Fillable Printable 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.

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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

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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

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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.