Common use of Level of Care Re-Determinations Clause in Contracts

Level of Care Re-Determinations. The MCO shall develop procedures to assure that all members have a current and accurate level of care as determined by the LTCFS. Level of care re- determinations may only be completed by an individual trained and certified to administer the LTCFS. The responsibility to assure that all members have a current and accurate level of care shall include: Post-Enrollment Re-Determination The MCO may re-determine level of care for a new member shortly after enrollment if the interdisciplinary team believes that different or additional information has come to light as a result of the initial comprehensive assessment. The MCO shall consult with the ADRC if the MCO re-determines level of care for a newly enrolled member or when a newly enrolled member is found to be functionally ineligible or eligibility changes to a non-nursing home level of care within six (6) months of the submission of the most recent pre-enrollment screen. The MCO shall review and compare the screens, attempt to resolve the differences, and contact the Department or its designee if differences cannot be resolved. Annual Re-Determination An annual re-determination of level of care shall be completed within 365 days of the most recent functional screen. If the level of care re-determination is not completed in the designated timeframe, the MCO is required to inform the income maintenance agency of the lack of functional eligibility determination according to change reporting requirements identified in Article IV, Enrollment and Disenrollment. (The member will lose eligibility if the re-determination is not done timely.) Change of Condition Re-Determination A re-determination of level of care should be done whenever a member’s situation or condition changes significantly. Private pay individuals must meet the functional eligibility conditions for eligibility (see Article I for definition of “Private Pay Individual”). The initial level of care determination for a private pay individual is performed by the resource center and the annual redetermination of level of care is performed by the MCO.

Level of Care Re-Determinations. The MCO shall develop procedures to assure that all members have a current and accurate level of care as determined by the LTCFSLTC FS. Level of care re- determinations may only be completed by an individual trained and certified to administer the LTCFSLTC FS. The responsibility to assure that all members have a current and accurate level of care shall include: Post-Enrollment Re-Determination The MCO may re-determine level of care for a new member shortly after enrollment if the interdisciplinary team believes that different or additional information has come to light as a result of the initial comprehensive assessment. The MCO shall consult with the ADRC if the MCO re-determines level of care for a newly enrolled member or when a newly enrolled member is found to be functionally ineligible or eligibility changes to a non-nursing home level of care within six (6) months of the submission of the most recent pre-enrollment screen. The MCO shall review and compare the screens, attempt to resolve the differences, and contact the Department or its designee if differences cannot be resolved. Annual Re-Determination An annual re-determination of level of care shall be completed within 365 days of the most recent functional screen. The member must receive a nursing home level of care to remain functionally eligible for Partnership or PACE. The member must receive a nursing home or non-nursing home level of care to remain functionally eligible for Family Care. If the level of care re-determination is not completed in the designated timeframe, the MCO is required to inform the income maintenance agency of the lack of functional eligibility determination according to change reporting requirements identified in Article IV, Enrollment and Disenrollment, page 45. (The member will lose eligibility if the re-re- determination is not done timely.) Change of Condition Re-Determination A re-determination of level of care should be done whenever a member’s situation or condition changes significantly. Private pay individuals must meet the functional eligibility conditions for eligibility (see Article I for definition of “Private Pay Individual”). The initial level of care determination for a private pay individual is performed by the resource center and the annual redetermination of level of care is performed by the MCO.

