Individuals with Special Health Care Needs Sample Clauses

Individuals with Special Health Care Needs. Adults and children/adolescents, who face physical, mental or environmental challenges daily that place at risk their health and ability to fully function in society. Factors include individuals with mental retardation or related conditions; individuals with serious chronic illnesses, such as human immunodeficiency virus (HIV), schizophrenia or degenerative neurological disorders; individuals with disabilities resulting from many years of chronic illness such as arthritis, emphysema or diabetes; and children/adolescents and adults with certain environmental risk factors such as homelessness or family problems that lead to the need for placement in xxxxxx care.
Sample 1Sample 2Sample 3See All (5)
AutoNDA by SimpleDocs
Individuals with Special Health Care Needs. 1. The Health Plan shall implement mechanisms for identifying, assessing and ensuring the existence of an individualized treatment plan for individuals with special health care needs, as defined in Attachment II, Section I, Definitions and Acronyms. Mechanisms shall include evaluation of risk assessments, claims data, and CPT/ICD-9 codes. Additionally, the Health Plan shall implement a process for receiving and considering provider and enrollee input.
Sample 1Sample 2Sample 3See All (4)
Individuals with Special Health Care Needs. The plan shall implement mechanisms for identifying, assessing and ensuring the existence of an Individualized Treatment Plan for individuals with special health care needs as defined in Section I, Definitions and Acronyms. Mechanisms shall include evaluation of risk assessments, claims data, and CPT/ICD-9 codes. Additionally, the plan shall implement a process for receiving and considering provider and enrollee input. In accordance with this contract and 42 CFR 438.208(c)(3), an Individualized Treatment Plan for an enrollee determined to need a course of treatment or regular care monitoring must be: · Developed by the enrollee's direct service mental health care professional with enrollee participation and in consultation with any specialists caring for the enrollee; · Approved by the plan in a timely manner if this approval is required; and · Developed in accordance with any applicable Agency quality assurance and utilization review standards. Pursuant to 42 CFR 438.208(c)(4), for Enrollees with special health care needs determined through an assessment by appropriate mental health care professionals (consistent with 42 CFR 438.208(c)(2)) to need a course of treatment or regular care monitoring, the plan must have a mechanism in place to allow Enrollees to directly access a mental health care specialist (for example, through a standing referral or an approved number of visits) as appropriate for the Enrollee's condition and identified needs.
Sample 1Sample 2
Individuals with Special Health Care Needs. Enrollees who face physical, behavioral or environmental challenges daily that place at risk their health and ability to fully function in society. This includes individuals with mental retardation or related conditions; individuals with serious chronic illnesses, such as human immunodeficiency virus (HIV), schizophrenia or AHCA Contract No. FPOO5, Attachment H, Page 17 of 157 degenerative neurological disorders; individuals with disabilities resulting from many years of chronic illness such as arthritis, emphysema or diabetes; children/adolescents and adults with certain environmental risk factors such as homelessness or family problems that lead to the need for placement in xxxxxx care; and all enrollees in LTC plans.
Sample 1
Individuals with Special Health Care Needs. The plan shall implement mechanisms for identifying, assessing and ensuring the existence of a treatment plan for individuals with special health care needs, as specified in Section 20.12,
Sample 1
Individuals with Special Health Care Needs. Enrollees who face physical, behavioral or environmental challenges daily that place at risk their health and ability to fully function in society. This includes individuals with mental retardation or related conditions; individuals with serious chronic illnesses, such as human immunodeficiency virus (HIV), schizophrenia or degenerative neurological disorders; individuals with disabilities resulting from many years of chronic illness such as arthritis, emphysema or diabetes; children/adolescents and adults with certain environmental risk factors such as homelessness or family problems that lead to the need for placement in xxxxxx care; and all enrollees in LTC plans.
Sample 1
Individuals with Special Health Care Needs. The PDHP shall implement mechanisms for identifying, assessing and ensuring the existence of a treatment plan for individuals with special health care needs, as specified in Section 20.12,
Sample 1
AutoNDA by SimpleDocs

Related to Individuals with Special Health Care Needs

  • HEALTH CARE PLANS ‌ Notwithstanding the references to the Pacific Blue Cross Plans in this article, the parties agree that Employers, who are not currently providing benefits under the Pacific Blue Cross Plans may continue to provide the benefits through another carrier providing that the overall level of benefits is comparable to the level of benefits under the Pacific Blue Cross Plans.

