Access to Long-Term Care Services Sample Clauses

Access to Long-Term Care Services. The ultimate objective of the QEx Demonstration is that QExA beneficiaries meeting an institutional level of care shall have a choice of institutional services or HCBS. The HCBS provided must be sufficient to meet the needs identified in the functional assessment, taking into account family and other supports available to the beneficiary. In order to move toward the objective of providing beneficiaries with a choice of services, the State must require the following from QExA health plans: i. If the individual has previously received services under a Section 1915(c) waiver and continues to meet an institutional level of care, the individual must continue to receive HCBS appropriate to his or her needs. Based upon the functional assessment at the time of QExA program implementation, the services need not be identical to the ones previously received under the Section 1915(c) waiver, but any change must be based upon the functional assessment. ii. For all other beneficiaries, if the estimated costs of providing necessary HCBS to the beneficiary are less than the estimated costs of providing necessary care in an institution (hospital or nursing facility), the plan must provide the HCBS to an individual who so chooses, subject to the limitations described in paragraph (c). Health plans will be required to document good-faith efforts to establish a cost-effective, person-centered plan of care in the community using industry best practices and guidelines. If the estimated costs of providing necessary HCBS to the beneficiary exceed the estimated costs of providing necessary care in an institution (hospital or nursing facility), a plan may refuse to offer HCBS if the State or its independent oversight contractor so approves. In reviewing such a request, the State must take into account the plan’s aggregate HCBS costs as compared to the aggregate costs that it would have paid for institutional care. iii. A plan is not required to provide HCBS if the individual chooses institutional services, if he or she cannot be safely served in the community, if there are not adequate or appropriate providers for the services, or if there is an exceptional increase in the demand for HCBS. An exceptional increase in demand is defined as an increase beyond annual thresholds to be established by the State. In the case of an exceptional increase, the State shall be responsible for monitoring any wait for services as set forth below and reporting its findings to CMS. iv. Plans may offe...