Appears in 3 contracts

Samples: Managed Care Services Agreement, Services Agreement, Managed Care Services Agreement

Level of Care Determinations for Not Otherwise Medicaid Eligible Individuals. 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 ~~HCA~~ HSD or its designee, are found to have indicators that may warrant a NF LOC. 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 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. The CONTRACTOR shall use the tools and processes that have been approved by ~~HCA~~ HSD in conducting the NF LOC evaluation. The CONTRACTOR shall interface with ~~HCA~~ HSD’s eligibility system for level of care in a file format prescribed and approved by ~~HCA~~HSD. If a Not Otherwise Medicaid Eligible individual has met the NF LOC determination, either because he or she is in a NF or because ~~HCA issued a waiver allocation~~ HSD has capacity for Community Benefit services, the CONTRACTOR shall inform ~~HCA~~ HSD of the individual’s level of care determination. If the individual is determined to meet a NF LOC, the CONTRACTOR shall notify ~~HCA~~ HSD to continue the eligibility determination process. 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 Members who are expected to always meet NF LOC If the CONTRACTOR determines that the Member meets ongoing NF LOC based on criteria prescribed by ~~HCA~~ HSD and outlined in the Managed Care Policy Manual, the CONTRACTOR shall approve an ongoing NF LOC for the Member and will not annually assess the Member for NF LOC. The CONTRACTOR is required to perform a CNA and develop an annual care plan for these Members as described in Sections 4.4.5 and 4.4.9 of this Agreement. The CONTRACTOR shall monitor the ongoing NF LOC status of Members, and report to ~~HCA~~ HSD as required. ~~Enrollment~~Enrollment General HSD shall enroll individuals determined eligible for Turquoise Care. Enrollment in a MCO may be the result of a Recipient’s selection of a particular MCO or assignment by HSD. Mandatory Enrollment of CISC Recipients HSD shall assign all CISC Recipients to the CISC CONTRACTOR, with the exception of the following: Enrollment of Native American CISC Recipients in the CISC CONTRACTOR shall be voluntary. Native American CISC Recipients may enroll with the CISC CONTRACTOR, another MCO, or receive services through HSD’s FFS program. Current Medicaid Recipients Recipients who are eligible and currently enrolled will have an opportunity to select a Turquoise Care MCO beginning in October 2023 (unless excluded from mandatory enrollment in Turquoise Care). If the recipient fails to select a Turquoise Care MCO, the recipient will be auto-assigned in accordance with Section 4.2.5 of this Agreement. New Medicaid Recipients. Individuals determined eligible for Centennial Care 2.0 after October 2023 and before January 1, 2024, will select a current Centennial Care 2.0 MCO at the time of application for Medicaid eligibility. These individuals will also have an opportunity to select a Turquoise Care MCO prior to January 1, 2024. Recipients eligible on or after January 1, 2024, will have the opportunity to select a Turquoise Care MCO at the time of application. Recipients who fail to select a Turquoise Care MCO upon the opportunity to do so will be auto-assigned in accordance with Section 4.2.5 of this Agreement. Auto-Assignment HSD will auto-assign a Recipient to a Turquoise Care MCO in specified circumstances, including but not limited to: (i) the Recipient does not select an MCO at the time of eligibility or (ii) the Recipient cannot be enrolled in the requested MCO pursuant to the terms of this Agreement (e.g., the CONTRACTOR is subject to and has reached its enrollment limit). Auto-assignment during the initial open enrollment period for Turquoise Care will be determined by HSD. Following the initial open enrollment period for Turquoise Care, the auto-assignment process will consider the following: If a Recipient was previously enrolled with a Turquoise Care MCO and loses eligibility for a period of three (3) months or less, the Recipient will be re-enrolled with that Turquoise Care MCO; If the Recipient has family Members in a Turquoise Care MCO, the Recipient will be enrolled in that Turquoise Care MCO; If the Recipient is a newborn, the Recipient will be assigned to their mother’s Turquoise Care MCO; and If none of the above applies, the Recipient will be assigned using an auto-assignment algorithm default logic that considers one (1) or more of the following factors: (i) Member experience based