Common use of Intake Clause in Contracts

Intake. The intake process begins when you or someone on your behalf contacts CHA PACE. A representative will explain our program and obtain further information about you. • How CHA PACE works • The kinds of services CHA PACE offers • The answers to any questions you may have about CHA PACE • That when you enroll, you must agree to receive all your medical and health care exclusively from CHA PACE or its contracted service providers, with the exception of emergency services • Your monthly payment, if any If you are interested in joining CHA PACE, the CHA PACE enrollment staff will discuss your health and safety status with other members of the enrollment team. CHA PACE will ask that you sign a release allowing us to obtain your past medical records so our team has complete information about your health conditions. Within three weeks, we will have evaluated your health and safety status. We will meet to share our findings and ideas for your care. At this meeting, we will decide whether you meet the criteria for admission into the program, that is, whether your health needs appear to meet the MassHealth criteria for nursing facility level-of-care and whether you are living safely in your home or in the community. This includes assessing whether CHA PACE can meet your medical, nursing, psychological and social needs in conjunction with your family or support network, if any, and whether remaining in your home or in the community jeopardizes your health and safety. You may be denied enrollment if remaining in your home and or the community would jeopardize your health and safety. In such cases, the CHA PACE staff will provide written notification explaining the reason for the denial and refer you to appropriate alternative services. Mailing Address: Executive Office of Health & Human Services Board of Hearings Location: ▇▇▇ ▇▇▇▇▇▇▇ ▇▇. Quincy, MA 02171 Phone: (▇▇▇) ▇▇▇-▇▇▇▇ Or ▇-▇▇▇-▇▇▇-▇▇▇▇ TTY: (▇▇▇) ▇▇▇-▇▇▇▇ Fax: (▇▇▇) ▇▇▇-▇▇▇▇ If we assess that you are eligible for CHA PACE, you and your care giver/family will be invited to meet with our staff. At that time, we will review and come to an agreement about your participation in CHA PACE before you sign the Enrollment Agreement. At this meeting you and your care giver/family will have an opportunity to: • Discuss the plan of care recommended by enrollment staff and your suggestions and preferences. • Ask questions about your monthly payment, if any. • Ask questions about losing Medicare and MassHealth benefits that you may currently have (except for emergency or urgent care), as you will only be eligible for services provided and/or authorized by CHA PACE after enrollment. • Discuss the partnership between you, and/or your caregiver/family and CHA PACE. • What to do if you are dissatisfied with the care you receive from CHA PACE (see the Grievances and Appeals section of this agreement). • If you decide to join CHA PACE, you will be given the opportunity to agree to and accept the conditions of enrollment by signing the Enrollment Agreement.

Intake. The intake process Intake begins when you or someone calls on your behalf contacts CHA PACEor comes to LIFE. A representative • If it appears from this conversation that you are potentially eligible, a LIFE Enrollment Specialist will schedule a visit to your home, explain our program and obtain further information about youconduct a preliminary screening. • How CHA PACE works • The kinds of services CHA PACE offers • The answers to any questions you may have about CHA PACE • That when you enroll, you must agree to receive all your medical and health care exclusively from CHA PACE or its contracted service providers, with the exception of emergency services • Your monthly payment, if any If you are interested in joining CHA PACE, the CHA PACE enrollment staff will discuss your health and safety status with other members of the enrollment team. CHA PACE We will ask that you sign a release of information allowing us to obtain your past medical records so our team has complete information about Interdisciplinary Team can fully assess your health conditions. Within three weeks, we will have evaluated your health and safety status. We • Gathering this information will meet allow you to share our findings attend the LIFE center so that you can get to know us and ideas for your care. At this meeting, we will decide whether you meet the criteria for admission into the program, that is, whether have your health needs appear evaluated by each Interdisciplinary Team Member. A tuberculosis skin test(s) or a chest x-ray, or proof of within