Nursing Facility Level of Care Sample Clauses

Nursing Facility Level of Care. The determination that the level of care (LOC) required to adequately serve a STAR+PLUS MMP Enrollee is at or above the level of care provided by a Nursing Facility.

Nursing Facility Level of Care. For Members who have indicators that may warrant a NF LOC, the CONTRACTOR shall conduct an in-person CNA at the Member’s primary residence. The CONTRACTOR shall use the New Mexico Medicaid NF LOC Criteria and instructions to determine NF LOC eligibility for all Members. For Members in the ABP who meet NF LOC, the CONTRACTOR shall notify the Member that they may be ABP Exempt, explain the benefit differences for ABP Exempt individuals and facilitate their movement into the ABP exempt benefit package (the Covered Services included in Attachment 1: Turquoise Care Covered Services) at the Member’s choice. For Members transitioning from a Medicare NF stay to a Medicaid short-term acute NF stay, the CONTRACTOR shall complete the short-term stay authorization determination no later than five (5) Business Days before the transition occurs, and follow the process prescribed by HSD so as to ensure no lapse in payment to the NF if the Member is determined to meet the criteria for Medicaid payment. The CONTRACTOR's Care Coordination program description shall specify the CONTRACTOR’s process for the assignment of a Care Coordination Level, a change in Care Coordination Level, assignment of care coordinators, and care coordinator caseload ratios. The process shall be consistent with the Care Coordination assignment requirements in this Section 4.4.5 and dependent on the outcome of the CNA. Care Coordination Level Two (CCL2) The CONTRACTOR shall assign CCL2, at a minimum, to Members with one (1) or more of the following factors: Has multi-comorbidity; Has high emergency room use, defined as three (3) or more emergency room visits in ninety (90) days; Has a mental health or substance abuse condition causing moderate functional impairment; Requires assistance with two (2) or more ADLs and/or IADLs and is living in the community at low risk; Has mild cognitive deficits requiring prompting or cues: Has poly-pharmaceutical use, which is defined as simultaneous use of six (6) or more medications from different drug classes and/or simultaneous use of three (3) or more medications from the same drug class; Is a Member with a high risk pregnancy (including pregnant Members who are eighteen (18) years and younger); Is a CISC; Is a Justice-Involved Member (refer to Section 5.12 of the Managed Care Policy Manual for details); or Is a CARA Member. Care Coordination Level Three (CCL3) The CONTRACTOR shall assign to CCL3, at a minimum, to Members with one (1) or more of the following f...