No. 27629 (New Rule): R414-507. Medicaid Long Term Care Managed Care

DAR File No.: 27629
Filed: 12/30/2004, 02:25
Received by: NL

 

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rulemaking incorporates the design and operation requirements of the Medicaid Long Term Care (LTC) Managed Care program. Medicaid recipients eligible for this program may choose to receive care in the community as an alternative to nursing care facilities. It operates as a demonstration project to determine the feasibility of the program for residents in nursing care facilities. The program design and operation requirements describe the formal contract terms contained in the contract between the Division of Health Care Financing and managed care organizations. Thus, this rulemaking presents the major elements of the statewide program design that are an ongoing component of the Medicaid LTC system.

 

Summary of the rule or change:

This is a new rule for the LTC Managed Care Program that formalizes the long term care managed care program structure. Up to this point, it has been a demonstration project operated through the Medicaid managed care contracts.

 

State statutory or constitutional authorization for this rule:

Section 26-1-5, and Subsection 26-18-3(2)(a)

 

Anticipated cost or savings to:

the state budget:

There are no anticipated costs or savings to the state because reimbursement rates are equivalent in both nursing home and LTC managed care.

 

local governments:

There is no budget impact to local governments as a result of this rulemaking because local governments do not provide the service.

 

other persons:

This rule does not change reimbursement or add additional requirements over what the providers currently provide under contract. Therefore, there are no costs or savings to providers. Medicaid recipients will experience no change in coverage or services as a result of this rule.

 

Compliance costs for affected persons:

There are no compliance costs as a result of this program as it imposes no additional requirements.

 

Comments by the department head on the fiscal impact the rule may have on businesses:

This rulemaking is necessary to incorporate the design and operation requirements of a Medicaid LTC Managed Care program into the administrative rules of the Division of Health Care Financing as it moves from a demonstration project to a statewide program. This program provides options to Medicaid recipients of Long Term Care and has a positive fiscal impact on those that provide care for these recipients in facilities other than nursing facilities. Providers of care in nursing care facilities will lose income if residents choose to receive care elsewhere. The Department is committed to pursuing policies that balance free market forces with efficiency and quality of care assurances and provide maximum choice to eligible recipients. Scott D. Williams, MD

 

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY UT 84116-3231

 

Direct questions regarding this rule to:

Ross Martin or Craig Devashrayee at the above address, by phone at 801-538-6592 or 801-538-6641, by FAX at 801-538-6099 or 801-538-6099, or by Internet E-mail at [e-mail] or [e-mail]

 

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

02/14/2005

 

This rule may become effective on:

02/15/2005

 

Authorized by:

Scott D. Williams, Executive Director

 

 

RULE TEXT

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-507. Medicaid Long Term Care Managed Care.

R414-507-1. Introduction and Authority.

(1) The Medicaid LTC Managed Care program is designed to enable an adult Medicaid recipient who needs a level of care consistent with the need for services provided in a nursing facility to receive an individualized package of services to maintain health and safety in a variety of appropriate service settings.

(2) This rule is authorized by Utah Code Section 26-18-3. This program is authorized by 42 USC 1396n(a) and is a component of the Utah Medicaid State Plan. As provided in 42 USC 1396n(a), the state is not out of compliance with the requirements of paragraphs (1), (10) or (23) of 42 USC 1396a solely because the state has entered into a contract with an organization that has agreed to provide care and services in addition to those offered under the State Plan to individuals eligible for medical assistance. The Department may enter into one or more contracts with Medicaid managed care organizations for the operation of projects under the LTC Managed Care program.

 

R414-507-2. Definitions.

The definitions in R414-1 apply to this rule. In addition:

(1) "Care Coordination" is a process where representatives of Medicaid programs serving an individual, and the individual's attending physician when possible, participate in the exchange of information and service planning to assure that the individual's health and welfare needs are identified, develop a comprehensive service plan, and implement the service plan to achieve integration of care across programs.

(2) "Long Term Care" (LTC) means a comprehensive array of services provided to persons of all ages who are experiencing chronic functional limitations due to illness, disability or injury.

(3) "LTC Managed Care Project Contractor" is a Medicaid Primary Inpatient Health Plan or a Medicaid Prepaid Mental Health Plan that has contracted with the Medicaid agency to provide a long term care service package as part of its array of covered services.