the last year is required during the enrollment/ intake process. Testing will be done at intake if needed and results will not impact or preclude enrollment. • LIFE is committed to meet serving the MassHealth criteria for nursing facility levelelderly who need long-of-care and whether you are living safely in your home or in the community. This includes assessing whether CHA PACE can meet your medicalterm care; therefore, nursing, psychological and social needs in conjunction with your family or support network, if any, and whether remaining in your home or in the community jeopardizes an independent opinion must confirm that your health and safety. You may be denied enrollment if remaining in your home and or the community would jeopardize your health and safety. In such cases, the CHA PACE staff will provide written notification explaining the reason for the denial and refer status qualifies you to appropriate alternative services. Mailing Address: Executive Office of Health & Human Services Board of Hearings Location: ▇▇▇ ▇join the PACE program administered by LIFE St. ▇▇▇▇▇▇ ▇▇of the Pines. Quincy• Our LIFE Staff will complete the information on the North Carolina Medicaid Program Long Term Care Services Assessment tool and will submit to the Division of Medical Assistance. • The Division of Medical Assistance will review this Assessment tool submitted by LIFE and determine if you are eligible for nursing home care by state requirements. In the event that the Division of Medical Assistance finds that you are not eligible for nursing home care by state requirements, MA 02171 Phone: (▇▇▇) ▇▇▇-▇▇▇▇ Or ▇-▇▇▇-▇▇▇-▇▇▇▇ TTY: (▇▇▇) ▇▇▇-▇▇▇▇ Fax: (▇▇▇) ▇▇▇-▇▇▇▇ you will not be able to enroll into the program. If we assess determine you are not able to live safely in the community, your enrollment will be denied. LIFE will work with you to make other arrangements for the care you need. You have the right to appeal your eligibility determination or a denial of enrollment. This appeal should be made through the State Fair Hearing Process through the Office of Administrative Hearings: If you are a Medicare Beneficiary or Private Pay for the LIFE program you can contact: • Should the Division of Medical Assistance approve that you are eligible for CHA PACEnursing home care by state requirements, assessments will occur in the LIFE Center and in your home. • First, the In-Home Services Coordinator, RN, a member of the Interdisciplinary Team, will coordinate a time to visit you in your home and determine if you can live safely in the community with LIFE services. There may be other members of the Interdisciplinary Team who may also visit you in your care giver/family will be invited home. • Next, the Interdisciplinary Team and an Enrollment Specialist coordinate a time for you to meet with our staff. At that time, we will review and come to an agreement about the LIFE Center. Here, various Interdisciplinary Team members shall evaluate your participation in CHA PACE before you sign needs. • When each Interdisciplinary Team member has evaluated your situation, the Enrollment Agreement. At this meeting you Interdisciplinary Team will meet to share their findings and will develop your care giver/family will have an opportunity to: • Discuss the individual plan of care recommended by enrollment staff and your suggestions and preferences. • Ask questions about your monthly payment, if any. • Ask questions about losing Medicare and MassHealth benefits that you may currently have (except for emergency or urgent care), as you will only be eligible for services provided and/or authorized by CHA PACE after enrollment. • Discuss the partnership between you, and/or your caregiver/family and CHA PACE. • What to do if you are dissatisfied with the care you receive from CHA PACE (see the Grievances and Appeals section of this agreement). • If you decide to join CHA PACE, you will be given the opportunity to agree to and accept the conditions of enrollment by signing the Enrollment Agreement.

