Long Term Care Services. Respite Care Services, except as specifically mentioned under Hospice Care Benefits.
Long Term Care Services. Respite Care Services, except as specifically mentioned under Hospice Care Benefits. — Services or supplies received during an Inpatient stay when the stay is solely related to behavioral, social maladjustment, lack of discipline or other anti social actions which are not specifically the result of Mental Illness. This does not include services or supplies provided for the treatment of an injury resulting from an act of domestic violence or a medical condition (including both physical and mental health conditions). — Special education therapy such as music therapy or recreational therapy, ex cept as specifically provided for in this Certificate. — Cosmetic Surgery and related services and supplies, except for the correc tion of congenital deformities or for conditions resulting from accidental injuries, tumors or disease. — Services or supplies received from a dental or medical department or clinic maintained by an employer, labor union or other similar person or group. — Services or supplies for which you are not required to make payment or would have no legal obligation to pay if you did not have this or similar cov erage. — Charges for failure to keep a scheduled visit or charges for completion of a Claim form or charges for the transfer of medical records. — Personal hygiene, comfort or convenience items commonly used for other than medical purposes such as air conditioners, humidifiers, physical fitness equipment, televisions and telephones. — Special braces, splints, specialized equipment, appliances, ambulatory appa ratus or, battery implants except as specifically stated in this Certificate. — Prosthetic devices, special appliances or surgical implants which are for cos metic purposes, the comfort or convenience of the patient or unrelated to the treatment of a disease or injury. — Nutritional items such as infant formula, weight‐loss supplements, over‐the‐ counter food substitutes, non‐prescription vitamins and herbal supplements, except as stated in this Certificate. — Blood derivatives which are not classified as drugs in the official formu laries. — Hypnotism. — Inpatient and Outpatient Private Duty Nursing Service. — Routine foot care, except for persons diagnosed with diabetes. — Maintenance Occupational Therapy, Maintenance Physical Therapy and Maintenance Speech Therapy, except as specifically mentioned in this Cer tificate. — Maintenance Care. — Self‐management training, education and medical nutrition therapy, except as specifical...
Long Term Care Services. The following is a non-exhaustive, high-level listing of Community Based Long Term Care Covered Services included under the STAR+PLUS Medicaid managed care program. • Community Based Long Term Care Services for all Members o Personal Attendant Services - All Members of a STAR+PLUS MCO may receive medically and functionally necessary Personal Attendant Services (PAS). o Day Activity and Health Services - All Members of a STAR+PLUS MCO may receive medically and functionally necessary Day Activity and Health Care Services (DAHS). • HCBS STAR+PLUS Waiver Services for those Members who qualify for these services The state provides an enriched array of services to clients who would otherwise qualify for nursing facility care through a Home and Community Based Medicaid Waiver. In traditional Medicaid, this is known as the Community Based Alternatives (CBA) waiver. The STAR+PLUS MCO must also provide medically necessary services that are available to clients through the CBA waiver in traditional Medicaid to those clients that meet the functional and financial eligibility for the HCBS STAR+PLUS Waiver. o Personal Attendant Services (including the three service delivery options: Self-Directed; Agency Model, Self-Directed; and Agency Model) o In-Home or Out-of-Home Respite Services o Nursing Services (in home) o Emergency Response Services (Emergency call button) o Home Delivered Meals o Minor Home Modifications o Adaptive Aids and Medical Equipment o Medical Supplies not available under the Texas Medicaid State Plan/ Texas Healthcare Transformation and Quality Improvement Program (THTQIP) 1115 Waiver o Physical Therapy, Occupational Therapy, Speech Therapy o Day Activity Health Services (DAHS) (for members in 217-Like STAR+PLUS eligibility group, as identified in the Texas Healthcare Transformation and Quality Improvement Program 1115 Waiver, whose income exceeds 150% FPL) o Adult Xxxxxx Care o Assisted Living o Transition Assistance Services (These services are limited to a maximum of $2,500.00. If the MCO determines that no other resources are available to pay for the basic services/items needed to assist a Member, who is leaving a nursing facility, with setting up a household, the MCO may authorize up to $2,500.00 for Transition Assistance Services (TAS). The $2,500.00 TAS benefit is part of the expense ceiling when determining the Total Annual Individual Service Plan (ISP) Cost.) o Dental Services (The annual cost cap of this service is $5,000 per waiver plan ye...
