Common use of LTSS Service Plan Clause in Contracts

LTSS Service Plan. A LTSS Service Plan to identify and address how LTSS needs will be met and how services will be provided in accordance with the PCSP. The LTSS Service Plan must include the following: • All LTSS services necessary to support the Participant in living as independently as possible and remaining as engaged in their community as possible. • For the needs identified in the comprehensive needs assessment, the interventions to address each need or preference, reasonable long-term and short-term goals, the measurable outcomes to be achieved by the interventions, the anticipated time lines in which to achieve the desired outcomes, and the staff responsible for conducting the interventions and monitoring the outcomes. • Potential problems that can be anticipated, including the risks and how these risks can be minimized to xxxxxx the Participant’s maximum functioning level of well-being. • Participant decisions around self-directed care and whether the Participant is participating in Participant-Direction. • Communications plan. • How frequently specific services will be provided. • Whether and, if so, how technology and telehealth will be used. • Participant choice of Providers. • Individualized Back-Up Plans. • The person(s)/Providers responsible for specific interventions/services. • Participant’s available, willing, and able informal support network and services. • Participant’s need for and plan to access community resources, non- covered services, and other supports, including any reasonable accommodations. • How to accommodate preferences for leisure activities, hobbies, and community engagement. • Any other needs or preferences of the Participant. • Participant’s goals for the least restrictive setting possible, if they are being discharged or transitioned from an inpatient setting. • How the CHC-MCO will coordinate with the Participant’s Medicare, Veterans, BH-MCO, other health coverage, and other supports. • Participant’s employment and educational goals. The PCSP may specify the need for referrals and the need for assistance from the Service Coordinator in obtaining referrals. To the extent that the PCP is part of the PCSP development or PCTP process, the PCSP may also articulate referrals that the Service Coordinator will enter in the appropriate systems. The PCSP must consider both In and Out-of-Network Covered Services to support the individual in the environment of their choice as well as caregivers’ support needs. PCSPs must be completed no more than 30 days from the date the comprehensive needs assessment or reassessment is completed. PCSPs for Participants who require LTSS will be developed by the Service Coordinator, the Participant, and the Participant’s PCPT. Participants may appeal part or all of their Service Plan as provided in Exhibit T Complaint, Grievance and DHS Fair Hearing Processes.

LTSS Service Plan. A LTSS Service Plan to identify and address how LTSS needs will be met and how services will be provided in accordance with the PCSP. The LTSS Service Plan must include the following: •  All LTSS services necessary to support the Participant in living as independently as possible and remaining as engaged in their community as possible. •  For the needs identified in the comprehensive needs assessment, the interventions to address each need or preference, reasonable long-term and short-term goals, the measurable outcomes to be achieved by the interventions, the anticipated time lines in which to achieve the desired outcomes, and the staff responsible for conducting the interventions and monitoring the outcomes. •  Potential problems that can be anticipated, including the risks and how these risks can be minimized to xxxxxx the Participant’s maximum functioning level of well-being. •  Participant decisions around self-directed care and whether the Participant is participating in Participant-Direction. •  Communications plan. •  How frequently specific services will be provided. •  Whether and, if so, how technology and telehealth will be used. •  Participant choice of Providers. •  Individualized Back-Up Plans. •  The person(s)/Providers responsible for specific interventions/services. •  Participant’s available, willing, and able informal support network and services. •  Participant’s need for and plan to access community resources, non- covered services, and other supports, including any reasonable accommodations. •  How to accommodate preferences for leisure activities, hobbies, and community engagement. •  Any other needs or preferences of the Participant. •  Participant’s goals for the least restrictive setting possible, if they are being discharged or transitioned from an inpatient setting. •  How the CHC-MCO will coordinate with the Participant’s Medicare, Veterans, BH-MCO, other health coverage, and other supports. •  Participant’s employment and educational goals. The PCSP may specify the need for referrals and the need for assistance from the Service Coordinator in obtaining referrals. To the extent that the PCP is part of the PCSP development or PCTP process, the PCSP may also articulate referrals that the Service Coordinator will enter in the appropriate systems. The PCSP must consider both In and Out-of-Network Covered Services to support the individual in the environment of their choice as well as caregivers’ support needs. PCSPs must be completed no more than 30 days from the date the comprehensive needs assessment or reassessment is completed. PCSPs for Participants who require LTSS will be developed by the Service Coordinator, the Participant, and the Participant’s PCPT. Participants may appeal part or all of their Service Plan as provided in Exhibit T Complaint, Grievance and DHS Fair Hearing Processes.

