Common use of Long-Term Institutional Care Clause in Contracts

Long-Term Institutional Care. Package A members requiring long-term care in a nursing facility or Intermediate Care Facility for the Mentally Retarded (ICF/MR) must be disenrolled from the Hoosier Healthwise program and converted to fee-for-service eligibility in the IHCP. Before the nursing facility can be reimbursed by IHCP for the care provided, the nursing facility must request a Pre-Admission Screening Resident Review (PASRR) for nursing facility placement. The State must then approve the PASRR request, designate the appropriate level of care in CoreMMIS and disenroll the member from Hoosier Healthwise. The Contractor must coordinate care for its members that are transitioning into long-term care by working with the facility to ensure timely submission of the request for a PASRR, as described in the IHCP Provider Manual. The Contractor is responsible for payment for up to sixty (60) calendar days for its members placed in a long-term care facility while the level of care determination is pending. However, the Contractor may obtain services for its members in a nursing facility setting on a short-term basis, i.e., for fewer than thirty (30) calendar days. This may occur if this setting is more cost-effective than other options and the member can obtain the care and services needed in the nursing facility. The Contractor may negotiate rates for reimbursing the nursing facilities for these short-term stays. If a member admitted to a nursing facility for a short-term stay remains in the nursing facility for more than thirty (30) days, the Contractor shall notify the State or its designee, in the timeframe and format required by FSSA. The Contractor may request disenrollment of a member in these cases.

Long-Term Institutional Care. Package A members requiring long-term care in a nursing facility or Intermediate Care Facility for the Mentally Retarded (ICF/MR) must be disenrolled from the Hoosier Healthwise program and converted to fee-for-service eligibility in the IHCP. Before the nursing facility can be reimbursed by IHCP for the care provided, the nursing facility must request a Pre-Pre- Admission Screening Resident Review (PASRR) for nursing facility placement. The State must then approve the PASRR request, designate the appropriate level of care in CoreMMIS and disenroll the member from Hoosier Healthwise. The Contractor must coordinate care for its members that are transitioning into long-term care by working with the facility to ensure timely submission of the request for a PASRR, as described in the IHCP Provider Manual. The Contractor is responsible for payment for up to sixty (60) calendar days for its members placed in a long-term care facility while the level of care determination is pending. However, the Contractor may obtain services for its members in a nursing facility setting on a short-term basis, i.e., for fewer than thirty (30) calendar days. This may occur if this setting is more cost-effective than other options and the member can obtain the care and services needed in the nursing facility. The Contractor may negotiate rates for reimbursing the nursing facilities for these short-term stays. All over the counter, legend, and nonlegend drugs, including physician-administered drugs are not considered allowable costs and should not be included in the per diem rate. All drugs must be reimbursable through the pharmacy benefit but may be subject to prior authorization and safety edits that are no more restrictive than Fee-for-Service. If a member admitted to a nursing facility for a short-term stay remains in the nursing facility for more than thirty (30) days, the Contractor shall notify the State or its designee, in the timeframe and format required by FSSA. The Contractor may request disenrollment of a member in these cases.

