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Fillable Printable Form 421

Fillable Printable Form 421

Form 421

Form 421

AHCCCS CONTRACTOR OPERATIONS MANUAL
CHAPTER 400 OPERATIONS
421 - Page 1 of 4
421 CONTRACT TERMINATION: NURSING FACILITIES AND ALTERNATIVE
HOME AND COMMUNITY BASED
SETTINGS
EFFECTIVE DATES: 04/08/09, 11/01/12, 10/01/13, 10/01/15, 10/01/17
REVISION DATES: 10/11/12, 08/29/13, 07/30/15, 07/26/17
I. PURPOSE
This Policy applies to ALTCS/EPD Contractors. This Policy is limited to and defines the
relationship between a Nursing Facility (NF) and/or an Alternative Home and Community
Based Setting
and a Contractor following the termination of a contract between these entities,
regardless of which entity terminates the contract or the reason for contract termination. This
policy delineates how the Contractor, NF and Alternative Home and Community Based Setting
shall collaborate to provide for the needs of the members residing in the facility at the time of
contract termination.
II. DEFINITIONS
ADD-ON
Generally refers to contract standards that a Contractor may have
with a NF to establish criteria for additional payment to the Class
1, 2 or 3 levels determined by the Uniform
Assessment Tool
(UAT).
ALTERNATIVE
HOME AND COMMUNITY
BASED SETTING
Under the Home and Community Based Services (HCBS)
program, members may receive certain services while they are
living in an alternative HCBS setting. HCBS settings as defined in
9 A.A.C. 28 Article 1 and AMPM Chapter 1200, section 1230.
Alternative residential settings include but are not limited to
Assisted Living Centers (ALC), Assisted Living Homes (ALH)
Adult Foster Care (AFC) Homes, Behavioral Health Residential
facilities, and Behavioral Health Supportive Homes.
ANNIVERSARY DATE
The Anniversary Date is 12 months from the date the member is
enrolled with the Contractor and annually thereafter. In some
cases, the anniversary date will change based on the last date the
member changed Contractors or the last date the member was
given an opportunity to change.
BED HOLD DAY
A 24 hour per day unit of service that is authorized by an ALTCS
member’s case manager or the behavioral health case manager or
a subcontractor for an acute care member, which may be billed
despite the member’s absence from the facility for the purposes of
short term hospitalization leave and/or therapeutic leave. Refer to
the Arizona Medicaid State Plan, 42 CFR 447.40 and 42 CFR
483.12, 9 A.A.C. 28 and AMPM Chapter 100.
AHCCCS CONTRACTOR OPERATIONS MANUAL
CHAPTER 400 OPERATIONS
421 - Page 2 of 4
NURSING FACILITY (NF)
A health care facility that is licensed and Medicare/Medicaid
certified by the Arizona Department of Health Services in
accordance with 42 CFR 483.75 to provide inpatient room, board
and nursing services to members who require these services on a
continuous basis but who do not require hospital care or direct
daily care from a physician. Contracted NFs are those facilities
that have a contract with a Contractor. Non-contracted NFs are
those facilities that do not have a contract with a Contractor.
ROOM AND BOARD (R&B)
The amount paid for food and/or shelter. Medicaid funds can be
expended for room and board when a person lives in an
institutional setting (e.g. NF, ICF). Medicaid funds cannot be
expended for room and board when a member resides in an
alternative residential setting (e.g. Assisted Living Home,
Behavioral Health Residential Facilities) or an apartment like
setting that may provide meals.
SUBACUTE OR SPECIALTY
CARE
Generally refers to contract standards that a Contractor may have
with a NF to establish criteria for paying a rate higher than the
Class 1, 2 and 3 levels determined by the UAT.
SHARE OF COST (SOC)
The amount an ALTCS member is required to pay toward the cost
of long term care services.
UNIFORM
ASSESSMENT
TOOL (UAT)
A standardized tool that is used by Contractors to assess the
acuity of NF residents and commonly used for ARS residents
residing in Assisted Living Centers (ALC), Assisted Living
Holmes (ALH) and Adult Foster Care (AFC) settings. The use of
the Uniform Assessment Tool (UAT) is not intended to impact
how Contractors determine authorizations for specialty levels of
care (e.g., wandering dementia, medical sub-acute and behavioral
management). This tool is located in AMPM Policy 1620-B.
III. POLICY
A. MEMBER/RESIDENT OPTIONS WHEN A NF OR ALTERNATIVE HOME AND COMMUNITY
BASED SETTING CONTRACT IS TERMINATED
Affected members residing in a NF and/or Alternative Home and Community Based Setting
