Benefits

Medicare Hospice Benefits CENTERS FOR MEDICARE & MEDICAID SERVICES Medicare Hospice Benefits This official government booklet includes information about Medicare hospice benefits: Who is eligible for hospice care What services

More information

Chapter 14: Long Term Care

Chapter 14: Long Term Care I N D I A N A H E A L T H C O V E R A G E P R O G R A M S P R O V I D E R M A N U A L Chapter 14: Long Term Care Library Reference Number: PRPR10004 14-1 Chapter 14 Indiana Health Coverage Programs Provider

More information

All program transmittals: October 7 October 12, 2013

All program transmittals: October 7 October 12, 2013 All program transmittals: October 7 October 12, 2013 To go directly to the transmittal, mouse over the transmittal number (left column), hold down Ctrl, and click on the transmittal number. Transmittal

More information

Providers who see Empire Medicare Advantage HMO members also are considered contractually eligible to see Empire D-SNP members.

Providers who see Empire Medicare Advantage HMO members also are considered contractually eligible to see Empire D-SNP members. Empire BlueCross BlueShield FAQs for 2017 D-SNP Plans Introduction: Empire BlueCross BlueShield is offering Special Needs Plans (SNPs) to people who are eligible for both Medicare and Medicaid benefits

More information

3 rd Quarter MSHO/MSC+ Care Coordination Training

3 rd Quarter MSHO/MSC+ Care Coordination Training 3 rd Quarter MSHO/MSC+ Care Coordination Training Care Systems & UCare Care Coordinators: September 13 th, 2017 Recorded WebEx: September 14 th, 2017 Agenda STARS Cindy Radke Bus Pass Transportation Jeremy

More information