Common use of Nursing Facilities Clause in Contracts

Nursing Facilities. Nursing facility care, although a part of the care continuum, presents a challenge for managed care. Because of the process for becoming eligible for Medicaid assistance in a nursing facility, there is frequently a significant time gap between entry into the nursing home and determination of Medicaid eligibility. During this gap from entry to Medicaid eligibility, the resident has “nested” in the facility and many of the community supports are no longer available. To require participation of all nursing facility residents would result in the HMO maintaining a Member in the nursing facility without many options for managing their health. For this reason, persons who qualify for Medicaid as a result of nursing facility residency are not enrolled in STAR+PLUS. The STAR+PLUS HMO must participate in the Promoting Independence initiative for such individuals. Promoting Independence (PI) is a philosophy that aged and disabled individuals remain in the most integrated setting to receive long-term care services. PI is Texas' response to the U.S. Supreme Court ruling in Xxxxxxxx v. X.X. that requires states to provide community-based services for persons with disabilities who would otherwise be entitled to institutional services, when: • the state's treatment professionals determine that such placement is appropriate; • the affected persons do not oppose such treatment; and • the placement can be reasonably accommodated, taking into account the resources available to the state and the needs of others who are receiving state supported disability services. In accordance with legislative direction, the HMO must designate a point of contact to receive referrals for nursing facility residents who may potentially be able to return to the community through the use of 1915(c) Nursing Facility Waiver services. To be eligible for this option, an individual must reside in a nursing facility until a written plan of care for safely moving the resident back into a community setting has been developed and approved. A STAR+PLUS Member who enters a nursing facility will remain a STAR+PLUS Member for a total of four months. The nursing facility will xxxx the state directly for covered nursing facility services delivered while the Member is in the nursing facility. See Section 8.3.2.7 for further information.

Nursing Facilities. Nursing facility care, although a part of the care continuum, presents a challenge for managed care. Because of the process for becoming eligible for Medicaid assistance in a nursing facility, there is frequently a significant time gap between entry into the nursing home and determination of Medicaid eligibility. During this gap from entry to Medicaid eligibilitygap, it is likely that the resident has will have “nested” in the facility and many of the community supports are no longer available. To require participation of all nursing facility residents would result in the HMO MCO maintaining a Member in the nursing facility without many options for managing their health. For this reason, persons who qualify for Medicaid as a result of nursing facility residency are not enrolled in STAR+PLUS. The STAR+PLUS HMO MCO must participate in the Promoting Independence (PI) initiative for such individuals. Promoting Independence (PI) PI is a philosophy that aged and disabled individuals remain in the most integrated setting to receive longLong-term care servicesServices and Supports. PI is Texas' response to the U.S. Supreme Court ruling in Xxxxxxxx v. X.X. that X.X., which requires states to provide community-based services for persons with disabilities who would otherwise be entitled to institutional services, when: • : 1. the state's treatment professionals determine that such placement is appropriate; • ; 2. the affected persons do not oppose such treatment; and • and 3. the placement can be reasonably accommodated, taking into account the resources available to the state and the needs of others who are receiving state supported disability services. In accordance with legislative direction, the HMO MCO must designate a point of contact to receive referrals for nursing facility residents who may potentially be able to return to the community through the use of 1915(c) Nursing Facility Waiver services. To be eligible for this option, an individual must reside in a nursing facility until a written plan of care for safely moving the resident back into a community setting has been developed and approved. A STAR+PLUS Member who enters a nursing facility will remain a STAR+PLUS Member for a total of four (4) months. The nursing facility will xxxx the state directly for covered nursing facility services delivered while the Member is in the nursing facility. See Section 8.3.2.7 for further information.

