Community Benefit. For Members meeting NF LOC, the CONTRACTOR shall provide the Community Benefit, as determined appropriate based on the CNA. The CONTRACTOR shall offer Members eligible for the Community Benefit the option to select either the Agency-Based Community Benefit or the SDCB. The CONTRACTOR shall offer Members selecting the Agency-Based Community Benefit the choice of the consumer delegated model or consumer directed model for Personal Care Services (PCS). The SDCB is further described in Section 4.6 of this Agreement. Members may not choose to move between the Agency-Based Community Benefit and the SDCB without prior approval from HCA. The CONTRACTOR shall track each Member's Community Benefit and provide reports on such benefit as directed by HCA. The maximum allowable cost of care (cost limitation) for the Community Benefit will be tied to the State’s cost of care for persons served in a private NF, except as described in Section 4.6.1.7 of this Agreement (for “grandfathered” SDCB Members). However, the maximum allowable cost of care is not an entitlement. The actual amount that can be spent by a Member for the Community Benefit will be determined by the Member’s CNA. The annual cost limitation will be determined by HCA prior to the beginning of each annual period for this Agreement based on the projected cost of placement in a Medicaid custodial Nursing Facility, excluding State Owned NFs for low level of care. The actual amount that can be spent by a Member in their CCP per year is determined by the Member’s CNA. The CONTRACTOR may choose to spend additional amounts but will not be compensated by HCA for expenditures exceeding the cost limitation developed by HCA Section 4.5.7.5.1 and 4.6.1.7.1 of this Agreement. The CONTRACTOR shall ensure that any services covered in this Agreement that could be authorized through a 1915(c) Waiver or a State Plan amendment authorized through Sections 1915(i) or 1915(k) of the Social Security Act are delivered in settings consistent with federal HCB settings requirements. The CONTRACTOR shall monitor the provision of all Community Benefits to ensure provider compliance with all applicable federal HCB settings requirements. The CONTRACTOR must conduct monitoring activities to ensure that all Community Benefit providers, including SDCB employees meet provider requirements per the Managed Care Policy Manual, including individual attendant/Caregiver requirements. The monitoring activities may not be delegated to the provider. The CONTRACTOR must perform annual audits of all contracted Agency-Based Community Benefit (ABCB) providers using an audit tool that is approved by HCA. The CONTRACTOR shall collaborate with other MCO CONTRACTORS to develop an audit schedule that ensures that all ABCB providers are audited only once per calendar year. The CONTRACTOR must perform an annual audit of the contracted SDCB Fiscal Management Agency using an audit tool that is approved by HCA. Federal law prohibits restricting access to family planning services for Medicaid recipients. The CONTRACTOR shall not require prior authorization for family planning services. The CONTRACTOR shall implement written policies and procedures, prior approved by HCA in writing, that define how Members are educated about their right to family planning services, freedom of choice (including access to Non-Contract Providers) and methods for accessing family planning services. The CONTRACTOR’s family planning policy shall ensure that Members of the appropriate age, regardless of sex or gender, who seek family planning services shall be provided with counseling pertaining to the following: Human Immunodeficiency Virus (HIV) and other sexually transmitted diseases and risk reduction practices; All methods of contraception, including birth control pills and devices (including Plan B) and that such family planning services do not require prior authorization; and The ability of Members to self-refer to Non-Contracted family planning Providers.
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Samples: Medicaid Managed Care Services Agreement, Medicaid Managed Care Services Agreement, Medicaid Managed Care Services Agreement
Community Benefit. For Members meeting NF LOC, the CONTRACTOR shall provide the Community Benefit, as determined appropriate based on the CNA. The CONTRACTOR shall offer Members eligible for the Community Benefit the option to select either the Agency-Based Community Benefit or the SDCBSDBC. The CONTRACTOR shall offer Members selecting the Agency-Based Community Benefit the choice of the consumer delegated model or consumer directed model for Personal Care Services (PCS). The SDCB SDBC is further described in Section 4.6 of this Agreement. Members may not choose to move between the Agency-Based Community Benefit and the SDCB SDBC without prior approval from HCAHSD. The CONTRACTOR shall track each Member's Community Benefit and provide reports on such benefit as directed by HCAHSD. The maximum allowable cost of care (cost limitation) for the Community Benefit will be tied to the State’s cost of care for persons served in a private NF, except as described in Section 4.6.1.7 of this Agreement (for “grandfathered” SDCB SDBC Members). However, the maximum allowable cost of care is not an entitlement. The actual amount that can be spent by a Member for the Community Benefit will be determined by the Member’s CNA. The annual cost limitation will be determined by HCA HSD prior to the beginning of each annual period for this Agreement based on the projected cost of placement in a Medicaid custodial Nursing Facility, excluding State Owned NFs for low level of care. The actual amount that can be spent by a Member in their CCP per year is determined by the Member’s CNA. The CONTRACTOR may choose to spend additional amounts but will not be compensated by HCA HSD for expenditures exceeding the cost limitation developed by HCA HSD in Section 4.5.7.5.1 and 4.6.1.7.1 of this Agreement. The CONTRACTOR shall ensure that any services covered in this Agreement that could be authorized through a 1915(c) Waiver or a State Plan amendment authorized through Sections 1915(i) or 1915(k) of the Social Security Act are delivered in settings consistent with federal HCB settings requirements. The CONTRACTOR shall monitor the provision of all Community Benefits to ensure provider compliance with all applicable federal HCB settings requirements. The CONTRACTOR must conduct monitoring activities to ensure that all Community Benefit providers, including SDCB employees meet provider requirements per the Managed Care Policy Manual, including individual attendant/Caregiver requirements. The monitoring activities may not be delegated to the provider. The CONTRACTOR must perform annual audits of all contracted Agency-Based Community Benefit (ABCB) providers using an audit tool that is approved by HCA. The CONTRACTOR shall collaborate with other MCO CONTRACTORS to develop an audit schedule that ensures that all ABCB providers are audited only once per calendar yearHSD. The CONTRACTOR must perform an annual audit of the contracted SDCB Fiscal Management Agency using an audit tool that is approved by HCAHSD. Federal law prohibits restricting access to family planning services for Medicaid recipients. The CONTRACTOR shall not require prior authorization for family planning services. The CONTRACTOR shall implement written policies and procedures, prior approved by HCA HSD in writing, that define how Members are educated about their right to family planning services, freedom of choice (including access to Non-Contract Providers) and methods for accessing family planning services. The CONTRACTOR’s family planning policy shall ensure that Members of the appropriate age, regardless of sex or gender, who seek family planning services shall be provided with counseling pertaining to the following: Human Immunodeficiency Virus (HIV) and other sexually transmitted diseases and risk reduction practices; All methods of contraception, including birth control pills and devices (including Plan B) and that such family planning services do not require prior authorization; and The ability of Members to self-refer to Non-Contracted family planning Providers.
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