  • Health Care Operations Health Care Operations shall have the meaning set out in its definition at 45 C.F.R. § 164.501, as such provision is currently drafted and as it is subsequently updated, amended or revised.

  • Extended Health Care Plan (a) The Employer shall pay the monthly premium for regular employees entitled to coverage under a mutually acceptable Extended Health Care Plan.

  • Health Care Matters Without limiting the generality of any representation or warranty made in Article 7 or any covenant made in Articles 8 or 9, each Borrower represents and warrants on a joint and several basis to and covenants with the Administrative Agent and each Lender, and shall be deemed to represent, warrant and covenant on each day on which any advance or accommodation in respect of any Loan is requested or made or any Liabilities shall be outstanding under this Agreement (or any Affiliate Term Loan Liabilities shall be outstanding under the Term Loan Agreement), that:

  • Health Care Spending Account After six (6) months of permanent employment, full time and part time (20/40 or greater) employees may elect to participate in a Health Care Spending Account (HCSA) Program designed to qualify for tax savings under Section 125 of the Internal Revenue Code, but such savings are not guaranteed. The HCSA Program allows employees to set aside a predetermined amount of money from their pay, not to exceed the maximum amount authorized by federal law, per calendar year, of before tax dollars, for health care expenses not reimbursed by any other health benefit plans. HCSA dollars may be expended on any eligible medical expenses allowed by Internal Revenue Code Section 125. Any unused balance is forfeited and cannot be recovered by the employee.

  • Medicaid If and when the Resident’s assets/funds have fallen below the Medicaid eligibility levels, and the Resident otherwise satisfies the Medicaid eligibility requirements and is not entitled to any other third party coverage, the Resident may be eligible for Medicaid (often referred to as the “payor of last resort”). THE RESIDENT, RESIDENT REPRESENTATIVE AND SPONSOR AGREE TO NOTIFY THE FACILITY AT LEAST THREE (3) MONTHS PRIOR TO THE EXHAUSTION OF THE RESIDENT’S FUNDS (APPROXIMATELY $50,000) AND/OR INSURANCE COVERAGE TO CONFIRM THAT A MEDICAID APPLICATION HAS OR WILL BE SUBMITTED TIMELY AND ENSURE THAT ALL ELIGIBILITY REQUIREMENTS HAVE BEEN MET. THE RESIDENT, RESIDENT REPRESENTATIVE AND/OR SPONSOR AGREE TO PREPARE AND FILE AN APPLICATION FOR MEDICAID BENEFITS PRIOR TO THE EXHAUSTION OF THE RESIDENT’S RESOURCES. Services reimbursed under Medicaid are outlined in Attachment “A” to this Agreement. Once a Medicaid application has been submitted on the Resident’s behalf, the Resident, Sponsor, and Resident Representative agree to pay, to the extent they have access to the Resident’s funds, to the Facility the Resident’s monthly income, which will be owed to the Facility under the Resident’s Medicaid budget. Medicaid recipients are required to pay their Net Available Monthly Income (“NAMI”) to the Facility on a monthly basis as a co-payment obligation as part of the Medicaid rate. A Resident’s NAMI equals his or her income (e.g., Social Security, pension, etc.), less allowed deductions. The Facility has no control over the determination of NAMI amounts, and it is the obligation of the Resident, Resident Representative and/or Sponsor to appeal any disputed NAMI calculation with the appropriate government agency. Once Medicaid eligibility is established, the Resident, Resident Representative and/or Sponsor agree to pay NAMI to the Facility or to arrange to have the income redirected by direct deposit to the Facility and to ensure timely Medicaid recertification. The Resident, Sponsor and Resident Representative agree to provide to the Facility copies of any notices (such as requests for information, budget letters, recertification, denials, etc.) they receive from the Department of Social Services related to the Resident’s Medicaid coverage. Until Medicaid is approved, the Facility may bill the Resident’s account as private pay and the Resident will be responsible for the Facility’s private pay rate. If Medicaid denies coverage, the Resident or the Resident’s authorized representative can appeal such denial; however, payment for any uncovered services will be owed to the Facility at the private pay rate pending the appeal determination. If Medicaid eligibility is established and retroactively covers any period for which private payment has been made, the Facility agrees to refund or credit any amount in excess of the NAMI owed during the covered period.

