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 HCA so as to ensure no lapse in payment to the NF if the Member is determined to meet the criteria for Medicaid payment. Care Coordination Assignment 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 Zero (CCL0) The CONTRACTOR shall assign Members to CCL 0, as follows: Members the CONTRACTOR was unable to reach after making reasonable outreach efforts as described in Section 4.4.4.4.3, Members assessed to not have a current need for an assigned care coordinator; Members who have been contacted and refuse Care Coordination; Care Coordination Level One (CCL1) The CONTRACTOR shall assign Members to CCL1, at a minimum, as follows: Members who meet NF LOC; Perinatal and maternal health Members, including Members in the MHV program Members receiving LTSS; Members in a Nursing Facility Level of Care Waiver populations not listed in CCL2; and Members with multiple (three or more) complaints, grievances, or appeals related to the Member’s experience with the service delivery system. Care Coordination Level Two (CCL2) The CONTRACTOR shall assign Members to CCL2 who, at a minimum, have the following: HCHN Members; Members with SUD; Members with SED; Members with SMI; Justice-Involved Individuals; Members with TBI; Members with housing inse...
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.