at the time of a contract termination may continue to reside in that facility until their open
enrollment period, at which time members must either choose an available Contractor that is
contracted with the facility, or move to a setting that is contracted with their current
Contractor.
The Contractor in collaboration with the NF and/or Alternative Home and Community
Based Setting and AHCCCS must develop a member/representative communication plan
AHCCCS CONTRACTOR OPERATIONS MANUAL
CHAPTER 400 OPERATIONS
421 - Page 3 of 4
and a member transition plan. The purpose of the communication plan is to provide affected
or impacted members and/or their representatives with consistent information regarding the
contract termination. The purpose of the transition plan is to ensure a seamless transition to
another placement
, continuity of care and follow up monitoring of the member post move.
The Contractor must receive approval of the member/representative communication and
transition plan from the Division of Health Care Management Operations Unit. The plan
must be submitted to AHCCCS within five business days of the termination decision. All
member communications must be consistent with guidelines found in ACOM Policy 404.
B. REIMBURSEMENT
1. Nursing Facilities
The Contractor shall reimburse the NF at the previously contracted rates or the
AHCCCS fee for service schedule rates, whichever are greater. Should AHCCCS
increase its fee schedule, the Contractor shall reimburse the NF at the greater of the
increased AHCCCS fee for service schedule rates or the Contractor’s previously
contracted rates. Should AHCCCS reduce its fee schedule, the Contractor shall reduce
its previously contracted rates by the same percentage, and pay the greater of
the adjusted rates.
If the Contractor had in place a provision for subacute, specialty care or add-on rates at
the time of the contract termination, then the Contractor shall apply those rates. Should
AHCCCS adjust its fee schedule, then the Contractor will adjust its subacute or add-on
rate(s) by the average adjustment to the NF fee schedule rates.
2. Alternative Home and Community Based Settings
The Contractor shall reimburse the Alternative Home and Community Based Setting at
the previously contracted rate. Should AHCCCS adjust its HCBS Fee Schedule rates,
the Contractor will adjust its Alternative Home and Community Based Residential
Setting rates by the average percentage that the HCBS Fee Schedule rates are adjusted
by.
C. QUALITY OF CARE
In the event that a Contractor, other entity,
or AHCCCS identify instances where the overall
quality of care delivered by an NF or Alternative Home and Community Based Setting
places residents in immediate jeopardy, the Contractor will inform members/representatives
of the problems and offer members alternative placement. Members may have the option to
continue to reside in the NF or Alternative Home and Community Based Setting.
In some cases,
AHCCCS may require that the Contractor find new placements for members.
In such cases, the Contractor shall work with the members/representative to identify an
appropriate placement that meets the needs of the member. AHCCCS may require
Contractors to increase monitoring of facilities identified as having health or safety issues
AHCCCS CONTRACTOR OPERATIONS MANUAL
CHAPTER 400 OPERATIONS
421 - Page 4 of 4
until AHCCCS is assured that the issues have been resolved or members have been
transitioned to a placement setting that can meet their needs.
In the event of a bankruptcy or foreclosure order of an NF or Alternative Home and
Community Based Setting, the Contractor shall notify AHCCCS of the situation. In these
instances, the Contractor shall review the financial, health and safety status prior to placing a
member in a placement owned by the same entity. In the event that a Contractor identifies a
member specific quality of care concern, the Contractor shall identify that concern to the NF
or Alternative Home and Community Based Setting for resolution. The Contractor shall
also report to external entities, and to AHCCCS as required by AMPM Policies 910 and 920.
D. ADMISSIONS/DISCHARGES/READMISSIONS
1. NFs or Alternative Home and Community Based Settings are not required to accept new
admissions of members who are enrolled with a non-contracted Contractor.
2. NFs are required to otherwise follow admission, readmission, transfer, and discharge
rights as per 42 CFR 438.12.
3. The Contractor may authorize bed hold days up to the allowed limit as described in 9
A.A.C. 28.
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