Medicaid SSI Sample Clauses

Medicaid SSI. If a member is in a nursing home 90 days or longer, the member shall be disenrolled. In the event the member transfers from the nursing home to a hospital and back to the nursing home, the applicable 90 day period shall run continuously from the first admission to the nursing home and shall include any days in the hospital.
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Medicaid SSI. All mandatory Medicaid SSI or SSI related Medicaid members shall have the right to disenroll from the HMO pursuant to 42 CFR 438.56 unless otherwise limited by a State Plan Amendment. A voluntary disenrollment shall be effective no later than the first day of the second month following the month in which the member requests termination. Wisconsin currently has a State Plan Amendment which allows the Department to “lock-in” members to the HMO for a period of 12 months in mandatory HMO service areas, unless disenrollment is allowed for just cause. Voluntary exemptions and disenrollments from the HMO are allowed for a variety of reasons. All voluntary Medicaid SSI members shall have the right to disenroll from the HMO within the first 90 days of enrollment. Such voluntary Medicaid SSI disenrollment shall be effective no earlier than the first day of the month following the request to disenroll. If the member, legal guardian or authorized representative does not elect disenrollment during the first three months of enrollment, the member will be locked-in to the HMO for the remainder of the 12-month enrollment period.
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Medicaid SSI. The PIHP may request an exemption after an SSI member has been in a nursing home 90 days and is expected to remain in the facility. In the event the member transfers from the nursing home to a hospital and back to the nursing home, the applicable 90 day period shall run continuously from the first admission to the nursing home and shall include any days in the hospital. The PIHP must wait until after 90 days before requesting an exemption, which will occur the first of the next month.
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Medicaid SSI. The HMO may request an exemption after an SSI member has been in a nursing home 90 days and is expected to remain in the facility. In the event the member transfers from the nursing home to a hospital and back to the nursing home, the applicable 90 day period shall run continuously from the first admission to the nursing home and shall include any days in the hospital. The HMO must wait until after 90 days before requesting an exemption, which will occur the first of the next month.
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Medicaid SSI. The current State Plan Amendment requires an all-in opt-out enrollment in the HMO for enrollment areas where there are two or more HMOs with sufficient slots for the eligible populations. See Article I for definition of “all-in opt-out”. If at any time during the Contract period the Department obtains a State Plan Amendment, a waiver or revised authority under the Social Security Act (as amended), the conditions of enrollment described, including but not limited to voluntary enrollment and the right to voluntary disenrollment will be amended by the terms of said waiver and a State Plan Amendment.
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Medicaid SSI. The current State Plan Amendment requires mandatory enrollment into an HMO for those service areas in which there are two or more HMOs with sufficient slots for the HMO eligible population and in rural areas, as defined in 42 CFR 438.52, where there is only one HMO with an adequate provider network as determined by the Department. Medicaid SSI members who are dual eligible for Medicaid and Medicare and members who are enrolled in a Medicaid Purchase Plan (XXXX) are not subject to mandatory enrollment.
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Medicaid SSI. The current State Plan Amendment requires mandatory enrollment into an HMO for those service areas in which there are two or more HMOs. Enrollment for an HMO is voluntary for Medicaid members who are enrolled in Medicare and members who are enrolled in Medicaid Purchase Plan (XXXX). Enrollment Determination The Department will identify BadgerCare Plus, Medicaid SSI and SSI-Related Medicaid members who are eligible for enrollment in the HMO as the result of eligibility under the medical eligibility status codes listed in the chart at the following link: xxxxx://xxx.xxxxxxxxxxxxx.xx.xxx/WIPortal/content/Managed%20Care%20Orga nization/Enrollment_Information/word/MedStats.docx.spage Medical Status Codes Eligible for BadgerCare Plus and Medicaid SSI HMO Enrollment. Enrollment Section
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Related to Medicaid SSI

  • Medicaid Enrollment Treatment Grantees shall enroll as a provider with Texas Medicaid and Healthcare Partnership (TMHP) and all Medicaid Managed Care organizations in Grantee’s service region within the first quarter of this procurement term and maintain through the procurement term.