Level of Care Re-Determinations. The MCO shall develop procedures to assure that all members have a current and accurate level of care as determined by the LTCFS. Level of care re- determinations may only be completed by an individual trained and certified to administer the LTCFS. The responsibility to assure that all members have a current and accurate level of care shall include: Post-Enrollment Re-Determination The MCO may re-determine level of care for a new member shortly after enrollment if the interdisciplinary team believes that different or additional information has come to light as a result of the initial comprehensive assessment. The MCO shall consult with the ADRC or Tribal ADRS (if applicable) if the MCO re-determines level of care for a newly enrolled member or when a newly enrolled member is found to be functionally ineligible or eligibility changes to a non-nursing home level of care within six (6) months of the submission of the most recent pre-enrollment screen. The MCO shall review and compare the screens, attempt to resolve the differences, and contact the Department or its designee Department’s LTCFS staff if differences cannot be resolved. Annual Re-Determination An annual re-determination of level of care shall be completed within 365 days of the most recent functional screen. If the level of care re-determination is not completed in the designated timeframe, the MCO is required to inform the income maintenance agency of the lack of functional eligibility determination according to change reporting requirements identified in Article IV, Enrollment and Disenrollment. (The member will lose eligibility if the re-determination is not done timely.) Change of Condition Re-Determination A re-determination of level of care should be done whenever a member’s situation or condition changes significantly. Private pay individuals must meet the functional eligibility conditions for eligibility (see eligibility. See Article I for definition of “Private Pay Individual”). .” The initial level of care determination for a private pay individual is performed by the resource center and the annual redetermination of level of care is performed by the MCO.

Level of Care Re-Determinations. The MCO shall develop procedures to assure that all members have a current and accurate level of care as determined by the LTCFS. Level of care re- determinations may only be completed by an individual trained and certified to administer the LTCFS. The responsibility to assure that all members have a current and accurate level of care shall include: Post-Enrollment Re-Determination The MCO may re-determine level of care for a new member shortly after enrollment if the interdisciplinary team believes that different or additional information has come to light as a result of the initial comprehensive assessment. The MCO shall consult with the ADRC or Tribal ADRS (if applicable) if the MCO re-determines level of care for a newly enrolled member or when a newly enrolled member is found to be functionally ineligible or eligibility changes to a non-nursing home level of care within six (6) months of the submission of the most recent pre-enrollment screen. The MCO shall review and compare the screens, attempt to resolve the differences, and contact the Department or its designee Department’s LTCFS staff if differences cannot be resolved. Annual Re-Determination An annual re-determination of level of care shall be completed within 365 days of the most recent functional screen. If the level of care re-determination is not completed in the designated timeframe, the MCO is required to inform the income maintenance agency of the lack of functional eligibility determination according to change reporting requirements identified in Article IV, Enrollment and Disenrollment. (The member will lose eligibility if the re-determination is not done timely.) Change of Condition Re-Determination A re-determination of level of care should be done whenever a member’s situation or condition changes significantly. Private pay individuals must meet the functional eligibility conditions for eligibility (see Article I for definition of “Private Pay Individual”). The initial level of care determination for a private pay individual is performed by the resource center and the annual redetermination of level of care is performed by the MCO.

Level of Care Re-Determinations. The MCO PO shall develop procedures to assure that all members have a current and accurate level of care as determined by the LTCFS. Level of care re- determinations may only be completed by an individual trained and certified to administer the LTCFS. The responsibility to assure that all members have a current and accurate level of care shall include: Post-Enrollment Re-Determination The MCO PO may re-determine level of care for a new member shortly after enrollment if the interdisciplinary team believes that different or additional information has come to light as a result of the initial comprehensive assessment. The MCO PO shall consult with the ADRC or Tribal ADRS (if applicable) if the MCO PO re-determines level of care for a newly enrolled member or when a newly enrolled member is found to be functionally ineligible or eligibility changes to a non-nursing home level of care within six (6) months of the submission of the most recent pre-enrollment screen. The MCO PO shall review and compare the screens, attempt to resolve the differences, and contact the Department or its designee Department’s LTCFS staff if differences cannot be resolved. Annual Re-Determination An annual re-determination of level of care shall be completed within 365 days of the most recent functional screen. If the level of care re-determination is not completed in the designated timeframe, the MCO PO is required to inform the income maintenance agency of the lack of functional eligibility determination according to change reporting requirements identified in Article IV, Enrollment and Disenrollmentrequirements. (The member will lose Medicaid eligibility if the re-determination is not done timely.) Change of Condition Re-Determination A re-determination of level of care should be done whenever a member’s situation or condition changes significantly. Level of Care Determinations and Redeterminations for Private Pay Individuals Private pay individuals must meet the functional eligibility conditions for eligibility (see Article I for definition of “Private Pay Individual”). The initial level of care determination for a private pay individual is performed by the resource center and the annual redetermination of level of care is performed by the MCOPO. The PACE organization shall not knowingly misrepresent or knowingly falsify any information on theLTCFS. The PACE organization shall also verify the information it obtains from or about the individual with the individual’s medical, educational, and other records as appropriate to ensure its accuracy.

