Common use of For MSHO Clause in Contracts

For MSHO. (1) Categories. Rate Cell Categories shall be assigned by the STATE upon receipt of the required information as specified in this section and section 3.4 above. Rate Cell Categories shall be assigned prospectively for the next available month. (2) Changes. Rate Cell Category changes due to a new living arrangement and/or NHC status must be entered into MMIS on or before the enrollment Cut-Off Date in order for the MCO to be paid at the rate corresponding to the new Rate Cell Category at the time that the Capitation Payment is to be paid. (3) Post-Cut-Off Changes. When a Rate Cell Category change has been entered in the STATE MMIS after the enrollment Cut-Off Date, the MCO will be paid at the rate corresponding to the new Rate Cell Category at the time of the MCO’s next Capitation Payment, unless the requirements provided for in section 4.2.7 are met. (4) Community Non-EW (Rate Cell Category “A”): (a) The Community Non-EW Rate Cell Category will be assigned to those Beneficiaries who, at the time of enrollment in the MCO, are coded in a community living arrangement in MMIS and are not on the Elderly Waiver program for the 1st day of the following month. (b) For changes in MSHO Rate Cell Categories after initial enrollment, the Community Non-EW Rate Cell Category will be assigned after the MCO notifies the STATE that an Enrollee is living in a community setting and has not been assessed to receive EW services. (5) Community Elderly Waiver (Rate Cell Category “B” and “C”): (a) The Community EW Rate Cell Category will be assigned to those Beneficiaries who, at the time of enrollment in the MCO, are coded in MMIS to be in a community living arrangement and are enrolled in the Elderly Waiver for the 1st of the following month. (b) For changes in MSHO Rate Cell Categories after initial enrollment, the Community EW Rate Cell Category will be assigned after the MCO: i) Notifies the STATE that an Enrollee is living in a community setting; and has indicated that the enrollee has received a Long Term Care Consultation and has been identified to be in need of Elderly Waiver services; and ii) Enters into MMIS the Screening Document (DHS-3427) completed for that Enrollee. (c) The Community EW Rate Cell Category will be assigned to those Beneficiaries, who, at capitation, have an open EW span for the next available month. (d) EW services must be delivered to Enrollees who meet the EW Level of Care criteria based on demonstrated need, and are eligible for payment of LTC services. MCOs are responsible for delivery of EW services even if the EW Rate Cell component was not paid in a given month. (6) Institutionalized (Rate Cell Category “D”): (a) The institutional Rate Cell Category will be assigned to those Beneficiaries who, at the time of enrollment in the MCO, are coded in an Institutionalized living arrangement in MMIS. (b) The Institutional Rate Cell Category will be assigned to those Beneficiaries who, at capitation, do not have an open EW span for the next available month and have an institutional living arrangement. (c) MCOs will be required to close waiver spans promptly following placement in a Nursing Facility of greater than thirty (30) days.

For MSHO. (1) Categories. Rate Cell Categories shall be assigned by the STATE upon receipt of the required information as specified in this section and section 3.4 above. Rate Cell Categories shall be assigned prospectively for the next available month.month.‌‌ (2) Changes. Rate Cell Category changes due to a new living arrangement and/or NHC status must be entered into MMIS on or before the enrollment Cut-Off Date in order for the MCO to be paid at the rate corresponding to the new Rate Cell Category at the time that the Capitation Payment is to be paid. (3) Post-Cut-Off Changes. When a Rate Cell Category change has been entered in the STATE MMIS after the enrollment Cut-Off Date, the MCO will be paid at the rate rate‌ corresponding to the new Rate Cell Category at the time of the MCO’s next Capitation Payment, unless the requirements provided for in section 4.2.7 4.2.6 are met.met.‌ (4) Community Non-EW (Rate Cell Category “A”): (a) The Community Non-EW Rate Cell Category will be assigned to those Beneficiaries who, at the time of enrollment in the MCO, are coded in a community living arrangement in MMIS and are not on the Elderly Waiver program for the 1st day of the following month. (b) For changes in MSHO Rate Cell Categories after initial enrollment, the Community Non-EW Rate Cell Category will be assigned after the MCO notifies the STATE that an Enrollee is living in a community setting and has not been assessed to receive EW services. (5) Community Elderly Waiver (Rate Cell Category “B” and “C”): (a) The Community EW Rate Cell Category will be assigned to those Beneficiaries who, at the time of enrollment in the MCO, are coded in MMIS to be in a community living arrangement and are enrolled in the Elderly Waiver for the 1st of the following month. (b) For changes in MSHO Rate Cell Categories after initial enrollment, the Community EW Rate Cell Category will be assigned after the MCO: i) Notifies the STATE that an Enrollee is living in a community setting; and has indicated that the enrollee has received a Long Term Care Consultation and has been identified to be in need of Elderly Waiver services; and ii) Enters into MMIS the Screening Document (DHS-3427) completed for that Enrollee. (c) The Community EW Rate Cell Category will be assigned to those Beneficiaries, who, at capitation, have an open EW span for the next available month. (d) EW services must be delivered to Enrollees who meet the EW Level of Care criteria based on demonstrated need, and are eligible for payment of LTC services. MCOs are responsible for delivery of EW services even if the EW Rate Cell component was not paid in a given month. (6) Institutionalized (Rate Cell Category “D”): (a) The institutional Rate Cell Category will be assigned to those Beneficiaries who, at the time of enrollment in the MCO, are coded in an Institutionalized living arrangement in MMIS. (b) The Institutional Rate Cell Category will be assigned to those Beneficiaries who, at capitation, do not have an open EW span for the next available month and have an institutional living arrangement. (c) MCOs will be required to close waiver spans promptly following placement in a Nursing Facility of greater than thirty (30) days.