upon Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey results and (ii) MCO enrollment size and financial viability. If a Turquoise Care MCO has fifty-five percent (55%) or more of the statewide enrollment, auto-assignment into that Turquoise Care MCO will be limited to Recipients meeting the auto-assignment criteria as described in 4.2.5.2.1 through 4.2.5.2.5 of this Section. HSD reserves the right to modify the auto-assignment methodology at its discretion. Newborns When a child is born to a mother enrolled in Turquoise Care, the hospital or other Provider shall complete a Notification of Birth, MAD Form 313 or its successor, prior to or at the time of discharge. HSD shall ensure that upon receipt of the MAD Form 313 or its successor, the eligibility process is immediately commenced and that upon completion of the eligibility process the newborn is enrolled into their mother’s MCO. Medicaid eligible newborns are eligible for a period of thirteen (13) months, starting with the month of birth. The newborn shall be enrolled retroactively to the month of birth with the mother’s MCO. When a Medicaid-eligible child is born to a mother on the New Mexico Health Insurance Exchange and the mother’s Qualified Health Plan is also a Turquoise Care MCO, the newborn shall be enrolled retroactively to the month of birth with that Turquoise Care MCO. When a Medicaid-eligible child is born to a mother on the New Mexico Health Insurance Exchange and the mother’s Qualified Health Plan is not a Turquoise Care MCO, the newborn shall be auto-assigned and enrolled in a Turquoise Care MCO (in accordance with Section 4.2.5 of this Agreement) retroactively to the month of birth. The mother shall have one (1) opportunity anytime during the three (3) months from the effective date of enrollment to change the newborn’s MCO assignment. Newborns are not considered part of the retroactive reconciliation period if the mother of the newborn is enrolled in Turquoise Care at the time of delivery. Non-Discrimination The CONTRACTOR shall accept Recipients in accordance with 42 C.F.R. § 438.206 and 42 C.F.R. § 438.3(d) and will not discriminate against, or use any policy or practice that has the effect of discriminating against, an individual on the basis of: (i) health status or need for services or (ii) race, color, national origin, sex, disability, ancestry, spousal affiliation, sexual orientation, and/or gender identity. The CONTRACTOR shall be in compliance with ACA Section 1557. Enrollment Limits HSD reserves the right to place limitations on enrollment with the CONTRACTOR. Effective Date of Enrollment Current Medicaid Recipients. The effective date of enrollment for Recipients who are enrolled in accordance with Section 4.2.3 of this Agreement shall be Go-Live. New Medicaid Recipients. The effective date of enrollment for Recipients who are enrolled in accordance with Section 4.2.4 of this Agreement is the first day of the month in which the Recipient’s eligibility becomes effective. At HSD’s discretion, the effective date of enrollment pursuant to Section 4.2.9.2 of this Agreement may be modified during the term of this Agreement. HSD will notify the CONTRACTOR of any changes to the effective date of enrollment and related processes with at least ninety (90) Calendar Days prior notice. Enrollment Period After enrolling in the CONTRACTOR’s MCO (whether as the result of selection or assignment, Members shall have one (1) opportunity anytime during the three (3) month period immediately following the effective date of enrollment with the CONTRACTOR’s MCO to request to change MCOs. After exercising this right to change MCOs, a Member shall remain enrolled with the MCO until the annual choice period described in Section 4.2.10.2 of this Agreement, unless disenrolled in accordance with Section 4.2 of this Agreement. Annual Choice Period. HSD shall provide an opportunity for Members to change MCOs every twelve (12) months. Members who do not select another MCO during their annual choice period will be deemed to have chosen to remain with their current MCO. Members who select a new MCO during their annual choice period shall have one (1) opportunity anytime during the three (3) month period immediately following the effective date of enrollment in the newly selected MCO to request to change MCOs. CISC Members mandatorily enrolled in the CISC CONTRACTOR shall not be offered an opportunity to change MCOs following enrollment in the CISC CONTRACTOR nor have an annual choice period. CISC Members shall be