Level of Care Determinations for Not Otherwise Medicaid Eligible Individuals. 4.1.2.1 The CONTRACTOR shall conduct a NF LOC evaluation for individuals who are Not Otherwise Medicaid Eligible (NOME) and who, through a waiver allocation issued by HSD or its designee, are found to have indicators that may warrant a NF LOC.
4.1.2.1.1 The CONTRACTOR shall have a special unit that identifies, tracks and processes all NOMEs that are issued a waiver allocation from the Long- Term Services and Support Bureau. This includes, but is not limited to, receiving the Primary Freedom of Choice (PFoC) form, ensuring a 112 file is received from ASPEN, assignment of a care coordinator to complete the comprehensive needs assessment (CNA) and submission to the UM department for a timely NF LOC determination. The unit shall have a supervisor that oversees and ensures NOMEs are properly routed by CONTRACTOR staff until Medicaid eligibility is established.
4.1.2.2 The CONTRACTOR shall use the tools and processes that have been approved by HSD in conducting the nursing facility level of care evaluation. The CONTRACTOR shall interface with HSD’s eligibility system for level of care in a file format prescribed and approved by HSD.
4.1.2.3 If a Not Otherwise Medicaid Eligible individual has met the nursing facility level of care determination, either because he or she is in a Nursing Facility or because HSD has capacity for Community Benefit services, the CONTRACTOR shall inform HSD of the individual’s level of care determination.
4.1.2.4 If the individual is determined to meet a nursing facility level of care, the CONTRACTOR shall notify HSD to continue the eligibility determination process.
4.1.2.5 To ensure continuity of care for Members with a category of eligibility (XXX) 92, the CONTRACTOR shall continue to determine these Members medically eligible if both of the following conditions are met: (i) the Member’s condition has not changed; and (ii) the Member had a prior year NF LOC approval.
Level of Care Determinations for Not Otherwise Medicaid Eligible Individuals. 4.1.2.1 The CONTRACTOR shall conduct a NF LOC evaluation for individuals who are Not Otherwise Medicaid Eligible and who, through a preliminary screening conducted by HSD or its designee, are found to have indicators that may warrant a NF LOC.
4.1.2.2 The CONTRACTOR shall use the tools and processes that have been approved by HSD in conducting the nursing facility level of care evaluation. The CONTRACTOR shall interface with HSD’s eligibility system for level of care in a file format prescribed and approved by HSD.
4.1.2.3 If a Not Otherwise Medicaid Eligible individual has met the nursing facility level of care determination, either because he or she is in a Nursing Facility or because HSD has capacity for Community Benefit services, the CONTRACTOR shall inform HSD of the individual’s level of care determination.
4.1.2.4 If the individual is determined to meet a nursing facility level of care, the CONTRACTOR shall notify HSD to continue the eligibility determination process.
4.1.2.5 To ensure continuity of care for Members with a category of eligibility (XXX) 92, the CONTRACTOR shall continue to determine these Members medically eligible if both of the following conditions are met: 1) the Member’s condition has not changed, and 2) the Member had a prior year NF LOC approval.
Level of Care Determinations for Not Otherwise Medicaid Eligible Individuals. 4.1.2.1 The CONTRACTOR shall conduct a nursing facility level of care evaluation for individuals who are Not Otherwise Medicaid Eligible and who, through a preliminary screening conducted by HSD or its designee, are found to have indicators that may warrant a nursing facility level of care.
4.1.2.2 The CONTRACTOR shall use the tools and processes that have been approved by HSD in conducting the nursing facility level of care evaluation. The CONTRACTOR shall interface with HSD’s eligibility system for level of care in a file format prescribed and approved by HSD.
4.1.2.3 If a Not Otherwise Medicaid Eligible individual has met the nursing facility level of care determination, either because he or she is in a Nursing Facility or because HSD has capacity for Community Benefit services, the CONTRACTOR shall inform HSD of the individual’s level of care determination.
4.1.2.4 If the individual is determined to meet a nursing facility level of care, the CONTRACTOR shall notify HSD to continue the eligibility determination process.