Nursing Facilities. Nursing facility care, although a part of the care continuum, presents a challenge for managed care. Because of the process for becoming eligible for Medicaid assistance in a nursing facility, there is frequently a significant time gap between entry into the nursing home and determination of Medicaid eligibility. During this gap from entry to Medicaid eligibility, the resident has “nested” in the facility and many of the community supports are no longer available. To require participation of all nursing facility residents would result in the HMO maintaining a Member in the nursing facility without many options for managing their health. For this reason, persons who qualify for Medicaid as a result of nursing facility residency are not enrolled in STAR+PLUS. The STAR+PLUS HMO must participate in the Promoting Independence initiative for such individuals. Promoting Independence (PI) is a philosophy that aged and disabled individuals remain in the most integrated setting to receive long-term care services. PI is Texas' response to the U.S. Supreme Court ruling in Xxxxxxxx v. X.X. L.C. that requires states to provide community-based services for persons with disabilities who would otherwise be entitled to institutional services, when: • the state's treatment professionals determine that such placement is appropriate; • the affected persons do not oppose such treatment; and • the placement can be reasonably accommodated, taking into account the resources available to the state and the needs of others who are receiving state supported disability services. In accordance with legislative direction, the HMO must designate a point of contact to receive referrals for nursing facility residents who may potentially be able to return to the community through the use of 1915(c) Nursing Facility Waiver services. To be eligible for this option, an individual must reside in a nursing facility until a written plan of care for safely moving the resident back into a community setting has been developed and approved. A STAR+PLUS Member who enters a nursing facility will remain a STAR+PLUS Member for a total of four months. The nursing facility will xxxx the state directly for covered nursing facility services delivered while the Member is in the nursing facility. See Section 8.3.2.7 for further information.

Nursing Facilities. Nursing facility care, although a part of the care continuum, presents a challenge for managed care. Because of the process for becoming eligible for Medicaid assistance in a nursing facility, there is frequently a significant time gap between entry into the nursing home and determination of Medicaid eligibility. During this gap from entry to Medicaid eligibilitygap, it is likely that the resident has “will have "nested” " in the facility and many of the community supports are no longer available. To require participation of all nursing facility residents would result in the HMO MCO maintaining a Member in the nursing facility without many options for managing their health. For this reason, persons who qualify for Medicaid as a result of nursing facility residency are not enrolled in STAR+PLUS. The STAR+PLUS HMO MCO must participate in the Promoting Independence (PI) initiative for such individuals. Promoting Independence (PI) PI is a philosophy that aged and disabled individuals remain in the most integrated setting to receive longLong-term care servicesServices and Supports. PI is Texas' response to the U.S. Supreme Court ruling in Xxxxxxxx v. X.X. that X.X., which requires states to provide community-based services for persons with disabilities who would otherwise be entitled to institutional services, when: • : 1. the state's treatment professionals determine that such placement is appropriate; • ; 2. the affected persons do not oppose such treatment; and • and 3. the placement can be reasonably accommodated, taking into account the resources available to the state and the needs of others who are receiving state supported disability services. In accordance with legislative direction, the HMO MCO must designate a point of contact to receive referrals for nursing facility residents who may potentially be able to return to the community through the use of 1915(c) Nursing Facility HCBS STAR+PLUS Waiver services. To be eligible for this option, an individual must reside in a nursing facility until a written plan of care for safely moving the resident back into a community setting has been developed and approved. A STAR+PLUS Member who enters a nursing facility will remain a STAR+PLUS Member for a total of four (4) months. The nursing facility will xxxx the state directly for covered nursing facility services delivered while the Member is in the nursing facility. See Section 8.3.2.7 for further information. The MCO is responsible for the Member at the time of nursing facility entry and must utilize the Service Coordinator staff to complete an assessment of the Member within 30 days of entry in the nursing facility, and develop a plan of care to transition the Member back into the community if possible. If at this initial review, return to the community is possible, the Service Coordinator will work with the resident and family to return the Member to the community using HCBS STAR+PLUS Waiver Services. If the initial review does not support a return to the community, the Service Coordinator will conduct a second assessment 90 days after the initial assessment to determine any changes in the individual's condition or circumstances that would allow a return to the community. The Service Coordinator will develop and implement the transition plan. The MCO will provide these services as part of the PI initiative. The MCO must maintain the documentation of the assessments completed and make them available for state review at any time. It is possible that the STAR+PLUS MCO will be unaware of the Member's entry into a nursing facility. It is the responsibility of the nursing facility to review the Member's Medicaid card upon entry into the facility and notify the MCO. The nursing facility is also required to notify HHSC of the entry of a new resident.