Level of Care Re-Determinations. The MCO shall develop procedures to assure that all members have a current and accurate level of care as determined by the LTCFS. Level of care re- determinations may only be completed by an individual trained and certified to administer the LTCFS. The responsibility to assure that all members have a current and accurate level of care shall include: Post-Enrollment Re-Determination The MCO may re-determine level of care for a new member shortly after enrollment if the interdisciplinary team believes that different or additional information has come to light as a result of the initial comprehensive assessment. The MCO shall consult with the ADRC or Tribal ADRS (if applicable) if the MCO re-determines level of care for a newly enrolled member or when a newly enrolled member is found to be functionally ineligible or eligibility changes to a non-nursing home level of care within six (6) months of the submission of the most recent pre-enrollment screen. The MCO shall review and compare the screens, attempt to resolve the differences, and contact the Department or its designee if differences cannot be resolved. Annual Re-Determination An annual re-determination of level of care shall be completed within 365 days of the most recent functional screen. If the level of care re-determination is not completed in the designated timeframe, the MCO is required to inform the income maintenance agency of the lack of functional eligibility determination according to change reporting requirements identified in Article IV, Enrollment and Disenrollment. (The member will lose eligibility if the re-determination is not done timely.) Change of Condition Re-Determination A re-determination of level of care should be done whenever a member’s situation or condition changes significantly. Private pay individuals must meet the functional eligibility conditions for eligibility (see Article I for definition of “Private Pay Individual”). The initial level of care determination for a private pay individual is performed by the resource center and the annual redetermination of level of care is performed by the MCO.

Level of Care Re-Determinations. The MCO PO shall develop procedures to assure that all members have a current and accurate level of care as determined by the LTCFS. Level of care re- re-determinations may only be completed by an individual trained and certified to administer the LTCFS. The responsibility to assure that all members have a current and accurate level of care shall include: Post-Enrollment Re-Determination The MCO PO may re-determine level of care for a new member shortly after enrollment if the interdisciplinary team believes that different or additional information has come to light as a result of the initial comprehensive assessment. The MCO PO shall consult with the ADRC or Tribal ADRS (if applicable) if the MCO re-PO re- determines level of care for a newly enrolled member or when a newly enrolled member is found to be functionally ineligible or eligibility changes to a non-non- nursing home level of care within six (6) months of the submission of the most recent pre-enrollment screen. The MCO PO shall review and compare the screens, attempt to resolve the differences, and contact the Department or its designee Department’s LTCFS staff if differences cannot be resolved. Annual Re-Determination An annual re-determination of level of care shall be completed within 365 days of the most recent functional screen. If the level of care re-determination is not completed in the designated timeframe, the MCO PO is required to inform the income maintenance agency of the lack of functional eligibility determination according to change reporting requirements identified in Article IV, Enrollment and Disenrollmentrequirements. (The member will lose Medicaid eligibility if the re-determination is not done timely.) Change of Condition Re-Determination A re-determination of level of care should be done whenever a member’s situation or condition changes significantly. Level of Care Determinations and Redeterminations for Private Pay Individuals Private pay individuals must meet the functional eligibility conditions for eligibility (see Article I for definition of ““Private Pay Individual”). The initial level of care determination for a private pay individual is performed by the resource center and the annual redetermination of level of care is performed by the MCOPO.