LTSS Service Plan. A LTSS Service Plan to identify and address how LTSS needs will be met and how services will be provided in accordance with the PCSP. The LTSS Service Plan must include the following: •  All LTSS services necessary to support the Participant in living as independently as possible and remaining as engaged in their his or her community as possible. •  For the needs identified in the comprehensive needs assessment, the interventions to address each need or preference, reasonable long-long- term and short-term goals, the measurable outcomes to be achieved by the interventions, the anticipated time lines timelines in which to achieve the desired outcomes, and the staff responsible for conducting the interventions and monitoring the outcomes. •  Potential problems that can be anticipated, including the risks and how these risks can be minimized to xxxxxx the Participant’s maximum functioning level of well-being. •  Participant decisions around self-directed care and whether the Participant is participating in Participant-Direction. •  Communications plan. •  How frequently specific services will be provided. •  Whether and, if so, how technology and telehealth will be used. •  Participant choice of Providers. •  Individualized Back-Up Plans. •  The person(s)/Providers person(s) and Providers responsible for specific interventions/interventions or services. •  Participant’s available, willing, and able informal support network and services. •  Participant’s need for and plan to access community resources, non- covered services, and other supports, including any reasonable accommodations. •  How to accommodate preferences for leisure activities, hobbies, and community engagement. •  Any other needs or preferences of the Participant. •  Participant’s goals for the least restrictive setting possible, if they are he or she is being discharged or transitioned from an inpatient setting. •  How the CHC-MCO will coordinate with the Participant’s Medicare, VeteransVeterans Benefits, BH-MCO, other health coveragecoverage insurers, and other supports. •  Participant’s employment and educational goals. The PCSP may must specify the need for referrals and the need for assistance from the Service Coordinator in obtaining referrals. To the extent that the PCP is part of the PCSP development or PCTP process, the PCSP may must also articulate referrals that the Service Coordinator will enter in the appropriate systems. The PCSP must consider both In and Out-of-Network Covered Services to support the individual in the environment of their his or her choice as well as caregivers’ support needs. PCSPs must be completed no more than 30 thirty (30) days from the date the comprehensive needs assessment or reassessment is completed. PCSPs for Participants who require LTSS will must be developed by the Service Coordinator, the Participant, the Participant’s representative, and the Participant’s PCPT. Participants may appeal part or all of their Service Plan as provided in Exhibit T G, Complaint, Grievance and DHS Fair Hearing Processes.

