Patient Liability. 2.6.7.2.1 TENNCARE will notify the CONTRACTOR of any applicable patient liability amounts for CHOICES and ECF CHOICES members via the outbound 834 enrollment file.
Patient Liability. 2.6.7.2.1 TENNCARE will notify the CONTRACTOR of any applicable patient liability amounts for CHOICES members in Group 1 via the eligibility/enrollment file. The CONTRACTOR shall delegate collection of patient liability to the nursing facility and shall pay the facility net of the applicable patient liability amount.
Patient Liability. The amount of a Covered Person’s income, as determined by the Tennessee Department of Human Services (DHS), to be collected each month to help pay for the Covered Person’s Long-Term Services and Supports.
Patient Liability. The amount of a member’s income, as determined by the State, to be collected each month to help pay for the member’s LTSS.
Patient Liability. 2.21.5.1 TENNCARE will notify the CONTRACTOR of any applicable patient liability amounts for members via the eligibility/enrollment file.
Patient Liability. Members receiving LTSS may be required to contribute income towards their long-term care costs. This can be applied to both nursing facility and HCBS services. In general, the providers are collecting the patient liability directly and therefore these payments are removed from the calculation of the capitation rates. The exception to this is for legacy PASSPORT and Choices waiver individuals where the ODM collects the patient liability amounts. For these 2 cases, the capitation rates were not reduced by patient liability amounts.
Patient Liability. The amount of an enrollee’s income, as determined by DHS, to be collected each month to help pay for the enrollee’s long-term care services.
Patient Liability. The amount of a member’s income, as determined by the State, to be collected each month to help pay for the member’s LTSS. Pediatric – Care for individuals age 0 to 17 years of age. Peer Review – An evaluation of the professional practices of a provider by the provider’s peers. The evaluation assesses the necessity, appropriateness and quality of care furnished by the provider in comparison to care customarily furnished by the provider’s peers and consistency with recognized health care standards. Performance Improvement Projects (PIPs) – Projects consistent with 42 CFR 438.330 Pharmacy Benefits Manager (PBM) – An entity responsible for the provision and administration of pharmacy services, whether part of the Contractor’s organization or Subcontracted with the Contractor. Post Stabilization Services – Covered Services related to an Emergency Medical Condition that are provided after a member is stabilized in order to maintain the stabilized condition, or, under the circumstances described in 42 CFR 438.114(e), to improve or resolve the member’s condition. Potential Member – In accordance with 42 CFR 438.2, a client who is subject to mandatory Enrollment in DSHP or DSHP Plus, but who is not yet a member of a specific MCO. (The initial letter of each word in this term is not capitalized in this Contract.) Pre-Admission Screening and Resident Review (PASRR) – A Federal requirement (see Section 1919(e)(7) of the Social Security Act and 42 CFR Part 483, Subpart C) to help ensure that individuals are not inappropriately placed in nursing facilities for long term services and supports. PASRR requires that (i) all applicants to a Medicaid certified nursing facility be evaluated for mental illness and/or intellectual disability; (ii) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care settings); and (iii) receive the services they need in those settings. Preferred Drug List (PDL) – A listing of prescription products selected by a pharmaceutical and therapeutics committee as being safe, efficacious and cost-effective choices for clinician consideration when prescribing.
Patient Liability. Members receiving LTSS may be required to contribute income towards their long-term care costs. This can be applied to both nursing facility and HCBS services. In general, the providers are collecting the patient liability directly and therefore these payments are not included in the base data. The exception to this is for legacy PASSPORT and Choices waiver individuals where ODM collects the patient liability amounts. For these two waiver types, the base data represents payments gross of patient liability amounts. We expect the proportion of legacy individuals to decrease over time; however, the expected impact to patient liability is not material to the CY 2017 rate development process. Potentially Preventable Readmissions (PPR). Effective January 1, 2017, hospitals with excessive preventable readmissions will be penalized in the form of hospital-specific base rate reductions. For hospitals with actual-to- expected readmission ratios greater than 1.0, a base rate reduction of 1% will be effective on January 1, 2017. ODM provided a list of hospitals impacted by this program change and estimated the impact to inpatient expenditures under the MyCare program. Estimated cost reductions were not material.