  • Medicare If the Resident meets the eligibility requirements for skilled nursing facility benefits under the Medicare Part A Hospital Insurance Program, the Facility will bill Medicare directly for Part A services provided to the Resident. Medicare will reimburse the Facility a fixed per diem or daily fee based on the Resident’s classification within the Medicare RUG IV guidelines or successor guidelines thereto. If the Resident continues to be eligible, Medicare may provide coverage of up to 100 days of care. The first 20 days of covered services are fully paid by Medicare and the next 80 days (days 21 through 100) of the covered services are paid in part by Medicare and subject to a daily coinsurance amount for which the Resident is responsible. A Resident with Medicare Part B and/or Part D coverage, who subsequently exhausts his/her Part A coverage or no longer needs a skilled level of care under Part A, may still be eligible to receive coverage for certain Part B services (previously included in the Part A payment to the Facility) and/or Part D services when Part A coverage ends. Medicare will terminate coverage for Medicare beneficiaries receiving physical, occupational and/or speech therapy (“therapy services”) if the Resident does not receive therapy for three (3) consecutive days, whether planned or unplanned, for any reason, including illness or refusals, doctor appointments or religious holidays. If such therapy was the basis for Medicare Part A coverage, the Resident would be responsible for the cost of his/her stay, unless another payor source is available. If Medicare denies coverage and denies further payment and/or recoups any payment made to the Facility, the Resident, Resident Representative, and/or Sponsor hereby agree to pay to the Facility any outstanding amounts for unpaid services not covered by other third party payers, subject to applicable federal and state laws and regulations. Such amounts shall be calculated in accordance with the Facility’s applicable prevailing private rates and charges for all basic and additional services provided to the Resident. Except for specifically excluded services, most nursing home services are covered under the consolidated billing requirements for Medicare Part A beneficiaries or under an all-inclusive rate for other third party insurers and managed care organizations (MCOs). Under these requirements, the Facility is responsible for furnishing directly, or arranging for, the services for its residents covered by Medicare Part A and MCOs. When not directly providing services, the Facility is required to enter into arrangements with outside providers and must exercise professional responsibility and control over the arranged-for services. All services that the Resident requires must be provided by the Facility or an outside provider approved by the Facility. Before obtaining any services outside of the Facility, the Resident must consult the Facility. While the Resident has the right to choose a health care provider, the Resident understands that by selecting the Facility, the Resident has effectively exercised his/her right of free choice with respect to the entire package of services for which the Facility is responsible under the consolidated billing and third party billing requirements. The Resident agrees that he/she will not arrange for the provision of ancillary services unless the Resident has obtained prior approval from the Facility. MEDICARE PART A, MANAGED CARE, AND THIRD-PARTY INSURANCE

  • Extended Health Care Benefits 12.02(a) The City will provide for all employees by contract through an insurer selected by the City an Extended Health Care Plan which will provide extended health care benefits. The City shall pay one hundred per cent (100%) of the premiums, which will include any premiums payable under The Health Insurance Act, R.S.O. 1990, as amended. Eligible Expenses (Benefit year January 1 – December 31)

  • HEALTH PROGRAM 3701 Health examinations required by the Employer shall be provided by the Employer and shall be at the expense of the Employer. 3702 Time off without loss of regular pay shall be allowed at a time determined by the Employer for such medical examinations and laboratory tests, provided that these are performed on the Employer’s premises, or at a facility designated by the Employer. 3703 With the approval of the Employer, a nurse may choose to be examined by a physician of her/his own choice, at her/his own expense, as long as the Employer receives a statement as to the fitness of the nurse from the physician. 3704 Time off for medical and dental examinations and/or treatments may be granted and such time off, including necessary travel time, shall be chargeable against accumulated income protection benefits.

  • Health Care Savings Plan As provided in this Agreement, eligible ASF Members will participate in the health care savings plan (HCSP) established under Minnesota Statute 352.98, and as administered by the Plan Administrator. The Employer is responsible only for transferring funds, as specified in this agreement, to the Plan Administrator.

Time is Money Join Law Insider Premium to draft better contracts faster.