Common use of Long-Term Institutional Care Clause in Contracts

Long-Term Institutional Care. Hoosier Care Connect members requiring long-term care in a nursing facility shall be disenrolled from the Contractor’s Hoosier Care Connect product and enrolled in traditional Medicaid. Before the nursing facility can be reimbursed fee-for-service for the care provided, the nursing facility must request a Pre-Admission Screening Resident Review (PASRR) for nursing facility placement. The State must then approve the PASRR request, designate the appropriate level of care in the MMIS and disenroll the member from Hoosier Care Connect. The Contractor must coordinate care for its members that are transitioning into long-term care by working with the facility to ensure timely submission of the request for a PASRR, as described in the IHCP Provider Manual. The Contractor is responsible for payment for up to sixty (60) calendar days for its members placed in a long-term care facility while the level of care determination is pending. The Contractor may obtain services for its members in a nursing facility setting on a short term basis, defined as fewer than thirty (30) calendar days. This may occur if this setting is more cost-effective than other options and the member can obtain the care and services needed in the nursing facility. The Contractor may negotiate rates for reimbursing the nursing facilities for these short-term stays. If a member admitted to a nursing facility for a short term stay remains in the nursing facility for more than thirty (30) days, the Contractor shall notify the State or its designee, in the timeframe and format required by FSSA. The Contractor may request disenrollment of a member in these cases, which shall be determined in FSSA’s sole discretion.

Long-Term Institutional Care. Hoosier Care Connect members requiring long-term care in a nursing facility shall be disenrolled from the Contractor’s Hoosier Care Connect product and enrolled in traditional Medicaid. Before the nursing facility can be reimbursed fee-for-service for the care provided, the nursing facility must request a Pre-Admission Screening Resident Review (PASRR) for nursing facility placement. The State must then approve the PASRR request, designate the appropriate level of care in the MMIS and disenroll the member from Hoosier Care Connect. The Contractor must coordinate care for its members that are transitioning into long-term care by working with the facility to ensure timely submission of the request for a PASRR, as described in the IHCP Provider Manual. The Contractor is responsible for payment for up to sixty (60) calendar days for its members placed in a long-term care facility while the level of care determination is pending. The Contractor may obtain services for its members in a nursing facility setting on a short short-term basis, defined as fewer than thirty (30) calendar days. This may occur if this setting is more cost-effective than other options and the member can obtain the care and services needed in the nursing facility. The Contractor may negotiate rates for reimbursing the nursing facilities for these short-term stays. All over-the-counter, legend, and nonlegend drugs, including physician-administered drugs are not considered allowable costs and should not be included in the per diem rate. All drugs must be reimbursable through the pharmacy benefit but may be subject to prior authorization and safety edits that are no more restrictive than Fee-for-Service. If a member admitted to a nursing facility for a short short-term stay remains in the nursing facility for more than thirty (30) days, the Contractor shall notify the State or its designee, in the timeframe and format required by FSSA. The Contractor may request disenrollment of a member in these cases, which shall be determined in FSSA’s sole discretion.

Long-Term Institutional Care. Hoosier Care Connect HIP members requiring long-term care in a nursing facility shall or Intermediate Care Facility for the Intellectually Disabled (ICF/ID) must be disenrolled from the Contractor’s Hoosier Care Connect product HIP program and enrolled in traditional Medicaidconverted to an appropriate IHCP eligibility category. The Contractor must work with the facility to determine the type of stay, rehabilitative or custodial, upon admission and follow up every five (5) business days of confirm the type of stay. The Contractor must also contact the State eligibility unit within ten (10) business days upon confirming a custodial stay with the facility to ensure the member is transitioning to another eligibility category. Before the nursing facility can be reimbursed fee-for-service by IHCP for the care provided, the nursing facility must request a Pre-Admission Screening Resident Review (PASRR) for nursing facility placement. The State must then approve the PASRR request, designate the appropriate level of care in the MMIS CoreMMIS and disenroll the member from Hoosier Care ConnectHIP. The Contractor must coordinate care for its members that are transitioning into long-term care by working with the facility to ensure timely submission of the request for a PASRR, as described in the IHCP Provider Manual. The Contractor is responsible for payment for up to sixty (60) calendar days for its members placed in a long-term care facility while However, the level of care determination is pending. The Contractor may obtain services for its members in a nursing facility setting on a short short-term basis, defined as i.e., for fewer than thirty (30) calendar days. This may occur if this setting is more cost-effective than other options and the member can obtain the care and services needed in the nursing facility. The Contractor may EXHIBIT 1.A SCOPE OF WORK negotiate rates for reimbursing the nursing facilities for these short-term stays. If a member admitted to a nursing facility for a short term stay remains All over-the-counter, legend, and nonlegend drugs, including physician-administered drugs are not considered allowable costs and should not be included in the nursing facility for per diem rate. All drugs must be reimbursable through the pharmacy benefit but may be subject to prior authorization and safety edits that are no more restrictive than thirty (30) days, the Contractor shall notify the State or its designee, in the timeframe and format required by FSSAFee-for-Service. The Contractor may request disenrollment of a member in these cases, which shall be determined in FSSA’s sole discretion.

