1915(c) Habilitation Supports Waiver Payments Sample Clauses

1915(c) Habilitation Supports Waiver Payments. The 1915(c) Habilitation Supports Waiver (HSW) capitation payment will be made to the PIHPs based on HSW beneficiaries who have enrolled through the MDCH enrollment process and have met the following requirements: Has a developmental disability (as defined by Michigan law) Is Medicaid-eligible (as defined in the CMS approved waiver) Is residing in a community setting If not for HSW services would require ICF/MR level of care services Chooses to participate in the HSW in lieu of ICF/MR services Receives at least one HSW approved service to each month enrolled Beneficiaries enrolled in the HSW may not be enrolled simultaneously in any other 1915(c) waiver, such as the Children’s Waiver Program (CWP) and Children with Serious Emotional Disturbance Waiver (SEDW). The PIHP will not receive payments for HSW enrolled beneficiaries who reside in an ICF/MR, Nursing Home or are incarcerated for an entire month. The PIHP will not receive payments for HSW enrolled beneficiaries enrolled with a Program All Inclusive Care (PACE) organization.
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1915(c) Habilitation Supports Waiver Payments. The 1915(c) Habilitation Supports Waiver capitation payment will be made to PIHPs based on all Medicaid eligibles within the PIHP region, excluding Children’s Waiver enrollees, persons residing in a ICF/MR-DD (MPC/CARO) individuals enrolled in a Program for All Inclusive Care (PACE) organization. SED Waiver enrollees, and individuals incarcerated who are also enrolled in the 1915(c) HSW, The HSW payment will include payment for months associated with periods of retro-eligibility including persons who met the spend-down requirements for a prior month. Additionally, the capitation payment will be adjusted each month for 1) recovery of payments for Medicaid eligibles who DCH has subsequently been notified of their date of death and 2) recovery of payments previously made on behalf of Medicaid eligibles enrolled in the HSW who, upon a retrospective review did not meet all the HSW enrollment criteria e. g. did not receive a 1915 (c) service within the payment month. This HSW payment will be scheduled the third Wednesday of the month. For those PIHPs opting to receive an EFT, the payment will be available on the Thursday following the third Wednesday of the month. When applicable, additional payments may be scheduled (i.e. retro-rate implementation). . HIPAA compliant 834 and 820 transactions will provide eligibility and remittance information. Encounters submitted on a HIPAA compliant 837 will be used to verify receipt of service. Continued HSW enrollment and monthly 1915(c) capitation payment will be made only for individuals who meet all of the following criteria: (a) Are full-coverage Medicaid beneficiaries (Scope/Coverage codes 1/F or 2/F) during the month for which the capitation payment is to be made. Note: the system has been coded to make retroactive capitation payments for past months on behalf of HSW enrollees who become full coverage after Medicaid “card cut off,” e.g., spend-downs or retro-eligible per DHS. (b) Are enrolled in the 1915(c) waiver program, with waiver certificates and all supporting documentation up-to-date for the month in which the capitation payment is made. (c) Receive at least one 1915(c) HSW service in the month for which the capitation payment is to be made. (d) Live in a community setting and receive an HSW service at least one day during the month, e.g., cannot live in a nursing facility or Mt. Pleasant Center during an entire month. The 1915(c) waiver payment process will permit payments based on county of financial responsi...

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