Nursing Facility Services. The PH-MCO is responsible for payment for nursing home care (including hospital reserve or bed hold days). A PH-MCO may not deny or otherwise limit Medically Necessary services, such as home health services, on the grounds that the Member needs, but is not receiving, a higher level of care. The PH-MCO must abide by the decision of the Functional Eligibility Determination process determination letter related to the need for Nursing Facility services. The Department will not enroll Recipients who are placed into a Nursing Facility and who were not previously enrolled in the HealthChoices Physical Health Program or individuals who enter a Nursing Facility and are then determined eligible for MA in the HealthChoices Physical Health Program. If an individual leaves the Nursing Facility to reside in the HealthChoices Physical Health Zone covered by this Agreement and is then determined eligible for Enrollment into the HealthChoices Physical Health Program, the individual will be enrolled in the HealthChoices Physical Health Program.
Nursing Facility Services. For Medicaid covered nursing facility stays, the MCP shall evaluate the member’s need for the level of services provided by a nursing facility. To make this decision, the MCP shall use the criteria for nursing facility-based level of care pursuant to OAC rules 5160-3-08, 5160-3-09, and 5160-1-01. The MCP shall evaluate for both intermediate and skilled levels of care concurrently when making a level of care determination. The MCP shall provide documentation of the member’s level of care determination to the nursing facility. If properly submitted by a provider, the MCP is required to accept the Ohio Medicaid Managed Care/MyCare Ohio Nursing Facility Request Form to prior authorize nursing facility services and determine level of care. The MCP shall maintain a written record that the criteria were met, or if not met, the MCP shall maintain documentation that a Notice of Action was issued in accordance with OAC rule 5160-26-08.4. In accordance with OAC rule 5160-3-14, the preadmission screening and resident review (PASRR) process must be completed before a level of care determination can be issued. The MCP shall have processes in place to ensure that PASRR requirements are met in accordance with OAC chapter 5160-3 prior to issuing a level of care determination. At a minimum, the MCP shall pay nursing facility providers in accordance with ORC section 5165.15. Additionally, the MCP shall ensure accurate claims payment to nursing facility providers by appropriately modifying payment pursuant to OAC rule 5160-3-39.1 when a member has patient liability obligations or lump sum amounts. Patient liability shall be applied as an offset against the amount Medicaid would otherwise reimburse for the claim. If the patient liability exceeds the amount Medicaid would reimburse, the claim shall be processed with a payment of zero dollars. The MCP is prohibited from paying for nursing facility services during restricted Medicaid coverage periods (RMCP). The MCP shall utilize HIPAA compliant enrollment files for patient liability obligations and RMCPs.
Nursing Facility Services. The PH-MCO is responsible for payment for up to thirty (30) days of nursing home care (including hospital reserve or bed hold days) if a Member is admitted to a Nursing Facility in accordance with Exhibit BB, Rule F.1 of this Agreement.. Members are disenrolled from HealthChoices thirty (30) days following the admission date to the Nursing Facility as long as the Member has not been discharged from the Nursing Facility. A PH-MCO may not deny or otherwise limit Medically Necessary services, such as home health services, on the grounds that the Member needs, but is not receiving, a higher level of care. A PH- MCO may not offer financial or other incentives to obtain or expedite a Member’s admission to a Nursing Facility except as short-term nursing care, not to exceed thirty (30) days. The PH-MCO must abide by the decision of the OPTIONS assessment process determination letter related to the need for Nursing Facility services. Recipients who are placed into a Nursing Facility from a hospital and who were not previously enrolled in the HealthChoices Program or individuals who enter a Nursing Facility from a hospital and are then determined eligible for MA will not be enrolled in HealthChoices. However, should an individual leave the Nursing Facility to reside in the HealthChoices Zone covered by this Agreement and then be determined eligible for Enrollment into HealthChoices, they will then be required to enroll into the HealthChoices Program. Individuals who are residing in Nursing Facilities and are subsequently found eligible for MA will not be enrolled in the HealthChoices Program. Individuals eligible for MA, but not mandated into the HealthChoices Program when they enter Nursing Facilities, or Recipients who are placed in Nursing Facilities inside the HealthChoices Zone covered by this Agreement, who previously resided outside the HealthChoices Zone covered by this agreement, will not be enrolled in the HealthChoices Program.
Nursing Facility Services. For Medicaid covered nursing facility stays, the MCP must evaluate the member’s need for the level of services provided by a nursing facility. To make this decision, the MCP must use the criteria for nursing facility-based level of care pursuant to OAC rules 5160- 3-08 and 5160-1-01. The MCP must maintain a written record that the criteria were met, or if not met, the MCP must maintain documentation that a Notice of Action was issued in accordance with OAC 5160-26-08.4.