LTSS Service Plan. A LTSS Service Plan to identify and address how LTSS needs will be met and how services will be provided in accordance with the PCSP. The LTSS Service Plan must include the following: • All LTSS services necessary to support the Participant in living as independently as possible and remaining as engaged in their his or her community as possible. • For the needs identified in the comprehensive needs assessmentAssessment, the interventions to address each need or preference, reasonable long-term and short-short- term goals, the measurable outcomes to be achieved by the interventions, the anticipated time lines timelines in which to achieve the desired outcomes, and the staff responsible for conducting the interventions and monitoring the outcomes. • Potential problems that can be anticipated, including the risks and how these risks can be minimized to xxxxxx the Participant’s maximum functioning level of well-being. • Participant decisions around self-directed care and whether the Participant is participating in Participant-Direction. • Communications plan. • How frequently The scope, amount, duration and frequency that specific services will be provided. • Whether and, if so, how technology and telehealth will be used. • Participant choice of Providers. • Participant preferences for how often they would like to engage with their Service Coordinator (Participants must not be steered toward minimal quarterly contacts). • Participant communication preferences including how they would like to be identified, addressed and preferred method of communication. • Participant identified goals. • Health related education needs and a plan to ensure understanding of health needs and treatment plan. • Individualized Back-Up PlansPlan that is verified by the service coordinator. • Individuals and organizations identified to be included as part of the PCPT. • The person(s)/Providers person(s) and Providers responsible for specific interventions/interventions or services. • Participant’s available, willing, and able informal support network and services. • Participant’s need for and plan to access community resources, non- covered services, and other supports, including any reasonable accommodations. • How to accommodate preferences for leisure activities, hobbies, and community engagement. • Any other needs or preferences of the Participant. • Participant’s goals for the least restrictive setting possible, if they are he or she is being discharged or transitioned from an inpatient setting. • How the CHC-MCO will coordinate with the Participant’s Medicare, VeteransVeterans Benefits, BH-MCO, other health coveragecoverage insurers, and other supports. • Participant’s employment and educational goals. • Emergency back-up plan that is verified by the Service Coordinator, safe and realistic. • A plan for regularly scheduled follow up communications with the Participant. • Barriers to the Participant meeting defined goals. • Measures to prevent future falls which must include at a minimum offering exercise therapy or referral to exercise for participants who have a history of falls or who have been assessed as a fall risk. The PCSP may must specify the need for referrals and the need for assistance from the Service Coordinator in obtaining referrals. To the extent that the PCP is part of the PCSP development or PCTP process, the PCSP may must also articulate referrals that the Service Coordinator will enter in the appropriate systems. CHC-MCOs are required to utilize the PCSP checklist template developed by the Department. If requested, the MCO must share minimum necessary service plan information with providers, consistent with HIPAA rules and regulations. If sufficient justification is demonstrated by a provider, that information may include the following: • Total number of authorized units per week (i.e., amount); • Service provision dates (i.e., service begin and end dates); • Preferred schedule (i.e., duration and frequency); • List of tasks detailing participant needs (i.e., ADLs/IADLs); • Service coordinator name, phone, and email address; • Off hours service coordination contact number;• Special conditions and instructions; • Unique circumstances (e.g., allergies, smoking, pets, children under 18 years of age, etc.) When new services are authorized or services are increased via inclusion on a Participant’s PCSP, the new service or increased service level must commence within seven (7) business days of the approval, unless the Participant requests a longer timeframe for the services to start. If a Participant requests a voluntary reduction or termination of services authorized on their PCSP, the CHC-MCO must obtain a clear written statement signed by the Participant attesting to the fact that they no longer wish to receive the service as previously authorized. The PCSP must consider both In and Out-of-Network Covered Services to support the individual in the environment of their his or her choice as well as caregivers’ support needs. PCSPs must be completed developed and implemented no more than 30 thirty (30) calendar days from the date the comprehensive needs assessment Assessment or reassessment Reassessment is completed. PCSPs for Participants who require LTSS will must be developed by the Service Coordinator, the Participant, the Participant’s representative, as appropriate, and the Participant’s PCPT. Participants may appeal part or all of their Service Plan as provided in Exhibit T G, Complaint, Grievance and DHS Fair Hearing Processes.

LTSS Service Plan. ‌ A LTSS Service Plan to identify and address how LTSS needs will be met and how services will be provided in accordance with the PCSP. The LTSS Service Plan must include the following: • All LTSS services necessary to support the Participant in living as independently as possible and remaining as engaged in their his or her community as possible. • For the needs identified in the comprehensive needs assessment, the interventions to address each need or preference, reasonable long-long- term and short-term goals, the measurable outcomes to be achieved by the interventions, the anticipated time lines timelines in which to achieve the desired outcomes, and the staff responsible for conducting the interventions and monitoring the outcomes. • Potential problems that can be anticipated, including the risks and how these risks can be minimized to xxxxxx the Participant’s maximum functioning level of well-being. • Participant decisions around self-directed care and whether the Participant is participating in Participant-Direction. • Communications plan. • How frequently specific services will be provided. • Whether and, if so, how technology and telehealth will be used. • Participant choice of Providers. • Individualized Back-Up Plans. • The person(s)/Providers person(s) and Providers responsible for specific interventions/interventions or services. • Participant’s available, willing, and able informal support network and services. • Participant’s need for and plan to access community resources, non- covered services, and other supports, including any reasonable accommodations. • How to accommodate preferences for leisure activities, hobbies, and community engagement. • Any other needs or preferences of the Participant. • Participant’s goals for the least restrictive setting possible, if they are he or she is being discharged or transitioned from an inpatient setting. • How the CHC-MCO will coordinate with the Participant’s Medicare, VeteransVeterans Benefits, BH-MCO, other health coveragecoverage insurers, and other supports. • Participant’s employment and educational goals. The PCSP may must specify the need for referrals and the need for assistance from the Service Coordinator in obtaining referrals. To the extent that the PCP is part of the PCSP development or PCTP process, the PCSP may must also articulate referrals that the Service Coordinator will enter in the appropriate systems. The PCSP must consider both In and Out-of-Network Covered Services to support the individual in the environment of their his or her choice as well as caregivers’ support needs. PCSPs must be completed no more than 30 thirty (30) days from the date the comprehensive needs assessment or reassessment is completed. PCSPs for Participants who require LTSS will must be developed by the Service Coordinator, the Participant, the Participant’s representative, and the Participant’s PCPT. Participants may appeal part or all of their Service Plan as provided in Exhibit T G, Complaint, Grievance and DHS Fair Hearing Processes.