RFP 240000001827 - Attachment A - LTSS Definitions.docx

LTSS Definitions

Michigan Department of Health and Human Services (MDHHS)

Beneficiary: All Medicaid eligible individuals in the Fee for Service Program, (FFS), (Title XIX), Children’s Special Health Care Services Program (CSHCS dual eligible and CSHCS only) (Title V/XIX), Medicare/Medicaid, (Title XVIII/XIX).

CHAMPS: MDHHS’s Community Health Automated Medicaid Processing System

Health Insurance Portability and Accountability Act (HIPAA): a federal law that makes a number of changes that have the goal of allowing persons to qualify immediately for comparable health insurance coverage when they change their employment relationships. Title II, Subtitle F, of HIPAA gives U.S. Department of Health and Human Services (DHHS) the authority to mandate the use of standards for electronic exchange of health care data; to specify what medical and administrative codes sets should be used within those standards; to require the use of national identification systems for health care patients, provider, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care information. Also known as the Kennedy-Kassebaum Bill, the Kassebaum-Kennedy Bill, K2, or Public Law 104-191.

Long Term Services and Supports (LTSS): for this Contract only, LTC includes those programs that are required to adhere to the Michigan Medicaid Nursing Facility Level of Care Determination definition; specifically Nursing Facilities, MI Choice Waiver Program for Elderly and Disabled, the Program for All Inclusive Care for the Elderly (PACE), and MI Health Link (Community and Nursing Facilities).

interRAI (iHC): assessment that informs and guides comprehensive care and service planning in community-based settings.

MDS: Minimum Data Set-assessment information required for all nursing facility in Michigan.

MI Choice Waiver Program: The MI Choice program furnishes an array of home and community-based services to assist aged and disabled Medicaid beneficiaries to live in the community who would otherwise be institutionalized in a nursing facility. MI Choice is a 1915(b)(c) waiver program.

Michigan Medicaid Nursing Facility Level of Care Determination: Medicaid criteria established by the MDHHS, utilized by the Medicaid providers, to determine a beneficiary’s functional eligibility for nursing facility admission or MI Choice Waiver, PACE program, ad MI Health Link enrollment.

National Provider Identifier (NPI) Number: NPI is part of the HIPPA mandate requiring a standard unique identifier for health care providers.

Nurse Reviewer: A registered professional nurse with a current Michigan license and with appropriate education and clinical background, trained in the performance of utilization review and quality assurance to determine adherence to Medicaid policies.

Nursing Facility: A nursing home, county medical care facility, or hospital long-term care unity, with Medicaid certification.

Nursing Facility Level of Care Exception Process Criteria: Criteria established by the MDHHS, utilized by the Contractor, in determining Medicaid eligibility based on frailty for beneficiaries who do not meet the online Michigan Medicaid Nursing Facility Level of Care Determination criteria.

Nursing Facility Level of Care: Each state that participates in the Medicaid program is required to provide nursing facility care as a mandatory state plan service. Each state must determine function/medical eligibility criteria to determine the appropriateness for that setting. Federal regulations state that Medicaid covered nursing facility care must include the following:

(A) Skilled nursing care and related services for residents who require medical or nursing care,

(B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons, or

(C) on a regular basis, health-related care and services to individuals who because of their mental or physical condition require care and services (above the level of room and board) which can be made available to them only through institutional facilities.

PACE: The Program of All Inclusive Care for the Elderly, a capitated community program for persons with LTC needs. Funds are blended from both Medicare and Medicaid sources.

PASRR: The Pre-Admission Screening and Resident Review is required to be completed for all potential nursing facility residents. This review ensures that persons with mental health conditions are placed in the most appropriate setting.

Passive Redetermination: The process of utilizing MDS 3.0 data sent to the state by CMS to create qualifying Door LOCDs in CHAMPS or to create a temporary door that indicates the provider should do a new face to face within 45 days (Door 87).

Peer Review Organization (PRO): an organization that is Utilization Review Accreditation Commission (URAC) approved and experienced in utilization review and quality assurance which meets the guidelines set forth in 42 USC 1320(c) (1) and 42 CFR 475. Note: QIO-like entities satisfy the requirements of the Contract and are qualified to bid on the proposal.

Proposal: the response to this RFP submitted to the State by a bidder.

Provider: Medicaid enrolled Provider for Inpatient Hospital, Selected Durable Medical Equipment/Medical Supplies, Ventilator Dependent Care Units (within a Hospital or Nursing Facility) and Long-Term Care Facilities.