Fillable Printable Form 421
Fillable Printable Form 421
Form 421
AHCCCSCONTRACTOR 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 islimited to and defines the
relationship between a Nursing Facility (NF) and/or an Alternative Home and Community
BasedSetting
and a Contractor following the termination of a contract between these entities,
regardless of which entity terminates the contractor the reason for contract termination. This
policy delineates howthe Contractor, NF and Alternative Home and Community BasedSetting
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 tocontract 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
Underthe Home and CommunityBased Services (HCBS)
program,membersmay receivecertain services whiletheyare
living in an alternative HCBS setting. HCBS settings as defined in
9 A.A.C. 28 Article1 andAMPM Chapter1200,section 1230.
Alternativeresidentialsettings includebut are not limitedto
AssistedLivingCenters (ALC), Assisted LivingHomes(ALH)
AdultFoster Care(AFC) Homes, Behavioral HealthResidential
facilities, and Behavioral Health Supportive Homes.
ANNIVERSARY DATE
The AnniversaryDate 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 ofHealth 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. Medicaidfunds can be
expendedforroom andboardwhena person lives in an
institutionalsetting(e.g. NF, ICF).Medicaidfunds cannot be
expendedfor room and board when amemberresidesin an
alternativeresidentialsetting(e.g. Assisted Living Home,
BehavioralHealthResidential Facilities) or an apartmentlike
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 byContractors to assess the
acuity of NF residents and commonly used for ARSresidents
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 notintended to impact
how Contractors determine authorizations forspecialty 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 ANF OR ALTERNATIVE HOME AND COMMUNITY
BASED SETTING CONTRACT IS TERMINATED
Affected members residing in a NF and/or Alternative Home and Community BasedSetting
at the time of a contract termination maycontinue 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
BasedSetting and AHCCCS mustdevelop a member/representative communication plan
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CHAPTER 400–OPERATIONS
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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
, continuityofcare 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 NFat the greater of the
increased AHCCCS fee for service schedule rates or theContractor’s previously
contracted rates. Should AHCCCS reduce its fee schedule,the Contractor shall reduce
its previouslycontracted 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 willadjust 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 BasedSetting at
the previouslycontracted 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 ofcare delivered by an NF or Alternative Homeand Community BasedSetting
places residents in immediate jeopardy, the Contractorwill inform members/representatives
of the problems and offer members alternative placement. Members mayhave the option to
continue to reside in the NF or Alternative Home and Community BasedSetting.
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 mayrequire
Contractors to increase monitoring of facilities identified as having health or safety issues
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CHAPTER 400–OPERATIONS
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until AHCCCSis 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 BasedSetting, 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 BasedSetting 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 CommunityBasedSettings 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 bedhold days up to the allowed limit as described in 9
A.A.C. 28.
