Long Term Care Services Sample Clauses

Long Term Care Services. Respite Care Services, except as specifically mentioned under Hospice Care Benefits. — Services or supplies received during an Inpatient stay when the stay is solely related to behavioral, social maladjustment, lack of discipline or other anti­ social actions which are not specifically the result of Mental Illness. This does not include services or supplies provided for the treatment of an injury resulting from an act of domestic violence or a medical condition (including both physical and mental health conditions). — Special education therapy such as music therapy or recreational therapy, ex­ cept as specifically provided for in this Certificate. — Cosmetic Surgery and related services and supplies, except for the correc­ tion of congenital deformities or for conditions resulting from accidental injuries, tumors or disease. — Services or supplies received from a dental or medical department or clinic maintained by an employer, labor union or other similar person or group. — Services or supplies for which you are not required to make payment or would have no legal obligation to pay if you did not have this or similar cov­ erage. — Charges for failure to keep a scheduled visit or charges for completion of a Claim form or charges for the transfer of medical records. — Personal hygiene, comfort or convenience items commonly used for other than medical purposes such as air conditioners, humidifiers, physical fitness equipment, televisions and telephones. — Special braces, splints, specialized equipment, appliances, ambulatory appa­ ratus or, battery implants except as specifically stated in this Certificate. — Prosthetic devices, special appliances or surgical implants which are for cos­ metic purposes, the comfort or convenience of the patient or unrelated to the treatment of a disease or injury. — Nutritional items such as infant formula, weight‐loss supplements, over‐the‐ counter food substitutes, non‐prescription vitamins and herbal supplements, except as stated in this Certificate. — Blood derivatives which are not classified as drugs in the official formu­ laries. — Hypnotism. — Inpatient and Outpatient Private Duty Nursing Service. — Routine foot care, except for persons diagnosed with diabetes. — Maintenance Occupational Therapy, Maintenance Physical Therapy and Maintenance Speech Therapy, except as specifically mentioned in this Cer­ tificate. — Maintenance Care. — Self‐management training, education and medical nutrition therapy, except as specifical...
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Long Term Care Services. The following is a non-exhaustive, high-level listing of Community Based Long Term Care Covered Services included under the STAR+PLUS Medicaid managed care program. • Community Based Long Term Care Services for all Members o Personal Attendant Services - All Members of a STAR+PLUS MCO may receive medically and functionally necessary Personal Attendant Services (PAS). o Day Activity and Health Services - All Members of a STAR+PLUS MCO may receive medically and functionally necessary Day Activity and Health Care Services (DAHS). • HCBS STAR+PLUS Waiver Services for those Members who qualify for these services The state provides an enriched array of services to clients who would otherwise qualify for nursing facility care through a Home and Community Based Medicaid Waiver. In traditional Medicaid, this is known as the Community Based Alternatives (CBA) waiver. The STAR+PLUS MCO must also provide medically necessary services that are available to clients through the CBA waiver in traditional Medicaid to those clients that meet the functional and financial eligibility for the HCBS STAR+PLUS Waiver. o Personal Attendant Services (including the three service delivery options: Self-Directed; Agency Model, Self-Directed; and Agency Model) o In-Home or Out-of-Home Respite Services o Nursing Services (in home) o Emergency Response Services (Emergency call button) o Home Delivered Meals o Minor Home Modifications o Adaptive Aids and Medical Equipment o Medical Supplies not available under the Texas Medicaid State Plan/ Texas Healthcare Transformation and Quality Improvement Program (THTQIP) 1115 Waiver o Physical Therapy, Occupational Therapy, Speech Therapy o Day Activity Health Services (DAHS) (for members in 217-Like STAR+PLUS eligibility group, as identified in the Texas Healthcare Transformation and Quality Improvement Program 1115 Waiver, whose income exceeds 150% FPL) o Adult Xxxxxx Care o Assisted Living o Transition Assistance Services (These services are limited to a maximum of $2,500.00. If the MCO determines that no other resources are available to pay for the basic services/items needed to assist a Member, who is leaving a nursing facility, with setting up a household, the MCO may authorize up to $2,500.00 for Transition Assistance Services (TAS). The $2,500.00 TAS benefit is part of the expense ceiling when determining the Total Annual Individual Service Plan (ISP) Cost.) o Dental Services (The annual cost cap of this service is $5,000 per waiver plan ye...
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Long Term Care Services. The PO may use the Resource Allocation Decision Method (RAD) as its service authorization policy. If the PO does not use the RAD, it must seek Department approval of alternative service authorization policies and procedures. The policies and procedures must address how new and continuing authorizations of services are approved and denied. The PO may choose to create decision-making guidelines for more frequently used items and/or services. When the PO wishes to utilize these guidelines as part of the RAD or alternative service authorization documentation (instead of documenting evidence), the guidelines must be approved by the Department. Services shall be authorized in a manner that reflects the member’s ongoing need for such services and supports as determined through the comprehensive assessment and consistent with the member-centered plan.
