MANAGED CARE EFFECT Sample Clauses

MANAGED CARE EFFECT. The blended nature of the NFLOC rate cell encourages MCOPs to manage the mix of the population towards lower cost settings. This is the basis for efficiencies in LTSS programs. This transition between settings (e.g. nursing facility to HCBS waiver services) is gradual in nature and is not an immediate transition. Most often, individuals that are in a nursing facility for a long period of time have lost their community supports and it becomes difficult to change the setting away from a nursing facility. Therefore, MCOPs will need to seek individuals that are newer to LTSS benefits and avoid or delay nursing facility placement. Because of this, we assumed gradual increases in HCBS percentages and decreases in nursing facility percentages. Our assumption for CY 2017 is that the average mix between HCBS and nursing facility will shift by 1% in favor of HCBS for the year. We believe this assumption is reasonable, appropriate, and attainable, as the MCOPs reported on a composite basis for the Opt-Out population in the June 2016 YTD cost reports a 2% rebalancing shift from January 2016 through June 2016.
Sample 1
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MANAGED CARE EFFECT. The blended nature of the NFLOC rate cell encourages MCOPs to manage the mix of the population towards lower cost settings. This is the basis for efficiencies in LTSS programs. This transition between settings (e.g. nursing facility to HCBS waiver services) is gradual in nature and is not an immediate transition. Most often, individuals that are in a nursing facility for a long period of time have lost their community supports and it becomes difficult to change the setting away from a nursing facility. Therefore, MCOPs will need to seek individuals that are newer to LTSS benefits and avoid or delay nursing facility placement. Because of this, we assumed gradual increases in HCBS percentages and decreases in nursing facility percentages. Our assumption for CY 2018 is that the number of individuals in a nursing facility will be reduced by 1% in favor of HCBS for the year. This assumes MCOPs will achieve a shift of 1% on the entire year’s NF enrollment, or a gradual uniform shift ending at a 2% rebalancing factor by the end of CY 2018.
Sample 1
MANAGED CARE EFFECT. The blended nature of the NFLOC rate cell encourages MCOPs to manage the mix of the population towards lower cost settings. This is the basis for efficiencies in LTSS programs. This transition between settings (e.g. nursing facility to HCBS waiver services) is gradual in nature and is not an immediate transition. Most often, individuals that are in a nursing facility for a long period of time have lost their community supports and it becomes difficult to change the setting away from a nursing facility. Therefore, MCOPs will need to seek individuals that are newer to LTSS benefits and avoid or delay nursing facility placement. Because of this, we assumed gradual increases in HCBS percentages and decreases in nursing facility percentages. Our assumption for CY 2016 is that the average mix between HCBS and nursing facility will shift by 1% in favor of HCBS for the year.
Sample 1

Related to MANAGED CARE EFFECT

  • Medicare If the Resident meets the eligibility requirements for skilled nursing facility benefits under the Medicare Part A Hospital Insurance Program, the Facility will bill Medicare directly for Part A services provided to the Resident. Medicare will reimburse the Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG IV guidelines or successor guidelines thereto. If the Resident continues to be eligible, Medicare may provide coverage of up to 100 days of care. The first 20 days of covered services are fully paid by Medicare and the next 80 days (days 21 through 100) of the covered services are paid in part by Medicare and subject to a daily coinsurance amount for which the Resident is responsible. A Resident with Medicare Part B and/or Part D coverage, who subsequently exhausts his/her Part A coverage or no longer needs a skilled level of care under Part A, may still be eligible to receive coverage for certain Part B services (previously included in the Part A payment to the Facility) and/or Part D services when Part A coverage ends. Medicare will terminate coverage for Medicare beneficiaries receiving physical, occupational and/or speech therapy (“therapy services”) if the Resident does not receive therapy for three (3) consecutive days, whether planned or unplanned, for any reason, including illness or refusals, doctor appointments or religious holidays. If such therapy was the basis for Medicare Part A coverage, the Resident would be responsible for the cost of his/her stay, unless another payor source is available. If Medicare denies coverage and denies further payment and/or recoups any payment made to the Facility, the Resident, Resident Representative, and/or Sponsor hereby agree to pay to the Facility any outstanding amounts for unpaid services not covered by other third party payers, subject to applicable federal and state laws and regulations. Such amounts shall be calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and additional services provided to the Resident. Except for specifically excluded services, most nursing home services are covered under the consolidated billing requirements for Medicare Part A beneficiaries or under an all-inclusive rate for other third party insurers and managed care organizations (MCOs). Under these requirements, the Facility is responsible for furnishing directly, or arranging for, the services for its residents covered by Medicare Part A and MCOs. When not directly providing services, the Facility is required to enter into arrangements with outside providers and must exercise professional responsibility and control over the arranged-for services. All services that the Resident requires must be provided by the Facility or an outside provider approved by the Facility. Before obtaining any services outside of the Facility, the Resident must consult the Facility. While the Resident has the right to choose a health care provider, the Resident understands that by selecting the Facility, the Resident has effectively exercised his/her right of free choice with respect to the entire package of services for which the Facility is responsible under the consolidated billing and third party billing requirements. The Resident agrees that he/she will not arrange for the provision of ancillary services unless the Resident has obtained prior approval from the Facility. MEDICARE PART A, MANAGED CARE, AND THIRD-PARTY INSURANCE

  • Child Abuse Reporting Requirements A. Grantees shall comply with child abuse and neglect reporting requirements in Texas Family Code Chapter 261. This section is in addition to and does not supersede any other legal obligation of the Grantee to report child abuse.

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