 

R414-507-3. Client Eligibility Requirements.

(1) Participation in the LTC Managed Care program is limited to individuals who:

(a) have been in a medical institution for at least 30 consecutive days as a Medicare or Medicaid patient; or

(b) have been in a Medicaid 1915(c) Home and Community-Based Services waiver for at least 30 consecutive days.

(2) A client must meet all financial eligibility requirements for institutional care.

(3) Consistent with the provisions of 42 USC 1396n(a), individuals enrolled in the LTC Managed Care program remain eligible under 42 USC 1396a(10)(A), regardless of the setting in which the services of the program are delivered.

 

R414-507-4. Program Access Requirements.

(1) Participation in the LTC Managed Care program is limited to Medicaid recipients who:

(a) require the level of care provided in a nursing facility as determined under in R414-502 of the Utah Administrative Code;

(b) are age 18 or older; and

(c)(i) reside in a Medicaid certified nursing facility on an extended stay basis;

(ii) are on an inpatient status in a licensed Utah medical institution other than a Medicaid certified nursing facility and have been designated by the attending physician for discharge to a nursing facility for an extended stay of 30 days or more; or

(iii) are enrolled in a Medicaid 1915c Home and Community-Based Services waiver as an alternative to nursing facility placement and have been determined by the state to require disenrollment from the 1915c Home and Community-Based Services waiver due to health and welfare concerns.

(2) In the case of acute care hospitals, specialty hospitals, and Medicare skilled nursing facilities, participation is limited to persons who are admitted for the purpose of receiving a medical, non-psychiatric level of care more acute than the Medicaid nursing facility level of care provided in R414-502.

(3) Persons who meet the intensive skilled level of care as provided in R414-502 are not eligible for participation in the LTC Managed Care program.

(4) Persons who meet the level of care criteria for admission to an Intermediate Care Facility for the Mentally Retarded as provided in R414-502 are not eligible for participation in the LTC Managed Care program.

(5) Residents of a nursing facility who have selected the Medicare or Medicaid hospice benefit are eligible to participate in the LTC Managed Care program only if enrollment in the LTC Managed Care program results in the individual's receiving continued hospice care in his or her own home or the home of a family member or personal caregiver.

 

R414-507-5. Service Coverage.

(1) An enrollee in the LTC Managed Care program receives medical, mental health , and institutional and home and community-based LTC services to address the individual's health and safety needs.

(2) The LTC Managed Care program provides the Medicaid State Plan nursing facility service, care coordination, and home and community based long term care services.

(3) The LTC Managed Care Project Contractor must:

(i) use the InterRAI Minimum Data Set- HOME CARE assessment instrument and other clinical assessments necessary to identify the individual's needs;

(ii) develop, in consultation with the individual and the individual's attending physician when possible, a comprehensive written service plan that:

(A) addresses identified needs in an appropriate setting;

(B) coordinates LTC Managed Care program benefits between all service providers; and

(iii) assure implementation of the comprehensive written service plan.

(4) The LTC Managed Care Project Contractor may not pay for LTC services provided by persons who otherwise have a legal responsibility for providing the care, such as a spouse or legally appointed guardian.

(5) A resident of a nursing facility who is admitted from a home or community setting is not eligible for the LTC Managed Care program until a 90-day continuous stay has been completed in a Utah nursing facility or a Utah Medicaid enrolled nursing facility in an adjoining state.

(6) A participant in a Medicaid 1915c Home and Community-Based Services Waiver who is eligible for the LTC Managed Care program in accordance with R414-507-4(1)(e) may enroll in the LTC Managed care program without completing a stay in a Utah nursing facility if the state determines the LTC Managed care program can meet the health and safety needs of the individual in a community setting at the time of enrollment.

(7) An individual residing in a Medicare skilled unit is not eligible to enroll in the LTC Managed Care program until the full available Medicare Part A benefit for skilled nursing care is exhausted.

(8) An individual enrolled in the LTC Managed Care program must exhaust all available Medicare Part B benefits and other third party benefits before utilizing comparable services through the LTC Managed care program.

 

R414-507-6. Freedom of Choice.

(1) Upon enrollment in the LTC Managed Care program, the individual may choose among the LTC Managed Care Project Contractors serving in the individual's desired service area.