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Long Term Care Services. 10. Respite Care Services, except as specifically mentioned under Hospice Care Benefits.
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Long Term Care Services. Institutional and community-based long-term care services will be delivered through one of the following delivery systems: Fee-for-service: Beneficiaries will be able to access long-term care services in the same way that services are accessed today, through a fee-for-service system. Under this system, a beneficiary can choose the Medicaid participating agency or provider who will deliver the service(s). In turn, for those services requiring authorization or that are “out- of-plan,” the agency/provider bills the Medicaid agency for services authorized by the ACO and/or the health plan or PCCM network. Self-direction: Beneficiaries and their families will also have the option to purchase HCBS waiver like services through a self-direction service delivery system. Under this option, beneficiaries will work with the ACO to develop a budget amount for services needed. The beneficiary, with the support of a fiscal intermediary, will then be able to purchase services directly. This option is based on experience from Rhode Island’s section 1915(c) Cash and Counseling Waiver (RI Personal Choice), section 1915(c) Developmental Disabilities Waiver, and Personal Assistance Service and Supports program. Self-direction is fully described in the Self-direction Operations Section.
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Long Term Care Services. The PO may use the Resource Allocation Decision Method (RAD) as its service authorization policy. If the PO does not use the RAD, it must seek Department approval of alternative service authorization policies and procedures. The policies and procedures must address how new and continuing authorizations of services are approved and denied. The PO may choose to create decision-making guidelines for more frequently used items and/or services. When the PO wishes to utilize these guidelines as part of the RAD or alternative service authorization documentation (instead of documenting evidence), the guidelines must be approved by the Department. Services shall be authorized in a manner that reflects the member’s ongoing need for such services and supports as determined through the comprehensive assessment and consistent with the member-centered plan. Acute and Primary Care Services The PO shall have documented and Department-approved service authorization policies and procedures for acute and primary care services. Policies and procedures may differ from the authorization policies and procedures for long-term care services and may be based on accepted clinical practices. Decisions about the authorization of acute and primary care services may be made outside of the IDT by other clinical professionals with consideration for member preferences. Authorization of Medicare Services PACE organizations in making authorization decisions about services in PACE shall first use and follow Medicare coverage and authorization policies, procedures and requirements rather than the RAD or other Department-approved service authorization policies and procedures used for the authorization of Medicaid services under this contract. If the PO determines that Medicare will not cover the service, the PO must then use and follow the Medicaid coverage rules, including the RAD, to determine if Medicaid will cover the service.
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Long Term Care Services. With the exception of nursing facility services, the long-term care services in this section are authorized under the Medicaid home and community-based waiver. As required by Section 430.705(2)(b)2., F.S., the contractor shall have at least two (2) subcontractors for each service as listed below (with the exception of case management services, which are directly provided by the contractor):
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Long Term Care Services. With the exception of nursing facility services, the long-term care services in this section are authorized under the Medicaid home and community-based waiver. A. Adult Companion Services: Non-medical care, supervision and socialization provided to a functionally impaired adult. Companions assist or supervise the enrollee with tasks such as meal preparation or laundry and shopping, but do not perform these activities as discrete services. The provision of companion services does not entail hands-on nursing care. This service includes light housekeeping tasks incidental to the care and supervision of the enrollee. B. Adult Day Health Services: Services provided pursuant to Chapter 400, Part V, Florida Statutes. For example, services furnished in an outpatient setting, encompassing both the health and social services needed to ensure optimal functioning of an enrollee, including social services to help with personal and family problems, and planned group therapeutic activities. Adult day health services include nutritional meals. Meals are included as a part of this service when the patient is at the center during meal times. Adult day health care provides medical screening emphasizing prevention and continuity of care including routine blood pressure checks and diabetic maintenance checks. Physical, occupational and speech therapies indicated in the enrollee's plan of care are furnished as components of this service. Nursing services which include periodic evaluation, medical supervision and supervision of self-care services directed toward activities of daily living and personal hygiene are also a component of this service. The inclusion of physical, occupational and speech therapy services and nursing Attachment I- 25 of 55 Contract No. 0000-0000-00
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Related to Long Term Care Services