Nursing Facilities. Nursing facility care, although a part of the care continuum, presents a challenge for managed care. Because of the process for becoming eligible for Medicaid assistance in a nursing facility, there is frequently a significant time gap between entry into the nursing home and determination of Medicaid eligibility. During this gap from entry to Medicaid eligibilitygap, it is likely that the resident has “will have "nested” " in the facility and many of the community supports are no longer available. To require participation of all nursing facility residents would result in the HMO MCO maintaining a Member in the nursing facility without many options for managing their health. For this reason, persons who qualify for Medicaid as a result of nursing facility residency are not enrolled in STAR+PLUS. The STAR+PLUS HMO MCO must participate in the Promoting Independence (PI) initiative for such individuals. Promoting Independence (PI) PI is a philosophy that aged and disabled individuals remain in the most integrated setting to receive longLong-term care servicesServices and Supports. PI is Texas' response to the U.S. Supreme Court ruling in Xxxxxxxx v. X.X. that X.X., which requires states to provide community-based services for persons with disabilities who would otherwise be entitled to institutional services, when: • : 1. the state's treatment professionals determine that such placement is appropriate; • ; 2. the affected persons do not oppose such treatment; and • and 3. the placement can be reasonably accommodated, taking into account the resources available to the state and the needs of others who are receiving state supported disability services. In accordance with legislative direction, the HMO MCO must designate a point of contact to receive referrals for nursing facility residents who may potentially be able to return to the community through the use of 1915(c) Nursing Facility HCBS STAR+PLUS Waiver services. To be eligible for this option, an individual must reside in a nursing facility until a written plan of care for safely moving the resident back into a community setting has been developed and approved. A STAR+PLUS Member who enters a nursing facility will remain a STAR+PLUS Member for a total of four months. The nursing facility will xxxx the state directly for covered nursing facility services delivered while the Member is in the nursing facility. See Section 8.3.2.7 for further information.

Nursing Facilities. This section is deleted effective February 28, 2015. Nursing facility care, although a part of the care continuum, presents a challenge for managed care. Because of the process for becoming eligible for Medicaid assistance in a nursing facility, there is frequently a significant time gap between entry into the nursing home and determination of Medicaid eligibility. During this gap from entry to Medicaid eligibilitygap, it is likely that the resident has “will have "nested” " in the facility and many of the community supports are no longer available. To require participation of all nursing facility residents would result in the HMO MCO maintaining a Member in the nursing facility without many options for managing their health. For this reason, persons who qualify for Medicaid as a result of nursing facility residency are not enrolled in STAR+PLUS. The STAR+PLUS HMO MCO must participate in the Promoting Independence (PI) initiative for such individuals. Promoting Independence (PI) PI is a philosophy that aged and disabled individuals remain in the most integrated setting to receive longLong-term care servicesServices and Supports. PI is Texas' response to the U.S. Supreme Court ruling in Xxxxxxxx v. X.X. that X.X., which requires states to provide community-based services for persons with disabilities who would otherwise be entitled to institutional services, when: • : 1. the state's treatment professionals determine that such placement is appropriate; • ; 2. the affected persons do not oppose such treatment; and • and 3. the placement can be reasonably accommodated, taking into account the resources available to the state and the needs of others who are receiving state supported disability services. In accordance with legislative direction, the HMO MCO must designate a point of contact to receive referrals for nursing facility residents who may potentially be able to return to the community through the use of 1915(c) Nursing Facility HCBS STAR+PLUS Waiver services. To be eligible for this option, an individual must reside in a nursing facility until a written plan of care for safely moving the resident back into a community setting has been developed and approved. A STAR+PLUS Member who enters a nursing facility will remain a STAR+PLUS Member for a total of four (4) months. The nursing facility will xxxx the state directly for covered nursing facility services delivered while the Member is in the nursing facility. See Section 8.3.2.7 for further information. The MCO is responsible for the Member at the time of nursing facility entry and must utilize the Service Coordinator staff to complete an assessment of the Member within 30 days of entry in the nursing facility, and develop a plan of care to transition the Member back into the community if possible. If at this initial review, return to the community is possible, the Service Coordinator will work with the resident and family to return the Member to the community using HCBS STAR+PLUS Waiver Services. If the initial review does not support a return to the community, the Service Coordinator will conduct a second assessment 90 days after the initial assessment to determine any changes in the individual's condition or circumstances that would allow a return to the community. The Service Coordinator will develop and implement the transition plan. The MCO will provide these services as part of the PI initiative. The MCO must maintain the documentation of the assessments completed and make them available for state review at any time. It is possible that the STAR+PLUS MCO will be unaware of the Member's entry into a nursing facility. It is the responsibility of the nursing facility to review the Member's Medicaid card upon entry into the facility and notify the MCO. The nursing facility is also required to notify HHSC of the entry of a new resident.