Level of Care Determinations for Not Otherwise Medicaid Eligible Individuals. 4.1.2.1 The CONTRACTOR shall conduct a NF LOC evaluation for individuals who are Not Otherwise Medicaid Eligible (NOME) and who, through a waiver allocation issued by HSD or its designee, are found to have indicators that may warrant a NF LOC.
Level of Care Determinations for Not Otherwise Medicaid Eligible Individuals. The CONTRACTOR shall conduct a NF LOC evaluation for individuals who are Not Otherwise Medicaid Eligible (NOME) and who, through a waiver allocation issued by HCA or its designee, are found to have indicators that may warrant a NF LOC. The CONTRACTOR shall have a special unit that identifies, tracks, and processes all NOMEs that are issued a waiver allocation from the Long-Term Services and Support Bureau. This includes, but is not limited to, receiving the Primary Freedom of Choice (PFoC) form, ensuring a 112 file is received from ASPEN, assignment of a care coordinator to complete the CNA and submission to the UM department for a timely NF LOC determination. The unit shall have a supervisor that oversees and ensures NOMEs are properly routed by CONTRACTOR staff until Medicaid eligibility is established. The CONTRACTOR shall use the tools and processes that have been approved by HCA in conducting the NF LOC evaluation. The CONTRACTOR shall interface with HCA eligibility system for level of care in a file format prescribed and approved by HCA. If a Not Otherwise Medicaid Eligible individual has met the NF LOC determination, either because he or she is in a NF or because HCA issued a waiver allocation for Community Benefit services, the CONTRACTOR shall inform HCA of the individual’s level of care determination. If the individual is determined to meet a NF LOC, the CONTRACTOR shall notify HCA to continue the eligibility determination process. To ensure continuity of care for Members with a category of eligibility (XXX) 92, the CONTRACTOR shall continue to determine these Members medically eligible if both of the following conditions are met: (i) the Member’s condition has not changed; and (ii) the Member had a prior year NF LOC approval. Level of Care Determinations for Members who are expected to always meet NF LOC If the CONTRACTOR determines that the Member meets ongoing NF LOC based on criteria prescribed by HCA and outlined in the Managed Care Policy Manual, the CONTRACTOR shall approve an ongoing NF LOC for the Member and will not annually assess the Member for NF LOC. The CONTRACTOR is required to perform a CNA and develop an annual care plan for these Members as described in Sections 4.4.5 and 4.4.9 of this Agreement. The CONTRACTOR shall monitor the ongoing NF LOC status of Members, and report to HCA as required. Enrollment
Level of Care Determinations for Not Otherwise Medicaid Eligible Individuals. 4.1.2.1 The CONTRACTOR shall conduct a nursing facility level of care evaluation for individuals who are Not Otherwise Medicaid Eligible and who, through a preliminary screening conducted by HSD or its designee, are found to have indicators that may warrant a nursing facility level of care.