Long-Term Institutional Care. Package A members requiring long-term care in a nursing facility or Intermediate Care Facility for the Mentally Retarded Individuals with Intellectual Disability (ICF/MRIID) must be disenrolled from the Hoosier Healthwise program and converted an appropriate IHCP eligibility category. The Contractor must work with the facility to fee-for-service determine the type of stay, rehabilitative or custodial, upon admission and follow up every five (5) business days of confirm the type of stay. The Contractor must also contact the State eligibility in unit within ten (10) business days upon confirming a custodial stay with the IHCPfacility to ensure the member is transitioning to another eligibility category. Before the nursing facility can be reimbursed by IHCP for the care provided, the nursing facility must request a Pre-Admission Screening Resident Review (PASRR) for nursing facility placement. The State must then approve the PASRR request, designate the appropriate level of care in CoreMMIS and disenroll the member from Hoosier Healthwise. The Contractor must coordinate care for its members that are transitioning into long-term care by working with the facility to ensure timely submission of the request for a PASRR, as described in the IHCP Provider Manual. The Contractor is responsible for payment for up to sixty (60) calendar days for its members placed in a long-term care facility while the level of care determination is pending. However, the Contractor may obtain services for its members in a nursing facility setting on a short-term basis, i.e., for fewer than thirty (30) calendar days. This may occur if this setting is more cost-effective than other options and the member can obtain the care and services needed in the nursing facility. The Contractor may negotiate rates for reimbursing the nursing facilities for these short-term stays. If a member admitted to a nursing facility for a shortAll over the counter, legend, and non-term stay remains legend drugs, including physician-administered drugs are not considered allowable costs and should not be included in the nursing facility for per diem rate. All drugs must be reimbursable through the pharmacy benefit but may be subject to prior authorization and safety edits that are no more restrictive than thirty (30) days, the Contractor shall notify the State or its designee, in the timeframe and format required by FSSAFee- for-Service. The Contractor may request disenrollment of a member in these cases.

Long-Term Institutional Care. Package A members requiring long-term care in a nursing facility or Intermediate Care Facility for the Mentally Retarded (ICF/MR) must be disenrolled from the Hoosier Healthwise program and converted to fee-for-service eligibility in the IHCP. Before the nursing facility can be reimbursed by IHCP for the care provided, the nursing facility must request a Pre-Admission Screening Resident Review (PASRR) for nursing facility placement. The State must then approve the PASRR request, designate the appropriate level of care in CoreMMIS and disenroll the member from Hoosier Healthwise. The Contractor must coordinate care for its members that are transitioning into long-term care by working with the facility to ensure timely submission of the request for a PASRR, as described in the IHCP Provider Manual. The Contractor is responsible for payment for up to sixty (60) calendar days for its members placed in a long-term care facility while the level of care determination is pending. However, the Contractor may obtain services for its members in a nursing facility setting on a short-term basis, i.e., for fewer than thirty (30) calendar days. This may occur if this setting is more cost-effective than other options and the member can obtain the care and services needed in the nursing facility. The Contractor may negotiate rates for reimbursing the nursing facilities for these short-term stays. If a member admitted to a nursing facility for a short-term stay remains in the nursing facility for more than thirty (30) days, the Contractor shall notify the State or its designee, in the timeframe and format required by FSSA. The Contractor may request disenrollment of a member in these cases.EXHIBIT 1.E

Long-Term Institutional Care. Package A HIP members requiring long-term care in a nursing facility or Intermediate Care Facility for the Mentally Retarded Intellectually Disabled (ICF/MRID) must be disenrolled from the Hoosier Healthwise HIP program and converted to fee-for-service eligibility in the IHCP. Before the nursing facility can be reimbursed by IHCP for the care provided, the nursing facility must EXHIBIT 2.H HEALTHY INDIANA PLAN SCOPE OF WORK request a Pre-Admission Screening Resident Review (PASRR) for nursing facility placement. The State must then approve the PASRR request, designate the appropriate level of care in CoreMMIS and disenroll the member from Hoosier HealthwiseHIP. The Contractor must coordinate care for its members that are transitioning into long-long- term care by working with the facility to ensure timely submission of the request for a PASRR, as described in the IHCP Provider Manual. The Contractor is responsible for payment for up to sixty (60) calendar days for its members placed in a long-long- term care facility while the level of care determination is pending. However, the Contractor may obtain services for its members in a nursing facility setting on a short-term basis, i.e., for fewer than thirty (30) calendar days. This may occur if this setting is more cost-effective than other options and the member can obtain the care and services needed in the nursing facility. The Contractor may negotiate rates for reimbursing the nursing facilities for these short-term stays. If a member admitted to a nursing facility for a short-short term stay remains in the nursing facility for more than thirty (30) days, the Contractor shall notify the State or its designee, in the timeframe and format required by FSSA. The Contractor may request disenrollment of a member in these cases.

Long-Term Institutional Care. Package A HIP members requiring long-term care in a nursing facility or Intermediate Care Facility for the Mentally Retarded Intellectually Disabled (ICF/MRID) must be disenrolled from the Hoosier Healthwise HIP program and converted to fee-fee- for-service eligibility in the IHCP. Before the nursing facility can be reimbursed by IHCP for the care provided, the nursing facility must request a Pre-Admission Screening Resident Review (PASRR) for nursing facility placement. The State must then approve the PASRR request, designate the appropriate level of care in CoreMMIS and disenroll the member from Hoosier HealthwiseHIP. The Contractor must coordinate care for its members that are transitioning into long-term care by working with the facility to ensure timely submission of the request for a PASRR, as described in the IHCP Provider Manual. The Contractor is responsible for payment for up to sixty (60) calendar days for its members placed in a long-long- term care facility while the level of care determination is pending. However, the Contractor may obtain services for its members in a nursing facility setting on a short-term basis, i.e., for fewer than thirty (30) calendar days. This may occur if this setting is more cost-effective than other options and the member can obtain the care and services needed in the nursing facility. The Contractor may negotiate rates for reimbursing the nursing facilities for these short-term stays. If a member admitted to a nursing facility for a short-short term stay remains in the nursing facility for more than thirty (30) days, the Contractor shall notify the State or its designee, in the timeframe and format required by FSSA. The Contractor may request disenrollment of a member in these cases.

Long-Term Institutional Care. Package A members requiring long-term care in a nursing facility or Intermediate Care Facility for the Mentally Retarded (ICF/MR) must be disenrolled from the Hoosier Healthwise program and converted to fee-for-service eligibility in the IHCP. Before the nursing facility can be reimbursed by IHCP for the care provided, the nursing facility must request a Pre-Admission Screening Resident Review (PASRR) for nursing facility placement. The State must then approve the PASRR request, designate the appropriate level of care in CoreMMIS and disenroll the member from Hoosier Healthwise. The Contractor must coordinate care for its members that are transitioning into long-term care by working with the facility to ensure timely submission of the request for a PASRR, as described in the IHCP Provider Manual. The Contractor is responsible for payment for up to sixty (60) calendar days for its members placed in a long-term care facility while the level of care determination is pending. However, the Contractor may obtain services for its members in a nursing facility setting on a short-term basis, i.e., for fewer than thirty (30) calendar days. This may occur if this setting is more cost-effective than other options and the member can obtain the care and services needed in the nursing facility. The Contractor may negotiate rates for reimbursing the nursing facilities for these short-term stays. If a member admitted to a nursing facility for a short-term short terms stay remains in the nursing facility for more than thirty (30) days, the Contractor shall notify the State or its designee, in the timeframe and format required by FSSA. The Contractor may request disenrollment of a member in these cases.

Long-Term Institutional Care. Package A HIP members requiring long-term care in a nursing facility or Intermediate Care Facility for the Mentally Retarded (ICF/MR) must be disenrolled from the Hoosier Healthwise HIP program and converted to fee-for-service eligibility in the IHCP. Before the nursing facility can be reimbursed by IHCP for the care provided, the nursing facility must request a Pre-Admission Screening Resident Review (PASRR) for nursing facility placement. The State must then approve the PASRR request, designate the appropriate level of care in CoreMMIS IndianaAIM and disenroll the member from Hoosier HealthwiseHIP. The Contractor must coordinate care for its members that are transitioning into long-term care by working with the facility to ensure timely submission of the request for a PASRR, as described in the IHCP Provider Manual. The Contractor is responsible for payment for up to sixty (60) calendar days for its members placed in a long-long- term care facility while the level of care determination is pending. However, the Contractor may obtain services for its members in a nursing facility setting on a short-term basis, i.e., for fewer than thirty (30) calendar days. This may occur if this setting is more cost-effective than other options and the member can obtain the care and services needed in the nursing facility. The Contractor may negotiate rates for reimbursing the nursing facilities for these short-term stays. If a member admitted to a nursing facility for a short-term short terms stay remains in the nursing facility for more than thirty (30) days, the Contractor shall notify the State or its designee, in the timeframe and format required by FSSA. The Contractor may request disenrollment of a member in these cases.

Long-Term Institutional Care. Package A members requiring long-term care in a nursing facility or Intermediate Care Facility for the Mentally Retarded Individuals with Intellectual Disability (ICF/MRIID) must be disenrolled from the Hoosier Healthwise program and converted an appropriate IHCP eligibility category. The Contractor must work with the facility to fee-for-service determine the type of stay, rehabilitative or custodial, upon admission and follow up every five (5) business days of confirm the type of stay. The Contractor must also contact the State eligibility in unit within ten (10) business days upon confirming a custodial stay with the IHCPfacility to ensure the member is transitioning to another eligibility category. Before the nursing facility can be reimbursed by IHCP for the care provided, the nursing facility must request a Pre-Admission Screening Resident Review (PASRR) for nursing facility placement. The State must then approve the PASRR request, designate the appropriate level of care in CoreMMIS and disenroll the member from Hoosier Healthwise. The Contractor must coordinate care for its members that are transitioning into long-term care by working with the facility to ensure timely submission of the request for a PASRR, as described in the IHCP Provider Manual. The Contractor is responsible for payment for up to sixty (60) calendar days for its members placed in a long-term care facility while the level of care determination is pending. However, the Contractor may obtain services for its members in a nursing facility setting on a short-term basis, i.e., for fewer than thirty (30) calendar days. This may occur if this setting is more cost-effective than other options and the member can obtain the care and services needed in the nursing facility. The Contractor may negotiate rates for reimbursing the nursing facilities for these short-term stays. If a member admitted to a nursing facility for a shortAll over-term stay remains the-counter, legend, and non-legend drugs, including physician-administered drugs are not considered allowable costs and should not be included in the nursing facility for per diem rate. All drugs must be reimbursable through the pharmacy benefit but may be subject to prior authorization and safety edits that are no more restrictive than thirty (30) days, the Contractor shall notify the State or its designee, in the timeframe and format required by FSSAFee-for-Service. The Contractor may request disenrollment of a member in these cases.. EXHIBIT 1 SCOPE OF WORK – HOOSIER HEALTHWISE

Long-Term Institutional Care. Package A members requiring long-term care in a nursing facility or Intermediate Care Facility for the Mentally Retarded Individuals with Intellectual Disability (ICF/MRIID) must be disenrolled from the Hoosier Healthwise program and converted an appropriate IHCP eligibility category. The Contractor must work with the facility to fee-for-service determine the type of stay, rehabilitative or custodial, upon admission and follow up every five (5) business days of confirm the type of stay. The Contractor must also contact the State eligibility in unit within ten (10) business days upon confirming a custodial stay with the IHCPfacility to ensure the member is transitioning to another eligibility category. Before the nursing facility can be reimbursed by IHCP for the care provided, the nursing facility must request a Pre-Admission Screening Resident Review (PASRR) for nursing facility placement. The State must then approve the PASRR request, designate the appropriate level of care in CoreMMIS and disenroll the member from Hoosier Healthwise. The Contractor must coordinate care for its members that are transitioning into long-term care by working with the facility to ensure timely submission of the request for a PASRR, as described in the IHCP Provider Manual. The Contractor is responsible for payment for up to sixty (60) calendar days for its members placed in a long-term care facility while the level of care determination is pending. However, the Contractor may obtain services for its members in a nursing facility setting on a short-term basis, i.e., for fewer than thirty (30) calendar days. This may occur if this setting is more cost-effective than other options and the member can obtain the care and services needed in the nursing facility. The Contractor may negotiate rates for reimbursing the nursing facilities for these short-term stays. If a member admitted to a nursing facility for a shortAll over-term stay remains the-counter, legend, and non-legend drugs, including physician-administered drugs are not considered allowable costs and should not be included in the nursing facility for per diem rate. All drugs must be reimbursable through the pharmacy benefit but may be subject to prior authorization and safety edits that are no more restrictive than thirty (30) days, the Contractor shall notify the State or its designee, in the timeframe and format required by FSSAFee-for-Service. The Contractor may request disenrollment of a member in these cases.