(2) Upon selecting the LTC Managed Care Project Contractor, the individual is bound by the requirements of the LTC Managed Care program and the Department-approved policies and procedures adopted by the LTC Managed Care Project Contractor for operation of the program.

(3) A LTC Managed Care program enrollee may disenroll from the program at any time with or without cause. A voluntary disenrollment is effective when the enrollee has notified the Department and the Department issues a new Medicaid card that indicates disenrollment on the eligibility transmission.

(4) An enrollee of the LTC Managed Care program who desires to change LTC Managed Care Project Contractors is subject to the provisions of R414-140.

 

R414-507-7. Evaluation and Reevaluation of Nursing Facility Level of Care.

The Department, or its designee, initial evaluates and periodically reevaluates at least annually each LTC Managed Care enrollee to determine whether the individual meets the admission criteria of R414-502.

 

R414-507-8. Reimbursement for Services.

(1) Each LTC Managed Care Project Contractor receives a monthly pre-payment per enrollee in an amount established by the Department at the beginning of each state fiscal year.

(2) The LTC Managed Care Project Contractor must submit a financial report on a Department-approved form for the fiscal year reporting period, in accordance with the particular project contract requirements.

(3) After the conclusion of each fiscal year, the Department conducts a cost settlement with each LTC Managed Care Project Contractor. To conduct the cost settlement, the Department first reviews LTC Managed Care Project Contractor expense records and documentation to determine the amount of allowable program expenses. The Department then compares the allowable program expense amount with the aggregate amount of the prepayments the Department paid the LTC Managed Care Project Contractor during the prior fiscal year. The Department also calculates any financial incentives for which the LTC Managed Care Project Contractor qualifies. Based on these calculations, the Department determines an amount due to or owed by the LTC Managed Care Project Contractor.

 

R414-507-9. Cost Neutrality.

(1) Cost-effectiveness of the LTC Managed Care program is measured as an aggregate of all enrollees over time. The Department's total expenditures for the LTC Managed Care program and other Medicaid services provided to individuals enrolled in the LTC Managed Care program, shall in any given year, not exceed the amount that would be incurred by the Medicaid program for a comparable population in a nursing facility.

(2) The LTC Project Contractor must meet each enrollee's assessed needs regardless of the individual's cost or complexity of care. The LTC Project Contractor cannot place an expenditure cap on any enrollee.

 

R414-507-10. New Project and Project Expansion Proposals.

(1) Organizations interested in partnering with the Department of Health in a new LTC Managed Care project or to expand the geographical area served by an existing LTC Managed Care project must submit a written project proposal demonstrating the feasibility of the project for consideration by the Department.

(2) The written project proposal must include as a minimum the following topics to demonstrate the added value that the project will contribute to the LTC Managed Care program and the long term viability of the project for the specific geographical area to be served.

(a) project purpose, goals and objectives;

(b) project organizational structure;

(c) a description of services and supports to be provided and the general sequence in which the various elements of the long term care array will be developed;

(d) a description of the residential and work settings where services will be delivered;

(e) a description of the geographical area to be covered;

(f) a project development and implementation schedule;

(g) project quarterly growth projections and estimated maximum capacity;

(h) a description of the target populations;

(i) a description of the referral network to be accessed to identify potential project participants and the outreach approaches to be utilized to educate the referral network about the project;

(j) a description of the specific performance indicators to guide the progress of the project and to measure the level of achievement of stated goals and objectives;

(k) a description of long term care best practices incorporated into the project, that includes a self-directed approach to service planning and budgeting for enrollees who have the ability to be actively involved in their health care decisions;

(l) a financial pro forma statement for the project; and

(m) a description of other publicly financed programs that the project contractor or partners are involved with that present opportunities to integrate multiple program activities and strengthen common priorities or that pose potential conflicting priorities between programs and how the contributing and conflicting issues will be managed.

(3) Each proposal must include sufficient information to allow the Department to evaluate the project's ability to operate in accordance with R414-507, to protect the health and safety of persons served through an alternative delivery approach to nursing facility care, and to maintain financial stability.

(4) The Department will issue a written notice authorizing or denying a proposed project within 90 days of receipt of the written proposal. If the Department issues a written request for additional information, the additional information must be submitted within 30 days of the date of the Department's request and the maximum review time frame is extended to 120 days.

 

KEY: Medicaid

2005

26-1-5

26-18-3