Intake. The intake process begins when you or someone on your behalf contacts CHA PACEESP. A representative will explain our program and obtain further information about you. • How CHA PACE ESP works • The kinds of services CHA PACE ESP offers • The answers to any questions you may have about CHA PACE ESP • That when you enroll, you must agree to receive all your medical and health care exclusively from CHA PACE ESP or its contracted service providers, with the exception of emergency services • Your monthly payment, if any If you are interested in joining CHA PACEESP, the CHA PACE ESP’s enrollment staff will discuss your health and safety status with other members of the enrollment team. CHA PACE ESP will ask that you sign a release allowing us to obtain your past medical records so our team has complete information about your health conditions. Within three weeks, we will have evaluated your health and safety status. We will meet to share our findings and ideas for your care. At this meeting, we will decide whether you meet the criteria for admission into the program, that is, whether your health needs appear to meet the MassHealth criteria for nursing facility level-of-care and whether you are living safely in your home or in the community. This includes assessing whether CHA PACE ESP can meet your medical, nursing, psychological and social needs in conjunction with your family or support network, if any, and whether remaining in your home or in the community jeopardizes your health and safety. You may be denied enrollment if remaining in your home and or the community would jeopardize your health and safety. In such cases, the CHA PACE ESP staff will provide written notification explaining the reason for the denial and refer you to appropriate alternative services. Mailing Address: Executive Office of Health & Human Services Board of Hearings Location: ▇▇▇ ▇▇▇▇▇▇▇ ▇▇. Quincy, MA 02171 Phone: (▇▇▇) ▇▇▇-▇▇▇▇ Or ▇-▇▇▇-▇▇▇-▇▇▇▇ TTY: (▇▇▇) ▇▇▇-▇▇▇▇ Fax: (▇▇▇) ▇▇▇-▇▇▇▇ If we assess that you are eligible for CHA PACEESP, you and your care giver/family will be invited to meet with our staff. At that time, we will review and come to an agreement about your participation in CHA PACE ESP before you sign the Enrollment Agreement. At this meeting you and your care giver/family will have an opportunity to: • Discuss the plan of care recommended by enrollment staff and your suggestions and preferences. • Ask questions about your monthly payment, if any. • Ask questions about losing Medicare and MassHealth benefits that you may currently have (except for emergency or urgent care), as you will only be eligible for services provided and/or authorized by CHA PACE ESP after enrollment. • Discuss the partnership between you, and/or your caregiver/family and CHA PACEESP. • What to do if you are dissatisfied with the care you receive from CHA PACE ESP (see the Grievances and Appeals section of this agreement). • If you decide to join CHA PACEESP, you will be given the opportunity to agree to and accept the conditions of enrollment by signing the Enrollment Agreement. ESP is authorized to serve only those eligible for a nursing facility level of care. Accordingly, an outside screening must confirm that your health situation in fact qualifies you for this care. At the time of enrollment, MassHealth, through its screening agent, authorizes your eligibility for ESP. If the screening agent finds that you are not qualified for a nursing facility level of care, you will not be eligible to enroll, though you would have the right to appeal this finding. On an annual basis, the screening agent of the MassHealth program will determine whether you continue to be eligible for a nursing facility level of care. If, in the opinion of the screening agent, you do not meet the criteria for long term care, you will be deemed ineligible for ESP, and you must disenroll. ESP’s staff will work with you to reinstate you, if you are eligible.

Intake. The intake process Intake begins when you or someone on your behalf contacts CHA PACEmakes a call to Saint ▇▇▇▇▇▇▇ LIFE. A representative If it appears from this first conversation that you are potentially eligible, a Saint ▇▇▇▇▇▇▇ LIFE Enrollment Specialist will schedule an appointment and visit you at home. They will explain our the program and obtain further information about you. • How CHA PACE works • The During this visit: You will learn how the Saint ▇▇▇▇▇▇▇ LIFE program works, and the kinds of services CHA PACE offers • The answers to the program offers, and the Enrollment Specialist will answer any questions you may have about CHA PACE • That when have. We will explain that if you enroll, you must agree to receive that all your medical healthcare services will be provided and/or coordinated by Saint ▇▇▇▇▇▇▇ LIFE, including primary care and health care exclusively from CHA PACE or its contracted service providers, with the exception specialist provider services (other than emergency services). Members of emergency services • Your monthly payment, if any If you are interested in joining CHA PACE, the CHA PACE enrollment staff will discuss your health team will approve these services. You may be fully and safety status with personally liable