Nursing Facility Services. For Medicaid covered nursing facility stays, the MCP shall evaluate the member’s need for the level of services provided by a nursing facility. To make this decision, the MCP shall use the criteria for nursing facility-based level of care pursuant to OAC rules 5160-3-08, 5160-3-09, and 5160-1-01. The MCP shall provide documentation of the member’s level of care determination to the nursing facility. The MCP shall maintain a written record that the criteria were met, or if not met, the MCP shall maintain documentation that a Notice of Action was issued in accordance with OAC rule 5160-26-08.4. In accordance with OAC rule 5160-3-14, the preadmission screening and resident review (PASRR) process must be completed before a level of care determination can be issued. The MCP shall have processes in place to ensure that PASRR requirements are met in accordance with OAC chapter 5160-3 prior to issuing a level of care determination. The MCP shall ensure accurate claims payment to nursing facility providers by appropriately modifying payment pursuant to OAC rule 5160-3-39.1 when a member has patient liability obligations or lump sum amounts. Patient liability shall be applied as an offset against the amount Medicaid would otherwise reimburse for the claim. If the patient liability exceeds the amount Medicaid would reimburse, the claim shall be processed with a payment of zero dollars. The MCP is prohibited from paying for nursing facility services during restricted Medicaid coverage periods (RMCP). The MCP shall utilize HIPAA compliant enrollment files for patient liability obligations and RMCPs.
Nursing Facility Services. The PH-MCO is responsible for payment for up to thirty (30) days of nursing home care (including hospital reserve or bed hold days) if a Member is admitted to a Nursing Facility in accordance with Exhibit BB, Rule F.1. Members are disenrolled from HealthChoices thirty
Nursing Facility Services. The CHC-MCO is responsible for payment for Medically Necessary NF services, including bed hold days up to fifteen (15) days per hospitalization if the NF satisfies the occupancy percentage requirements and up to thirty (30) Therapeutic Leave Days per year if a Participant is admitted to a NF or resides in a NF at the time of Enrollment. The CHC-MCO must, in coordination with the Department, monitor for completion of all NF-related processes, including but not limited to: PASRR process, specialized service delivery, Participant’s rights, patient pay liability, personal care accounts, or other identified processes. In each CHC zone, and for at least 18 consecutive months following the Implementation Date, the CHC-MCO must contract, with any NF enrolled in the MA Program that: (1) is willing to accept, and does accept, the CHC- MCO’s payment rates; and (2) is willing to comply with, and does comply with, the quality and other standards and terms established by the Department and by the CHC-MCO. This requirement applies if the CHC-MCO contracts directly with individual NFs for services in its network or indirectly through provider groups or other joint arrangements. Before the expiration of the initial 18-month period, the Department, in its sole discretion and with notice to the CHC-MCO, may extend this requirement for an additional period determined by the Department and again for any additional periods thereafter. The Department may, in its sole discretion and upon notice to the CHC-MCO, impose any other NF network contracting requirements that the Department determines are necessary to ensure that Participants have adequate access to NF care.
Nursing Facility Services. For Medicaid covered nursing facility stays, the MCP shall evaluate the member’s need for the level of services provided by a nursing facility. To make this decision, the MCP shall use the criteria for nursing facility-based level of care pursuant to OAC rules 5160-3-08, 5160-3-09, and 5160-1-01. The MCP shall provide documentation of the member’s level of care determination to the nursing facility. The MCP shall maintain a written record that the criteria were met, or if not met, the MCP shall maintain documentation that a Notice of Action was issued in accordance with OAC rule 5160-26-08.4. In accordance with OAC rule 5160-3-14, the preadmission screening and resident review (PASRR) process must be completed before a level of care determination can be issued. The MCP shall have processes in place to ensure that PASRR requirements are met in accordance with OAC chapter 5160-3 prior to issuing a level of care determination. At a minimum, the MCP shall pay nursing facility providers in accordance with ORC section 5165.15. Additionally, the MCP shall ensure accurate claims payment to nursing facility providers by appropriately modifying payment pursuant to OAC rule 5160-3-39.1 when a member has patient liability obligations or lump sum amounts. Patient liability shall be applied as an offset against the amount Medicaid would otherwise reimburse for the claim. If the patient liability exceeds the amount Medicaid would reimburse, the claim shall be processed with a payment of zero dollars. The MCP is prohibited from paying for nursing facility services during restricted Medicaid coverage periods (RMCP). The MCP shall utilize HIPAA compliant enrollment files for patient liability obligations and RMCPs.
Nursing Facility Services. In any plan year, the PCO is responsible for up to 120 days of nursing facility care (including hospital reserve or bed hold days). The days need not be consecutive.
Nursing Facility Services. The CHC-MCO is responsible for payment for Medically Necessary NF services, including bed hold days and up to fifteen (15) days per hospitalization and up to thirty (30) Therapeutic Leave Days per year if a Participant is admitted to a NF or resides in a NF at the time of Enrollment. The CHC-MCO must, in coordination with the Department, monitor for completion of all NF related processes, including but not limited to: PASRR process, specialized service delivery, Participant’s rights, patient pay liability, personal care accounts or other identified processes.
