Plan of Care. The Care Manager will authorize and coordinate the provision of Covered Services rendered under this Agreement and as may be referenced in the Provider Handbook. Provider shall adhere to the Plan of Care established for Enrollees. Except in the case where a Enrollee's health or safety is in jeopardy, where such transfer to another Provider may be immediate, Provider shall refer and cooperate with the transfer of Enrollees for Covered Services only to Providers designated, specifically approved or under contract with ILS Community Network and Managed Care Plan. The Provider, in the event of a transitioning Enrollee, including in the event of the termination of this Agreement, shall cooperate in all respects with Providers of other Managed Care Plans to assure maximum health outcomes for Enrollees. In the event that Provider renders a Enrollee non-covered services or refers a Enrollee to an out-of-network provider without pre-authorization from ILS Community Network or Managed Care Plan, Provider shall prior to the provision of such non-covered services or such out-of- network referral, inform the Enrollee in writing: (1) of the services to be provided or referral to be made; (2) that ILS Community Network and Managed Care Plan will not pay (or may pay a reduced benefit in the case of ILS Community Network and Managed Care Plan's point of service (POS) and/or preferred provider organization (PPO) products) or be liable financially for such non-covered service or out-of network referral and (3) that Enrollee will be responsible financially for non-covered service(s) and/or out-of-network referral(s) that are requested by the Enrollee. Provider acknowledges and agrees that the failure to inform Xxxxxxxx(s) in accordance with this paragraph may result in financial liability to Provider for the cost of such non-covered or non-authorized service(s). The Provisions of this Section shall not prohibit a Enrollee from receiving inpatient services in a contracted hospital if such services are determined by the Managed Care Plan to be medically necessary Covered Services. This Agreement shall not prohibit a Provider from discussing treatment or non-treatment options with Enrollees that may not reflect the Managed Care Plan's position or may not be covered by the Managed Care Plan; and shall not prohibit a Provider from acting within the lawful scope of practice, from advising or advocating on behalf of a Enrollee for the Enrollee's health status, medical care, or treat...
Plan of Care. A plan which describes the service needs of each enrollee, showing the projected duration, desired frequency, type of provider furnishing each service, and scope of the services to be provided.
Plan of Care. The Plan of Care is a written plan developed in collaboration with the member, the member’s family (with written consent), guardian or adult caretaker, PCP and other providers involved with the member to delineate the Intensive Care Activities to be undertaken to address key issues of risk for the member.
Plan of Care. 20.6.1 As specified in BHIN 22-019, when a plan of care is required, Contractor shall follow the DHCS requirements outlined in the Alcohol and/or Other Drug Program Certification Standards document, available in the DHCS Facility Certification page at: xxxxx://xxx.xxxx.xx.xxx/provgovpart/Pages/Licensing- and-Certification-Facility-Certification.aspx
Plan of Care. All Qualified Long-Term Care Services for which You claim benefits must be prescribed in a written Plan of Care prepared by a Licensed Health Care Practitioner who is an employee of the Care Coordination Provider Agency or an Official Designee of the Care Coordination Provider Agency.
Plan of Care. The Health Plan shall perform a needs assessment and develop a plan of care for each enrollee. The Health Plan shall base the plan of care on a comprehensive assessment of the enrollee's health status, physical and cognitive functioning, environment, and social supports. The Health Plan shall not impose service limitations based solely on the enrollees’ place of residence. The plan of care must detail all interventions designed to address specific barriers to independent functioning. The Health Plan shall clearly identify barriers to the enrollee and caregivers, if applicable. The case manager must discuss barriers and explore potential solutions with the enrollee and caregivers when applicable. In developing the plan of care the Health Plan shall:
Plan of Care. A person-centered care plan that addresses acute care and LTSS for Enrollees. The plan is developed by the STAR+PLUS MMP Service Coordinator with the Enrollee, his/her family and caregiver supports, as appropriate, and Providers. The Plan of Care will contain the Enrollee’s health history; a summary of current, short- term, and long-term health and social needs, concerns, and goals; and a list of required services, their frequency, and a description of who will provide such services. For Enrollees eligible for HCBS, the Enrollee’s ISP is incorporated into the Plan of Care.
Plan of Care. The STAR+PLUS MMP is responsible for completing the assessment documentation, and preparing a HCBS STAR+PLUS ISP for identifying the needed HCBS STAR+PLUS Waiver services. The ISP is submitted to the State to ensure that the total cost does not exceed the 202% limit. The STAR+PLUS MMP must complete these activities within forty-five (45) days of receiving the State’s authorization form for eligibility testing. The STAR+PLUS MMP must complete the Community MN/LOC assessment instrument for MN/LOC determination, and submit the form to HHSC’s Administrative Services Contractor. If the STAR+PLUS MMP determines the Enrollee’s cost of care will exceed the 202% limit, the STAR+PLUS MMP will submit the individual service planning documents to HHSC utilization management review (UMR). The UMR may request a clinical review of the case to consider the use of State general Revenue funds to cover costs over the 202% allowance, as per HHSC’s policy and procedures related to use of general revenue for HCBS STAR+PLUS Waiver participants. If HHSC approves the use of state general revenue funds, the STAR+PLUS MMP will be allowed to provide waiver services as per the ISP, and non-waiver services (services in excess of the 202% allowance) utilizing State General Revenue Funds. Non-waiver services are not Medicaid Allowable Expenses, and may not be reported as such on the FSRs. The STAR+PLUS MMP will submit reports documenting expenses for non- waiver services in an HHSC-approved format. HHSC will reimburse the STAR+PLUS MMP for such expenses in excess of the 202% allowance.
Plan of Care. The contractor, through its care manager, shall ensure that a plan of care is developed and implementation has begun within thirty (30) business days of the date of a needs assessment, or sooner, according to the circumstances of the enrollee. The contractor shall ensure the full participation and consent of the enrollee or, where applicable, authorized person and participation of the enrollee's PCP and other case managers identified through the Complex Needs Assessment (e.g., DDD case manager) in the development of the plan. The plan shall specify treatment goals, identify medical service needs, relevant social and support services, appropriate linkages and timeframe as well as provide an ongoing accurate record of the individual's clinical history. The care manager shall be responsible for implementing the linkages identified in the plan and monitoring the provision of services identified in the plan. This includes making referrals, coordinating care, promoting communication, ensuring continuity of care, and conducting follow-up. The care manager shall also be responsible for ensuring that the plan is updated as needed, but at least annually. This includes early identification of changes in the enrollee's needs.
Plan of Care. I will work together with my JACC Care Manager to create a Plan of Care. This Plan of Care, and availability of services, will determine which services I receive. o I will receive a completed copy of the Plan of Care. o The Plan of Care will be revisited for potential revisions at least once annually. The Plan of Care can change more frequently, depending on my care needs, personal goals, service availability, and funding availability. o The JACC program will not provide any services which are not listed in my Plan of Care (POC). • Service limitations: Services are limited to a capped monthly budget and are provided by contracted providers. o Exceptions to the monthly budget may be made based on need and funding availability for specific, short-term expenses. o If there is no contracted provider for the needed service in the area, every effort will be made to contract with new providers. If no provider is able or willing to contract for the service, then the service cannot be provided through the JACC program. o If the required service is outside of the scope of the JACC program or the monthly budget, my JACC Care Manager will work with me to find an alternative way to secure the service.