Long Term Care Services. The PO may use the Resource Allocation Decision Method (RAD) as its service authorization policy. If the PO does not use the RAD, it must seek Department approval of alternative service authorization policies and procedures. The policies and procedures must address how new and continuing authorizations of services are approved and denied. The PO may choose to create decision-making guidelines for more frequently used items and/or services. When the PO wishes to utilize these guidelines as part of the RAD or alternative service authorization documentation (instead of documenting evidence), the guidelines must be approved by the Department. Services shall be authorized in a manner that reflects the member’s ongoing need for such services and supports as determined through the comprehensive assessment and consistent with the member-centered plan.
Long Term Care Services. Institutional and community-based long-term care services will be delivered through one of the following delivery systems: Self-direction: Beneficiaries and their families will also have the option to purchase HCBS waiver like services through a self-direction service delivery system. Under this option, beneficiaries will work with the ACO to develop a budget amount for services needed. The beneficiary, with the support of a fiscal intermediary, will then be able to purchase services directly. This option is based on experience from Rhode Island’s section 1915(c) Cash and Counseling Waiver (RI Personal Choice), section 1915(c) Developmental Disabilities Waiver, and Personal Assistance Service and Supports program. Self-direction is fully described in the Self-direction Operations Section.
Long Term Care Services. The PO may use the Resource Allocation Decision Method (RAD) as its service authorization policy. If the PO does not use the RAD, it must seek Department approval of alternative service authorization policies and procedures. The policies and procedures must address how new and continuing authorizations of services are approved and denied. The PO may choose to create decision-making guidelines for more frequently used items and/or services. When the PO wishes to utilize these guidelines as part of the RAD or alternative service authorization documentation (instead of documenting evidence), the guidelines must be approved by the Department. Services shall be authorized in a manner that reflects the member’s ongoing need for such services and supports as determined through the comprehensive assessment and consistent with the member-centered plan. Acute and Primary Care Services The PO shall have documented and Department-approved service authorization policies and procedures for acute and primary care services. Policies and procedures may differ from the authorization policies and procedures for long-term care services and may be based on accepted clinical practices. Decisions about the authorization of acute and primary care services may be made outside of the IDT by other clinical professionals with consideration for member preferences. Authorization of Medicare Services PACE organizations in making authorization decisions about services in PACE shall first use and follow Medicare coverage and authorization policies, procedures and requirements rather than the RAD or other Department-approved service authorization policies and procedures used for the authorization of Medicaid services under this contract. If the PO determines that Medicare will not cover the service, the PO must then use and follow the Medicaid coverage rules, including the RAD, to determine if Medicaid will cover the service.
Long Term Care Services. With the exception of nursing facility services, the long-term care services in this section are authorized under the Medicaid home and community-based waiver.
A. Adult Companion Services: Non-medical care, supervision and socialization provided to a functionally impaired adult. Companions assist or supervise the enrollee with tasks such as meal preparation or laundry and shopping, but do not perform these activities as discrete services. The provision of companion services does not entail hands-on nursing care. This service includes light housekeeping tasks incidental to the care and supervision of the enrollee.
Long Term Care Services. With the exception of nursing facility services, the long-term care services in this section are authorized under the Medicaid home and community-based waiver. As required by Section 430.705(2)(b)2., F.S., the contractor shall have at least two (2) subcontractors for each service as listed below (with the exception of case management services, which are directly provided by the contractor):
A. Adult Companion Services: Non-medical care, supervision and socialization provided to a functionally impaired adult. Companions assist or supervise the enrollee with tasks such as meal preparation or laundry and shopping, but do not perform these activities as discrete services. The provision of companion services does not entail hands-on nursing care. This service includes light housekeeping tasks incidental to the care and supervision of the enrollee.
B. Adult Day Health Services: Services provided pursuant to Chapter 429, Part HI, F.S. For example, services furnished in an outpatient setting, encompassing both the health and social services needed to ensure optimal functioning of an enrollee, including social services to help with personal and family problems, and planned group therapeutic activities. Adult day health services include nutritional meals. Meals are included as a part of this service when the patient is at the center during meal times. Adult day health care provides medical screening emphasizing prevention and continuity of care including routine blood pressure checks and diabetic maintenance checks. Physical, occupational and speech therapies indicated in the enrollee's plan of care are furnished as components of this service. Nursing services which include periodic evaluation, medical supervision and supervision of self-care services directed toward activities of daily living and personal hygiene are also a component of this service. The inclusion of physical, occupational and speech therapy services and nursing services as components of adult day health services does not require the contractor to contract with the adult day health provider to deliver these services when they are included in an enrollee's plan of care. The contractor may contract with the adult day health provider for the delivery of these services or the contractor may contract with other providers qualified to deliver these services pursuant to the terms of this contract.