  • Vision Care Services For purposes of coordination of benefits, vision care services covered under other plans are not considered an allowable expense, as defined in the Coordination of Benefits and Subrogation in Section 7.

  • Long Term Care The City may offer an option for employees to purchase a new long-term care benefit for themselves and certain family members.

  • Core Services The Company agrees to provide those Core Services to the Municipality as set forth in Schedule “A” and further agrees to the process contained in Schedule “A”.

  • COVERED HEALTHCARE SERVICES This section describes covered healthcare services. This plan covers services only if they meet all of the following requirements: • Listed as a covered healthcare service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered healthcare service under this plan. • Medically necessary, consistent with our medical policies and related guidelines at the time the services are provided. • Not listed in Exclusions Section. • Received while a member is enrolled in the plan. • Consistent with applicable state or federal law. We review medical necessity in accordance with our medical policies and related guidelines. Our medical policies can be found on our website. Our medical policies are written to help administer benefits for the purpose of claims payment. They are made available to you for informational purposes and are subject to change. Medical policies are not meant to be used as a guide for your medical treatment. Your medical treatment remains a decision made by you with your physician. If you have questions about our medical policies, please call Customer Service. When a new service or drug becomes available, when possible, we will review it within six (6) months of one of the events described below to determine whether the new service or drug will be covered: • the assignment of an American Medical Association (AMA) Current Procedural Terminology (CPT) code in the annual CPT publication; • final Food and Drug Administration (FDA) approval; • the assignment of processing codes other than CPT codes or approval by governing or regulatory bodies other than the FDA; • submission to us of a claim meeting the criteria above; and • generally, the first date an FDA approved prescription drug is available in pharmacies (for prescription drug coverage only). During the review period, new services and drugs are not covered. For all covered healthcare services, please see the Summary of Medical Benefits and the Summary of Pharmacy Benefits to determine the amount that you pay and any benefit limits.

  • Hospice Services Services are available for a Member whose Attending Physician has determined the Member's illness will result in a remaining life span of six months or less.

  • Office Visits (other than Preventive Care Services) This plan covers office and clinic visits to diagnose or treat a sickness or injury. Office visit copayments differ depending on the type of provider you see. This plan covers physician visits in your home if you have an injury or illness that: • confines you to your home; or • requires special transportation; and • because of this injury or illness, you are physically unable to travel to the provider’s

  • Software Services If elected by Customer, the following Software Services will be made available for Customer’s use.

  • Education services 1.1 Catholic education is intrinsic to the mission of the Church. It is one means by which the Church fulfils its role in assisting people to discover and embrace the fullness of life in Xxxxxx. Catholic schools offer a broad, comprehensive curriculum imbued with an authentic Catholic understanding of Xxxxxx and his teaching, as well as a lived appreciation of membership of the Catholic Church. Melbourne Archdiocese Catholic Schools Ltd (MACS) governs the operation of MACS schools and owns, governs and operates the School.

  • Long Term Care Insurance The University offers full-time faculty the opportunity to purchase Long-Term Care Insurance through a voluntary Long-Term Care Insurance policy. Faculty members are responsible for 100% of the premium, which may be remitted through payroll deduction.

  • Educational Services Any service or supply for education, training or retraining services or testing including: special education, remedial education; cognitive remediation; wilderness/outdoor treatment, therapy or adventure programs (whether or not the program is part of a Residential Treatment facility or otherwise licensed institution); job training or job hardening programs; educational services and schooling or any such related or similar program including therapeutic programs within a school setting.

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