For MSHO Clause Samples
For MSHO. When enrollment has been approved on or before the last day of the month, medical coverage shall commence at midnight Minnesota time on the first day of the month following the month in which enrollment was approved. Enrollments received after capitation must be submitted directly to the STATE.
For MSHO. (1) The MSHO Institutionalized Rate Cell Category includes the following component adjusted for age, sex and county or region:
(a) Medicaid Institutional Basic Care payment rate.
(2) The MSHO Community EW Rate Cell Category includes the following components, which are adjusted for age, sex and county or region:
(a) Medicaid Community EW Basic Care payment rate.
(b) Elderly Waiver Add-On.
(c) Medicaid one hundred and eighty (180) day NF Add-On.
(3) The MSHO Community Non-EW Rate Cell Category includes the following components, which are adjusted for age, sex and county or region:
(a) Medicaid Community Non-EW Basic Care payment rate.
(b) Medicaid one hundred and eighty (180) day NF Add-On.
For MSHO. (1) Categories. Rate Cell Categories shall be assigned by the STATE upon receipt of the required information as specified in this section and section 3.4 above. Rate Cell Categories shall be assigned prospectively for the next available month.
(2) Changes. Rate Cell Category changes due to a new living arrangement and/or NHC status must be entered into MMIS on or before the enrollment Cut-Off Date in order for the MCO to be paid at the rate corresponding to the new Rate Cell Category at the time that the Capitation Payment is to be paid.
(3) Post-Cut-Off Changes. When a Rate Cell Category change has been entered in the STATE MMIS after the enrollment Cut-Off Date, the MCO will be paid at the rate corresponding to the new Rate Cell Category at the time of the MCO’s next Capitation Payment, unless the requirements provided for in section 4.2.6 are met.
(4) Community Non-EW (Rate Cell Category “A”):
(a) The Community Non-EW Rate Cell Category will be assigned to those Beneficiaries who, at the time of enrollment in the MCO, are coded in a community living arrangement in MMIS and are not on the Elderly Waiver program for the 1st day of the following month.
(b) For changes in MSHO Rate Cell Categories after initial enrollment, the Community Non-EW Rate Cell Category will be assigned after the MCO notifies the STATE that an Enrollee is living in a community setting and has not been assessed to receive EW services.
(5) Community Elderly Waiver (Rate Cell Category “B” and “C”):
(a) The Community EW Rate Cell Category will be assigned to those Beneficiaries who, at the time of enrollment in the MCO, are coded in MMIS to be in a community living arrangement and are enrolled in the Elderly Waiver for the 1st of the following month.
(b) For changes in MSHO Rate Cell Categories after initial enrollment, the Community EW Rate Cell Category will be assigned after the MCO:
i) Notifies the STATE that an Enrollee is living in a community setting; and has indicated that the enrollee has received a Long Term Care Consultation and has been identified to be in need of Elderly Waiver services; and
ii) Enters into MMIS the Screening Document (DHS-3427) completed for that Enrollee.
(c) The Community EW Rate Cell Category will be assigned to those Beneficiaries, who, at capitation, have an open EW span for the next available month.
(d) EW services must be delivered to Enrollees who meet the EW Level of Care criteria based on demonstrated need, and are eligible for payment of LTC se...
For MSHO. (A) The Institutionalized Rate Cell Category includes the following components, which are adjusted for age, sex and county:
(1) Medicaid Institutional Basic Care rate.
(B) Community EW Rate Cell Category includes the following components, which are adjusted for age, sex and county:
(1) Medicaid Non-Institutional Basic Care rate.
(2) Average monthly Elderly Waiver payment.
(3) Medicaid one hundred and eighty (180) day NF Add-On.
(C) Community Non-EW Rate Cell Category includes the following components, which are adjusted for age, sex and county:
(1) Medicaid Non-Institutional Basic Care rate.
(2) Medicaid one hundred and eighty (180) day NF Add-On.
(D) Community Non-EW Hospice Rate Cell Category includes the following components, which are adjusted for age, sex and county:
(1) Medicaid Non-Institutional Basic Care rate.
(E) Community EW Hospice Rate Cell Category includes the following components, which are adjusted for age, sex and county:
(1) Medicaid Non-Institutional Basic Care rate.
(2) 50% of the Average Monthly Elderly Waiver payment.
For MSHO. The MCO, its agents and Marketing representatives, shall not:
(1) Offer or grant any reward, favor, compensation or provide for cash or any other monetary rebate, as an inducement to a Recipient or an MSHO Enrollee to enroll in the MCO. This restriction does not prohibit the MCO from explaining any legitimate benefits a Recipient might obtain as an Enrollee of the MCO. The MCO shall not seek to influence a Recipient’s enrollment with the MCO in conjunction with the sale of any private insurance.
(2) Offer or grant any reward, favor or compensation to a person, county or organization that is not directly hired or contracted by the MCO to conduct marketing, who in the process of informing potential Enrollees about Medical Assistance or other Medicare Programs, steers or attempts to steer the potential Enrollee toward a specific plan or limited number of plans.
(3) Engage in any discriminatory activities.
(4) Engage in any activities that could mislead or confuse Recipients, or misrepresent the MCO.
(5) Make any written or oral assertions or statements that a Recipient or Enrollee must enroll in the MCO in order to obtain or maintain Medical Assistance and covered Medicare benefits, or that the MCO is endorsed by CMS, Medicare, the STATE, or federal government. The MCO may explain that it is approved for participation in Medicare.
(6) Conduct door-to-door solicitation to current or potential MSHO Enrollees. In addition, the MCO must comply with Medicaid regulations that do not allow direct or indirect telephone or other cold-call marketing activities to potential MSHO Enrollees.
(7) Distribute Marketing Materials for which the MCO has not received STATE and CMS approval.
For MSHO. (1) The MSHO Institutionalized Rate Cell Category includes the following component adjusted for age, sex and county or region:
(a) Medicaid Institutional Basic Care payment rate.
(2) The MSHO Community EW Rate Cell Category includes the following components, which are adjusted for age, sex and county or region:
(a) Medicaid Community EW Basic Care payment rate.
(b) Elderly Waiver Add-On.
(c) Medicaid one hundred and eighty (180) day NF Add-On.
For MSHO. The MSHO Institutionalized Rate Cell Category includes the following components, which are adjusted for age, sex and county or region:
(a) Medicaid Institutional Basic Care rate. The MSHO Community EW Rate Cell Category includes the following components, which are adjusted for age, sex and county or region:
(a) Medicaid Community EW Basic Care rate.
(b) Elderly Waiver Add-On.
(c) Medicaid one hundred and eighty (180) day NF Add-On. The MSHO Community Non-EW Rate Cell Category includes the following components, which are adjusted for age, sex and county or region:
(a) Medicaid Community Non-EW Basic Care rate.
(b) Medicaid one hundred and eighty (180) day NF Add-On. The MSHO Community Non-EW Hospice Rate Cell Category includes the following components, which are adjusted for age, sex and county or region:
(a) Medicaid Community Non-EW Basic Care rate. The MSHO Community EW Hospice Rate Cell Category includes the following components, which are adjusted for age, sex and county or region:
(a) Medicaid Community EW Basic Care rate.
(b) 50% of the Elderly Waiver Add-On.
For MSHO. Section 20.2 to 20.2.8 63 (A) The Institutionalized Rate Cell Category includes the following components, which are adjusted for age, sex and county: