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 the Resident is not entitled to any other third-party coverage, the Resident should be eligible for Medicaid (see Attachment “B”), often referred to as the “payor of last resort.” THE RESIDENT, DESIGNATED REPRESENTATIVE AND/OR SPONSOR AGREE TO NOTIFY THE FACILITY AT LEAST THREE (3) MONTHS PRIOR TO THE EXHAUSTION OF THE RESIDENT’S FUNDS AND/OR INSURANCE COVERAGE TO CONFIRM THAT THE RESIDENT, DESIGNATED REPRESENTATIVE AND/OR SPONSOR HAS OR WILL SUBMIT A TIMELY MEDICAID APPLICATION AND ENSURE THAT ALL ELIGIBILITY REQUIREMENTS HAVE BEEN MET. THE RESIDENT, DESIGNATED REPRESENTATIVE AND/OR SPONSOR AGREE TO APPLY FOR MEDICAID BENEFITS PRIOR TO THE EXHAUSTION OF THE RESIDENT’S RESOURCES. Services reimbursed under Medicaid are outlined in Attachment “A” to this Agreement. Transfer(s) of the Resident’s assets that occurred on or after February 18, 2006 may result in a period of Medicaid ineligibility. The Resident, Designated Representative and/or Sponsor represent that no such transfer(s) have been made that would leave the Resident without a payment source when he or she is otherwise eligible for Medicaid. If the Resident’s care is covered by Medicaid, the Resident, Designated Representative and/or Sponsor agree to remit to the Facility the Resident’s Net Available Monthly Income or “NAMI” on a timely basis, pursuant to the Resident’s Medicaid budget (see Attachment “B”). The Resident’s NAMI, as determined by Medicaid, generally equals his or her income (for example Social Security income, pension income, etc.) which is available to offset the cost of care after all allowable deductions have been made. The Facility has no control over the determination of NAMI amounts. When the Resident is awaiting the issuance of a Medicaid budget, the Resident, Designated Representative and/or Sponsor shall remit the anticipated NAMI to the Facility in a timely manner as discussed more fully below. If Medicaid denies coverage, the Resident, Designated Representative and/or Sponsor hereby agree to remit to the Facility any outstanding amounts for unpaid services not covered by other third-party payors 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...
Medicaid the Wisconsin Medical Assistance program operated by the Wisconsin Department of Health Services under Title XIX of the Federal Social Security Act, Wis. Stats. ch. 49 and related state and federal rules and regulations. The term “Medicaid” will be used consistently in this contract. However, “Medicaid” is also known as “MA,” “Medical Assistance,” and “Wisconsin Medical Assistance Program” or “WMAP.”
Medicaid. The medical assistance program established by Title XIX of the Social Security Act, 42 U.S.C. Sections 1396 et seq., and any statutes succeeding thereto. Medical Asset. Single or multi-tenant facilities consisting of MOBs, inpatient rehabilitation hospitals, specialty hospitals, long-term acute care hospitals (LTACs), acute care hospitals, ambulatory surgery centers, diagnostic centers, health and wellness centers, integrated medical facilities, large physician clinics, diagnostic centers, imaging centers and senior housing facilities (memory care facilities, assisted living facilities and independent living facilities) and skilled nursing facilities.
Medicaid. The MDHHS shall provide to the PIHP both the state and federal share of Medicaid funds as a capitated payment based upon a per eligible per month (PEPM) methodology. The MDHHS will provide access to an electronic copy of the names of the Medicaid eligible people for whom a capitation payment is made. A PEPM is determined for each of the populations covered by this contract, which includes services for people with a developmental disability, a mental illness or emotional disturbance, and people with a substance use disorder as reflected in this contract. PEPM is made to PIHP for all eligibles in its region, not just those with the above-named diagnoses. The Medicaid PEPM rates, annual estimates of eligible by PIHP and rate cells, are attached to this contract. The actual number of Medicaid eligibles shall be determined monthly and the PIHP shall be notified of the eligibles in their service area via the pre-payment process. Beginning with the first month of this contract, the PIHP shall receive a pre-payment equal to one month. The MDHHS shall not reduce the PEPM to the PIHP to offset a statewide increase in the number of beneficiaries. All PEPM rates must be certified as falling within the actuarially sound rate range.