offered an opportunity to change MCOs when the CISC member transitions out of state custody. Transfers from Other MCOs The CONTRACTOR shall accept all Members transferring from any MCO as authorized by HSD. The transfer of membership may occur at any time during the year. The receiving CONTRACTOR shall not be responsible for payment of any Covered Services incurred by Members transferred to the CONTRACTOR prior to the effective date of transfer to the CONTRACTOR. The CONTRACTOR shall transfer all Member information electronically to the receiving MCO as referenced in the Managed Care Policy Manual. The CONTRACTOR shall develop policies and procedures for a mass transfer of Members, either into the CONTRACTOR’s MCO or to another MCO, to be reviewed and approved by HSD. The mass transfer process shall be initiated by HSD upon sixty (60) Calendar Days written notice by HSD when HSD determines, for reasonable cause, that the transfer of Members to or from the CONTRACTOR’s MCO is required. Enrollment Data The CONTRACTOR shall receive, process, and update enrollment files from HSD. Enrollment data shall be updated or uploaded to the CONTRACTOR’s eligibility/enrollment database(s) within twenty-four (24) hours of receipt from HSD to ensure that the CONTRACTOR complies with Section 4.20.2.6 of this Agreement. Member Disenrollment Initiated by Member In accordance with Section 4.2.10 of this Agreement, a Member, other than a CISC Member, has the opportunity to change MCOs during the first ninety (90) Calendar Days following the effective date of enrollment with the CONTRACTOR’s MCO. After exercising change rights, the Member shall remain enrolled with the CONTRACTOR until the annual choice period described in Section 4.2.10.2 of this Agreement. In accordance with Section 4.2.10.2 of this Agreement, a Member, other than a CISC Member, may select another MCO during the Member’s annual choice period. A Member, including a CISC Member, may request to be disenrolled from the CONTRACTOR for cause at any time. The Member must submit a written request to HSD for approval. HSD must respond no later than the first Calendar Day of the second month following the month in which the Member files the request. If HSD does not respond, the request will be deemed approved. The Member will have access to HSD’s Fair Hearing process if he/she is dissatisfied with the determination denying the request to disenroll. The following are causes for Member initiated disenrollment: The Member moves out of the State of New Mexico; The CONTRACTOR does not, because of moral or religious objections, cover the service the Member seeks; HSD has imposed intermediate sanctions on the CONTRACTOR in accordance with Section 7.3.3 of this Agreement; If the Member is automatically re-enrolled under 42 C.F.R. § 438.56(g) if temporary loss of Medicaid eligibility caused the Recipient to miss the Recipient’s annual choice period; The Member needs related services (for example a cesarean section and a tubal ligation) to be performed at the same time, the related services are not available within the network and the Member’s PCP or another provider determines that receiving the services separately would subject the Member to unnecessary risk; A Member’s LTSS residential or employment supports Provider is leaving the CONTRACTOR’s network. A Member may transfer MCOs at any time within ninety (90) Calendar Days from the date of notice of the Provider’s departure from the CONTRACTOR’s network. If the requested transfer cannot be arranged within ninety (90) Calendar Days of the Provider’s departure, the Member must be permitted to remain in his/her current residence until an appropriate transfer arrangement can be made. If the residential or employment supports provider goes out of business or no longer meets Provider requirements, the CONTRACTOR must assist the Member in locating a new provider or the Member may transfer MCOs; or Other reasons, including but not limited to, poor quality of care, lack of access to Covered Services, or lack of access to Providers experienced in addressing the Member's health care needs. Member Disenrollment Initiated by HSD HSD may disenroll a Member if: The Members loses Medicaid eligibility; or At any point in the Fair Hearing process when it is determined that such removal is in the best interest of the Member and/or HSD.

Appears in 1 contract

Samples: Managed Care Services Agreement

Common use of Level of Care Determinations for Not Otherwise Medicaid Eligible Individuals Clause in Contracts