for the cost of unauthorized or out-of-network services (other members of the enrollment teamthan emergency services). CHA PACE We will ask that have you sign a release allowing us form so that we can get your medical and financial information, as well as your eligibility for Medicare and Medicaid. The next step is that the Saint ▇▇▇▇▇▇▇ LIFE Level-of-Care Nurse will visit you at home to obtain discuss your past medical records so our team has complete information needs in more detail. The Saint ▇▇▇▇▇▇▇ LIFE Occupational Therapist might also visit you to discuss how you move about your health conditionshome and any safety issues. Within three weeksThen you will visit the Saint ▇▇▇▇▇▇▇ LIFE Center, we and you will have evaluated meet with the rest of the care team: Primary Care Provider, Nurse, Social Worker, Dietitian, Physical Therapist, Occupational Therapist, and Recreational Therapist, Day Center Manager, Home Care Coordinator, Personal Care Attendant, and Transportation Coordinator. Each member of this team will meet with you in person to evaluate your health needs and safety statusgoals. We After the assessment has been completed, the team will meet to share specifically discuss your evaluation and determine if your needs can be appropriately met by our findings program. If so, the team will develop an individual plan of care and ideas services and schedule time with you to explain how it will best meet your needs and preferences. However, Saint ▇▇▇▇▇▇▇ LIFE cannot guarantee or offer enrollment before a formal eligibility determination has been made. To be eligible for your care. At this meetingSaint ▇▇▇▇▇▇▇ LIFE, we will decide whether you meet the criteria for admission into the program, state must certify that is, whether your health needs appear to meet the MassHealth criteria for status meets its nursing facility level-of-level of care and whether you are living safely in your home or in the communitycriteria. This includes assessing whether CHA PACE can meet your medical, nursing, psychological and social needs in conjunction with your family or support network, if any, and whether remaining in your home or in the community jeopardizes your health and safety. You may be denied enrollment if remaining in your home and or the community would jeopardize your health and safety. In such cases, the CHA PACE staff will provide written notification explaining the reason for the denial and refer you to appropriate alternative services. Mailing Address: Executive Office of Health & Human Services Board of Hearings Location: ▇▇▇▇▇ ▇▇▇▇▇▇▇ LIFE submits its recommendation to a DMMA Pre-Admission Screening nurse, who will make the final decision. ▇▇. Quincy, MA 02171 Phone: (▇▇▇) ▇▇▇-▇▇▇▇ Or ▇-▇▇▇-▇▇▇-▇▇▇▇ TTY: (LIFE will let you know the decision. If DMMA determines that you are ineligible to enroll because you do not meet nursing home level of care, or you are denied enrollment because it has been determined that you are not able to live safely in the community, ▇▇▇) ▇▇▇-▇▇▇▇ Fax: (▇▇▇) ▇▇▇-▇▇▇▇ LIFE will work with you to find other services to meet your needs. You may also appeal the level of care determination. ▇▇▇▇▇ ▇▇▇▇▇▇▇ LIFE will give you information on how to appeal to DMMA. If we assess that you need Medicaid to pay for Saint ▇▇▇▇▇▇▇ LIFE services, your Enrollment Agreement will not be complete until you are eligible approved for CHA PACEby the DMMA for Medicaid long-term care community-based services. If you do not need Medicaid to pay, you and your care giver/family will be invited may opt to meet with our staffprivately pay a premium. At that timeOnce all requirements are met, we will review and come to an agreement about your participation in CHA PACE before you sign the Enrollment Agreement. At this meeting you and your care giver/family will have an opportunity to: • Discuss the plan of care recommended by enrollment staff and your suggestions and preferences. • Ask questions about your monthly payment, if any. • Ask questions about losing Medicare and MassHealth benefits that you may currently have (except for emergency or urgent care), as you will only be eligible for services provided and/or authorized by CHA PACE after enrollment. • Discuss enroll in the partnership between you, and/or your caregiver/family and CHA PACE. • What to do if you are dissatisfied with the care you receive from CHA PACE (see the Grievances and Appeals section of this agreement). • If you decide to join CHA PACE, you will be given the opportunity to agree to and accept the conditions of enrollment by signing the Enrollment AgreementSaint ▇▇▇▇▇▇▇ LIFE program.