Long-Term Institutional Care. Hoosier Care Connect members requiring long-term care in a nursing facility shall be disenrolled from the Contractor’s Hoosier Care Connect product and enrolled in traditional Medicaid. Before the nursing facility can be reimbursed fee-for-service for the care provided, the nursing facility must request a Pre-Admission Screening Resident Review (PASRR) for nursing facility placement. The State must then approve the PASRR request, designate the appropriate level of care in the MMIS and disenroll the member from Hoosier Care Connect. The Contractor must coordinate care for its members that are transitioning into long-term care by working with the facility to ensure timely submission of the request for a PASRR, as described in the IHCP Provider Manual. The Contractor is responsible for payment for up to sixty (60) calendar days for its members placed in a long-term care facility while the level of care determination is pending. The Contractor may obtain services for its members in a nursing facility setting on a short short-term basis, defined as fewer than thirty (30) calendar days. This may occur if this setting is more cost-effective than other options and the member can obtain the care and services needed in the nursing facility. The Contractor may negotiate rates for reimbursing the nursing facilities for these short-term stays. If a member admitted to a nursing facility for a short short-term stay remains in the nursing facility for more than thirty (30) days, the Contractor shall notify the State or its designee, in the timeframe and format required by FSSA. The Contractor may request disenrollment of a member in these cases, which shall be determined in FSSA’s sole discretion.. EXHIBIT 1 SCOPE OF WORK

Long-Term Institutional Care. Hoosier Care Connect members requiring long-term care in a nursing facility shall be disenrolled from the Contractor’s Hoosier Care Connect product and enrolled in traditional Medicaid. Before the nursing facility can be reimbursed fee-for-service for the care provided, the nursing facility must request a Pre-Admission Screening Resident Review (PASRR) for nursing facility placement. The State must then approve the PASRR request, designate the appropriate level of care in the MMIS and disenroll the member from Hoosier Care Connect. The Contractor must coordinate care for its members that are transitioning into long-term care by working with the facility to ensure timely submission of the request for a PASRR, as described in the IHCP Provider Manual. The Contractor is responsible for payment for up to sixty (60) calendar days for its members placed in a long-term care facility while the level of care determination is pending. The Contractor may obtain services for its members in a nursing facility setting on a short short-term basis, defined as fewer than thirty (30) calendar days. This may occur if this setting is more cost-effective than other options and the member can obtain the care and services needed in the nursing facility. The Contractor may negotiate rates for reimbursing the nursing facilities for these short-term stays. If a member admitted to a nursing facility for a short short-term stay remains in the nursing facility for more than thirty (30) EXHIBIT 1 SCOPE OF WORK days, the Contractor shall notify the State or its designee, in the timeframe and format required by FSSA. The Contractor may request disenrollment of a member in these cases, which shall be determined in FSSA’s sole discretion.

Long-Term Institutional Care. Hoosier Care Connect HIP members requiring long-term care in a nursing facility shall or Intermediate Care Facility for the Intellectually Disabled (ICF/ID) must be disenrolled from the Contractor’s Hoosier Care Connect product HIP program and enrolled in traditional Medicaidconverted to an appropriate IHCP eligibility category. The Contractor must work with the facility to determine the type of stay, rehabilitative or custodial, upon admission and follow up every five (5) business days of confirm the type of stay. The Contractor must also contact the State eligibility unit within ten (10) business days upon confirming a custodial stay with the facility to ensure the member is transitioning to another eligibility category. Before the nursing facility can be reimbursed fee-for-service by IHCP for the care provided, the nursing facility must request a Pre-Admission Screening Resident Review (PASRR) for nursing facility placement. The State must then approve the PASRR request, designate the appropriate level of care in the MMIS CoreMMIS and disenroll the member from Hoosier Care ConnectHIP. The Contractor must coordinate care for its members that are transitioning into long-term care by working with the facility to ensure timely submission of the request for a PASRR, as described in the IHCP Provider Manual. The Contractor is responsible for payment for up to sixty (60) calendar days for its members placed in a long-term care facility while However, the level of care determination is pending. The Contractor may obtain services for its members in a nursing facility setting on a short short-term basis, defined as i.e., for fewer than thirty (30) calendar days. This may occur if this setting is more cost-effective than other options and the member can obtain the care and services needed in the nursing facility. The Contractor may EXHIBIT 1.A SCOPE OF EXHIBIT negotiate rates for reimbursing the nursing facilities for these short-term stays. If a member admitted to a nursing facility for a short term stay remains All over-the-counter, legend, and nonlegend drugs, including physician-administered drugs are not considered allowable costs and should not be included in the nursing facility for per diem rate. All drugs must be reimbursable through the pharmacy benefit but may be subject to prior authorization and safety edits that are no more restrictive than thirty (30) days, the Contractor shall notify the State or its designee, in the timeframe and format required by FSSAFee-for-Service. The Contractor may request disenrollment of a member in these cases, which shall be determined in FSSA’s sole discretion.