Flexible Services DSRIP Payments. After July 1, 2018 or another date specified by EOHHS, EOHHS shall pay the Contractor Flexible Services DSRIP payments as follows: 1. EOHHS shall determine a per-Enrollee Flexible Services Allotment for each Performance Year; 2. EOHHS shall calculate the number of Enrollees to use in determining the Contractor’s total Flexible Services Allotment each Performance Year based on a schedule determined by EOHHS, as further specified by EOHHS; 3. EOHHS shall establish a process by which the Contractor may request reimbursement for the Contractor’s spending on qualified flexible services expenditures. For the purposes of this Section, “qualified flexible services expenditures” shall be amounts paid for services that meet all of the following requirements, in EOHHS’ sole determination: a. Fall into an EOHHS-approved category of Flexible Services. As further specified by EOHHS, EOHHS-approved categories of Flexible Services are as follows. EOHHS reserves the right to modify these categories of Flexible Services throughout the Contract Term: 1) Transition services for individuals transitioning from institutional settings into community settings; 2) Home and Community-Based Services to divert individuals from institutional placements; 3) Services to maintain a safe and healthy living environment: 4) Physical activity and nutrition; 5) Experience of violence support; or 6) Other individual goods and services that: a) Address medical needs and provide direct benefit and support specific outcomes that are identified in the Enrollee’s care plan; and b) Promote the delivery of Medically Necessary services in community settings; c) Decrease the need for other Medically Necessary services; d) Are directly related to the health and safety of the Enrollee in his/her home or community; b. Are health-related; c. Are not otherwise covered benefits under the MassHealth state plan or 1115 Demonstration Waiver, or other publicly-funded programs, including Home and Community-Based Waiver programs; d. Are consistent with and documented in the Enrollee’s care plan; e. May include, but are not limited to, classes, programs, equipment, appliances or special clothing or footwear likely to improve health outcomes, prevent or delay health deterioration; f. Are determined to be cost effective and informed by evidence that the service is related to health outcomes, in EOHHS’ sole determination; and g. Meet any additional requirements specified by EOHHS; 4. EOHHS shall make Flexible Services DSRIP payments to the Contractor to reimburse for any such requests that are approved by EOHHS, up to a maximum of the Contractor’s Flexible Services Allotment for the Performance Year during which the qualified flexible services were provided; and 5. EOHHS shall make Flexible Services DSRIP payments at a frequency and in a manner determined by EOHHS.
Appears in 3 contracts
Samples: Contract for Primary Care Accountable Care Organization Services, Contract for Primary Care Accountable Care Organization Services, Contract
Flexible Services DSRIP Payments. After July 1, 2018 or another date specified by EOHHS, EOHHS shall pay the Contractor Flexible Services DSRIP payments as follows:
1. EOHHS shall determine a per-Enrollee Flexible Services Allotment for each Performance Year;
2. EOHHS shall calculate the number of Enrollees to use in determining the Contractor’s total Flexible Services Allotment each Performance Year based on a schedule determined by EOHHS, as further specified by EOHHS;
3. EOHHS shall establish a process by which the Contractor may request reimbursement for the Contractor’s spending on qualified flexible services expenditures. For the purposes of this Section, “qualified flexible services expenditures” shall be amounts paid for services that meet all of the following requirements, in EOHHS’ sole determination:
a. Fall into an EOHHS-approved category of Flexible Services. As further specified by EOHHS, EOHHS-approved categories of Flexible Services are as follows. EOHHS reserves the right to modify these categories of Flexible Services throughout the Contract Term:
1) Transition services for individuals transitioning from institutional settings into community settings;
2) Home and Community-Based Services to divert individuals from institutional placements;
3) Services to maintain a safe and healthy living environment:
4) Physical activity and nutrition;
5) Experience of violence support; or
6) Other individual goods and services that:
a) Address medical needs and provide direct benefit and support specific outcomes that are identified in the Enrollee’s care plan; and
b) Promote the delivery of Medically Necessary services in community settings;
c) Decrease the need for other Medically Necessary services;
d) Are directly related to the health and safety of the Enrollee in his/her home or community;
b. Are health-related;
c. Are not otherwise covered benefits under the MassHealth state plan or 1115 Demonstration Waiver, or other publicly-funded programs, including Home and Community-Based Waiver programs;
d. Are consistent with and documented in the Enrollee’s care plan;
e. May include, but are not limited to, classes, programs, equipment, appliances or special clothing or footwear likely to improve health outcomes, prevent or delay health deterioration;
f. Are determined to be cost effective and informed by evidence that the service is related to health outcomes, in EOHHS’ sole determination; and
g. Meet x. Xxxx any additional requirements specified by EOHHS;
4. EOHHS shall make Flexible Services DSRIP payments to the Contractor to reimburse for any such requests that are approved by EOHHS, up to a maximum of the Contractor’s Flexible Services Allotment for the Performance Year during which the qualified flexible services were provided; and
5. EOHHS shall make Flexible Services DSRIP payments at a frequency and in a manner determined by EOHHS.
Appears in 1 contract
Samples: Primary Care Accountable Care Organization Contract