Intake. The intake process begins when you or someone on your behalf contacts CHA Harbor PACE. A representative will explain our program and obtain further information about you. You will learn: • How CHA Harbor PACE works • The kinds kind of services CHA Harbor PACE offers • The answers to any questions you may have about CHA Harbor PACE • That when you enrollupon enrollment, you must agree to receive all your medical and health care exclusively from CHA Harbor PACE or its contracted service providers, with the exception of emergency services or services prior authorized by Harbor PACE • Your anticipated monthly payment, payment if any one applies If you are interested in joining CHA Harbor PACE, the CHA PACE enrollment staff we will discuss assess your health and safety status with other members of the enrollment teamto determine your eligibility. CHA Harbor PACE will ask that you sign a medical release form allowing us to obtain your past medical records records, so our team has complete information about your health conditions. Within three weeksIf you and your care-partner(s) would like, we will have evaluated schedule a tour of the Harbor PACE Center or visits with other Harbor PACE staff. Shortly after your decision to explore the option of enrolling in Harbor PACE we will arrange for an evaluation of your health and safety status. We will meet to share assess our findings and ideas plans for your care. At During this meetingtime, we will decide whether you meet the criteria for admission into the program, that is, whether your health needs appear to meet the MassHealth criteria for nursing facility level-of-of- care and whether you are living safely in your home or in the community. This includes assessing whether CHA Harbor PACE can comprehensively meet your medical, nursing, psychological and social care needs in conjunction with your family care-partner(s) or support network, if any, and whether remaining in your home or in the community jeopardizes your health and safety. The assessment criteria includes: • Level of care required to meet on-going medical, health, and social needs in the community • Safety of the home environment • Cognitive capacity of the applicant regarding ability to be left unsupervised without jeopardizing health and/or safety • Willingness of the applicant and their care-partner(s) to comply with the plan of care and safety recommendations. Harbor PACE is authorized to serve only those eligible for a nursing facility level of care. Accordingly, an outside screening must confirm that your health situation qualifies you for this care. At the time of enrollment, MassHealth, through its screening agent, authorizes your eligibility for Harbor PACE. If the screening agent finds that you are not qualified for a nursing facility level of care, you will not be eligible to enroll, though you would have the right to appeal this finding using the appeal. You may also be denied enrollment if remaining in your home and or we find that you do not meet the community would jeopardize your health and safetyassessment criteria. In such cases, the CHA Harbor PACE staff will provide written notification explaining the reason for the denial and refer you to appropriate alternative services. Mailing Address: If you are denied enrollment, you have the right to appeal this decision with the Executive Office of Health & Human Services Board of Hearings LocationHearings. You can do so by sending in a Fair Hearing Request Form (see the Fair Hearing Request Form in this agreement on page 33) or calling. The information for this is below: ▇▇▇ ▇▇▇▇▇▇▇ ▇▇. Quincy, MA 02171 Phone: (▇▇▇) ▇▇▇-▇▇▇▇ Or ▇-▇▇▇-▇▇▇-▇▇▇▇ TTY: (▇▇▇) ▇▇▇-▇▇▇▇ Fax: (▇▇▇) ▇▇▇-▇▇▇▇ If we assess that you are eligible for CHA Harbor PACE, you and your care giver/family will be invited to meet with our Harbor PACE staff. At that time, we will review the program with you again and come to an agreement about your participation in CHA Harbor PACE before you sign the Enrollment Agreement. At this meeting you and your care giver/family care-partner(s) will have an opportunity to: • Discuss the plan of care recommended by enrollment staff and Harbor PACE, noting your suggestions and preferences. preferences • Ask questions about your monthly payment, payment if any. any • Ask questions about losing Medicare and MassHealth benefits that you may currently have (except for emergency or urgent care), as you will only be eligible for services provided and/or authorized by CHA Harbor PACE after enrollment. enrollment • Discuss the partnership between you, and/or your caregiver/family care-partner(s) and CHA PACE. Harbor PACE • What Learn what to do if you are dissatisfied with the care you receive from CHA Harbor PACE (see the Grievances and Appeals section of this agreement). agreement on page 16) • Review current services to ensure continuity of care, including the plan to continue or discontinue services after enrollment If you decide to join CHA Harbor PACE, we will then ask you will be given the opportunity to agree to and accept the conditions of enrollment by signing the Enrollment Agreement. Upon signing, you will receive an Enrollment Packet including: • A copy of the Harbor PACE enrollment agreement • Instructions on managing emergency/urgent care needs • HIPAA Information • A copy of your initial Service Plan • Listing of Harbor PACE IDT members • Copies of all signed enrollment documents • A membership card that will be mailed to your residence Enrollment in Harbor PACE will result in your disenrollment from any other Medicare plan, such as a Medicare Advantage Plan, or Medicaid prepayment plan or optional benefit. On an annual basis, the screening agent of the MassHealth program will determine whether you are still qualified for nursing facility level of care. If the screening agent determines that you no longer meet the criteria for nursing facility level of care, you will not be eligible to continue your enrollment with Harbor PACE and we must disenroll you from our program. You have the right to appeal involuntary disenrollment from Harbor PACE, you can do this by following the process described above on page 11. There is one exception to this rule. If the MassHealth screening agent determines through your reassessment that although you do not currently meet nursing facility level of care, absent of Harbor PACE care and services you would be likely to require nursing facility level of care within 6 months, you will be deemed eligible to continue your enrollment with Harbor PACE.