Long-Term Institutional Care. Package A members requiring long-term care in a nursing facility or Intermediate Care Facility for the Mentally Retarded Individuals with Intellectual Disability (ICF/MRIID) must be disenrolled from the Hoosier Healthwise program and converted an appropriate IHCP eligibility category. The Contractor must work with the facility to fee-for-service determine the type of stay, rehabilitative or custodial, upon admission and follow up every five (5) business days of confirm the type of stay. The Contractor must also contact the State eligibility in unit within ten (10) business days upon confirming a custodial stay with the IHCPfacility to ensure the member is transitioning to another eligibility category. Before the nursing facility can be reimbursed by IHCP for the care provided, the nursing facility must request a Pre-Admission Screening Resident Review (PASRR) for nursing facility placement. The State must then approve the PASRR request, designate the appropriate level of care in CoreMMIS and disenroll the member from Hoosier Healthwise. The Contractor must coordinate care for its members that are transitioning into long-term care by working with the facility to ensure timely submission of the request for a PASRR, as described in the IHCP Provider Manual. The Contractor is responsible for payment for up to sixty (60) calendar days for its members placed in a long-term care facility while the level of care determination is pending. However, the Contractor may obtain services for its members in a nursing facility setting on a short-term basis, i.e., for fewer than thirty (30) calendar days. This may occur if this setting is more cost-effective than other options and the member can obtain the care and services needed in the nursing facility. The Contractor may negotiate rates for reimbursing the nursing facilities for these short-term stays. If a member admitted to a nursing facility for a shortAll over-term stay remains the-counter, legend, and non-legend drugs, including physician-administered drugs are not considered allowable costs and should not be included in the nursing facility for per diem rate. All drugs must be reimbursable through the pharmacy benefit but may be EXHIBIT 1 SCOPE OF WORK – HOOSIER HEALTHWISE subject to prior authorization and safety edits that are no more restrictive than thirty (30) days, the Contractor shall notify the State or its designee, in the timeframe and format required by FSSAFee- for-Service. The Contractor may request disenrollment of a member in these cases.

Long-Term Institutional Care. Package A HIP members requiring long-term care in a nursing facility or Intermediate Care Facility for the Mentally Retarded Intellectually Disabled (ICF/MRID) must be disenrolled from the Hoosier Healthwise HIP program and converted to fee-for-service eligibility in the IHCP. Before the nursing facility can be reimbursed by IHCP for the care provided, the nursing facility must request a Pre-Pre- Admission Screening Resident Review (PASRR) for nursing facility placement. The State must then approve the PASRR request, designate the appropriate level of care in CoreMMIS and disenroll the member from Hoosier HealthwiseHIP. The Contractor must coordinate care for its members that are transitioning into long-term care by working with the facility to ensure timely submission of the request for a PASRR, as described in the IHCP Provider Manual. The Contractor is responsible for payment for up to sixty (60) calendar days for its members placed in a long-long- term care facility while the level of care determination is pending. However, the Contractor may obtain services for its members in a nursing facility setting on a short-term basis, i.e., for fewer than thirty (30) calendar days. This may occur if this setting is more cost-effective than other options and the member can obtain the care and services needed in the nursing facility. The Contractor may negotiate rates for reimbursing the nursing facilities for these short-term stays. All over the counter, legend, and nonlegend drugs, including physician-administered drugs are not considered allowable costs and should not be included in the per diem rate. All drugs must be reimbursable through the pharmacy benefit but may be subject to prior authorization and safety edits that are no more restrictive than Fee-for-Service. If a member admitted to a nursing facility for a short-short- term stay remains in the nursing facility for more than thirty (30) days, the Contractor shall notify the State or its designee, in the timeframe and format required by FSSA. The Contractor may request disenrollment of a member in these cases.