  • Medicaid If and when the Resident’s assets/funds have fallen below the Medicaid eligibility levels, and the Resident otherwise satisfies the Medicaid eligibility requirements and is not entitled to any other third party coverage, the Resident may be eligible for Medicaid (often referred to as the “payor of last resort”). THE RESIDENT, RESIDENT REPRESENTATIVE AND SPONSOR AGREE TO NOTIFY THE FACILITY AT LEAST THREE (3) MONTHS PRIOR TO THE EXHAUSTION OF THE RESIDENT’S FUNDS (APPROXIMATELY $50,000) AND/OR INSURANCE COVERAGE TO CONFIRM THAT A MEDICAID APPLICATION HAS OR WILL BE SUBMITTED TIMELY AND ENSURE THAT ALL ELIGIBILITY REQUIREMENTS HAVE BEEN MET. THE RESIDENT, RESIDENT REPRESENTATIVE AND/OR SPONSOR AGREE TO PREPARE AND FILE AN APPLICATION FOR MEDICAID BENEFITS PRIOR TO THE EXHAUSTION OF THE RESIDENT’S RESOURCES. Services reimbursed under Medicaid are outlined in Attachment “A” to this Agreement. Once a Medicaid application has been submitted on the Resident’s behalf, the Resident, Sponsor, and Resident Representative agree to pay, to the extent they have access to the Resident’s funds, to the Facility the Resident’s monthly income, which will be owed to the Facility under the Resident’s Medicaid budget. Medicaid recipients are required to pay their Net Available Monthly Income (“NAMI”) to the Facility on a monthly basis as a co-payment obligation as part of the Medicaid rate. A Resident’s NAMI equals his or her income (e.g., Social Security, pension, etc.), less allowed deductions. The Facility has no control over the determination of NAMI amounts, and it is the obligation of the Resident, Resident Representative and/or Sponsor to appeal any disputed NAMI calculation with the appropriate government agency. Once Medicaid eligibility is established, the Resident, Resident Representative and/or Sponsor agree to pay NAMI to the Facility or to arrange to have the income redirected by direct deposit to the Facility and to ensure timely Medicaid recertification. The Resident, Sponsor and Resident Representative agree to provide to the Facility copies of any notices (such as requests for information, budget letters, recertification, denials, etc.) they receive from the Department of Social Services related to the Resident’s Medicaid coverage. Until Medicaid is approved, the Facility may bill the Resident’s account as private pay and the Resident will be responsible for the Facility’s private pay rate. If Medicaid denies coverage, the Resident or the Resident’s authorized representative can appeal such denial; however, payment for any uncovered services will be owed to the Facility at the private pay rate pending the appeal determination. If Medicaid eligibility is established and retroactively covers any period for which private payment has been made, the Facility agrees to refund or credit any amount in excess of the NAMI owed during the covered period.

  • Medicaid Program Parties (applicable to any Party providing services and supports paid for under Vermont’s Medicaid program and Vermont’s Global Commitment to Health Waiver):

  • 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

  • Contractor Standards Contractor shall comply with Contractor Standards provisions codified in the SDMC. Contractor understands and agrees that violation of Contractor Standards may be considered a material breach of the Contract and may result in Contract termination, debarment, and other sanctions.

  • Medicaid-Funded Hours Worked Effective July 1, 2021, the Employer shall contribute the Retirement Rate or eighty cents ($0.80), whichever is higher, to the Retirement Trust for each Medicaid-Funded Hour worked by all home care workers covered by this Agreement with seven-hundred and one (701) or more cumulative career hours and fifty cents ($0.50) for each hour worked by all home care workers covered by this Agreement with less than seven-hundred one (701) cumulative career hours. Medicaid-Funded Hour(s) worked shall be defined as all hours worked by all employees covered by this Agreement in the Employer's in-home care program that are paid by Medicaid, excluding vacation hours, paid-time off hours, and training hours.

  • Compassionate Care Leave (a) Compassionate care leave will be granted to an employee for up to eight (8) weeks within a twenty-six (26) week period to provide care or support to a family member who is at risk of dying within that 26-week period in accordance with section 49.1 of the Employment Standards Act, 2000.

  • Extended Health Care Coverage A) The Employer shall pay one hundred percent (100%) of the monthly premiums for extended health care coverage for regular employees and their eligible dependents (including common-law spouses) under the Pacific Blue Cross Plan, or any other plan mutually acceptable to the Union and the Employer (See also Appendix “I”). The plan benefits shall be expanded to include:

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