For MSHO. (1A) Categories. Rate Cell Categories shall be assigned by the STATE upon receipt of the required information as specified in this section and section 3.4 3.1.4 above. Rate Cell Categories shall be assigned prospectively for the next available month. (2B) Changes. Rate Cell Category changes due to a new living arrangement and/or NHC status must be entered into MMIS on or before the enrollment Cut-Off Date in order for the MCO to be paid at the rate corresponding to the new Rate Cell Category at the time that the Capitation Payment is to be paid. (3C) Post-Cut-Off Changes. When a Rate Cell Category change has been entered in the STATE MMIS after the enrollment Cut-Off Date, the MCO will be paid at the rate corresponding to the new Rate Cell Category at the time of the MCO’s next Capitation Payment, unless the requirements provided for in section 4.2.7 4.9 below are met. (4D) Community Non-EW (Rate Cell Category “A”): (a1) The Community Non-EW Rate Cell Category will be assigned to those Beneficiaries Recipients who, at the time of enrollment in the MCO, are coded in a community living arrangement in MMIS and are not on the Elderly Waiver program for the 1st day of the following month. (b2) For changes in MSHO Rate Cell Categories after initial enrollment, the Community Non-EW Rate Cell Category will be assigned after the MCO notifies the STATE that an Enrollee is living in a community setting and has not been assessed to receive EW services. (5E) Community Elderly Waiver (Rate Cell Category “B” and “C”): (a1) The Community EW Rate Cell Category will be assigned to those Beneficiaries Recipients who, at the time of enrollment in the MCO, are coded in MMIS to be in a community living arrangement and are enrolled in the Elderly Waiver for the 1st of the following month. (b2) For changes in MSHO Rate Cell Categories after initial enrollment, the Community EW Rate Cell Category will be assigned after the MCO: i(a) Notifies the STATE that an Enrollee is living in a community setting; and has indicated that the enrollee has received a Long Term Care Consultation and has been identified to be in need of Elderly Waiver services; and ii(b) Enters into MMIS the Screening Document (DHS-3427DHS-3247) completed for that Enrollee. (c3) The Community EW Rate Cell Category will be assigned to those BeneficiariesRecipients, who, at capitation, have an open EW span for the next available month. (d4) EW services must be delivered to Enrollees who meet the EW Level of Care criteria based on demonstrated need, and are eligible for payment of LTC services. MCOs are responsible for delivery of EW services even if the EW Rate Cell component was not paid in a given month. (6F) Institutionalized (Rate Cell Category “D”): (a1) The institutional Rate Cell Category will be assigned to those Beneficiaries Recipients who, at the time of enrollment in the MCO, are coded in an Institutionalized living arrangement in MMIS. (b2) The Institutional Rate Cell Category will be assigned to those Beneficiaries Recipients who, at capitation, do not have an open EW span for the next available month and have an institutional living arrangement. (c3) MCOs will be required to close waiver spans promptly following placement in a Nursing Facility of greater than thirty (30) days. (G) The STATE reserves the right to retroactively recover overpayments of the EW rate component from the MCO that are identified as overpayments due to delays in closing EW spans.