Medicaid. The Provider shall file for Medicaid reimbursement for any Medicaid eligible services provided by the Provider to any Medicaid eligible child under the supervision or authority of the Buyer. The Provider shall be responsible for adhering to all Medicaid requirements, both service and fiscal. Any costs associated with improper management of Medicaid cases on the part of the provider shall be the sole responsibility of the Provider. The Provider shall provide the Buyer with documentation specifying the status of initial Medicaid approval within twenty-four (24) hours (one working day) of receipt of such by the Provider. All other documentation specific to Medicaid received by the Provider shall be provided in writing to the Buyer within forty-eight (48) hours (two working days) by the Provider. The Buyer shall not be responsible for payment of Medicaid eligible services that are denied by Medicaid for reasons attributable to fault of the Provider. With written authorization from the child’s parent or legal guardian to do so, the Buyer shall supply the Provider with the child’s Medicaid number, if applicable. The Buyer shall also Include a Certificate of Need from FAPT within 30 days prior to placement that indicates necessity of placement for residential treatment or a FAPT Assessment indicating medical necessity for therapeutic foster care placements; Provide a complete copy of the DSM-V diagnosis; Provide a completed CANS dated within 90 days of placement and as designated by State and Local Policy, Updated CANS should be given to the Provider in a timely manner for inclusion in the “Continued State Review” forms to DMAS prior to the expiration of the authorization period; Provide any relevant documentation for each child eligible for Medicaid reimbursement.
Medicaid. To the extent permitted by law, all rights to reimbursement under that certain program of medical assistance, funded jointly by the federal government and the states, for impoverished individuals who are aged, blind and/or disabled, and/or members of families with dependent children, which program is more fully described in Title XIX of the Social Security Act (42 U.S.C.ss.ss.1396 et seq.) and the regulations promulgated thereunder; and
Medicaid. The Covered Benefits payable by us under this Agreement, on behalf of a Member who is qualified for Medicaid, will be paid to the state Human Services Department, or its designee, when: The Human Services Department has paid or is paying benefits on behalf of the Member under the state's Medicaid program pursuant to Title XIX and/or Title XXI of the Federal Social Security Act. The payment for the services in question has been made by the state Human Services Department to the Medicaid Practitioner/Provider. Subrogation (Recovering Health Care Expenses from Others) The Covered Benefits under this Agreement will be available to you if you are injured by the act or omission of another person, firm, operation or entity. If you receive Covered Benefits under this Agreement for treatment of such injuries, we will be subrogated to your rights or the Personal Representative of a deceased Member, or Dependent Member, to the extent of all such payments made by us for such benefits. This means that if we provide or pay Covered Benefits, you must repay us the amounts recovered for all such payments made by us in any lawsuit, settlement, or by any other means. This rule applies to any and all monies you may receive from any third party or insurer, or from any uninsured or underinsured motorist insurance benefits, as well as from any other person, organization or entity. By way of illustration only, our right of subrogation includes, but is not limited to, the right to be repaid when you recover money for personal injury sustained in a car accident. The subrogation right applies whether you recover directly from the wrongdoer or from the wrongdoer’s insurer, or from your uninsured motorist insurance coverage. You agree to sign and deliver to us such documents and papers as may be necessary to protect our subrogation right. You also agree to keep us advised of: Any claims or lawsuits made against any person, firm or entity responsible for any injuries for which we have paid Covered Benefits. Any claim or lawsuit against any insurance company, or uninsured or underinsured motorist insurance carrier. Settlement of a legal claim or controversy without prior notice to us is a violation of this Agreement. In the event you fail to cooperate with us or take any action, through agents or otherwise, to interfere with the exercise of our subrogation right, we may recover our Covered Benefit payments from you. When reasonable collection costs and reasonable legal e...
Medicaid. Most state Medicaid payments are made under a prospective payment system or under programs which negotiate payment levels with individual hospitals. Medicaid reimbursement is often less than a hospital's cost of services. Medicaid is currently funded jointly by the state Federal governments. The Federal government and many states are currently considering significant reductions in the level of Medicaid funding while at the same time expanding Medicaid benefits, which could adversely affect future levels of Medicaid reimbursement received by the hospitals of LifePoint and Triad. On November 27, 1991, Congress enacted the Medicaid Voluntary Contribution and Provider-Specific Tax Amendments of 1991, which limit the amount of voluntary contributions and provider-specific taxes that can be used by states to fund Medicaid and require the use of broad-based taxes for such funding. As a result of enactment of these amendments, certain states in which LifePoint and Triad operate have adopted broad-based provider taxes to fund their Medicaid programs. The impact of these new taxes upon LifePoint and Triad has not been materially adverse. However, neither LifePoint nor Triad can predict whether any additional broad-based provider taxes will be adopted by the states in which it operates and, accordingly, neither is able to assess the effect of such additional taxes on its results of operations or financial position. 100