Current through September 17, 2024
Waiver of enrollment occurs when the Department determines
that a client is not mandatory for a Heritage Health plan or the Dental
Benefits Manager. The Department will notify the member, health plans, or the
Dental Benefits Manager of the waiver of enrollment. Waiver of enrollment is
prospective and is effective the first day of the next month.
005.01
WAIVER OF ENROLLMENT DUE
TO ELIGIBILITY CHANGES. Waiver of enrollment due to changes in
eligibility will occur in the following situations:
(A) The member's Medicaid case is closed or
suspended; or
(B) The member is no
longer mandatory for a Heritage Health plan (see Title 482 NAC 2-001.02 and
2-001.03) or the Dental Benefits Manager.
005.02
HOSPITALIZATION RELATED
WAIVER OF ENROLLMENT. Waiver of enrollment from Heritage Health
plans will occur automatically in the following situations due to a change in
mandatory status for Heritage Health plans. If the Heritage Health plan member
is receiving inpatient hospital services at the time of waiver, the following
rules apply:
(A) When a Heritage Health plan
member is receiving inpatient acute or rehabilitation hospital services on the
first day of a month that the member is no longer eligible for Medicaid
benefits, the Heritage Health plan is not responsible for services effective
the first day of the month the member is no longer Medicaid eligible;
or
(B) When a Heritage Health plan
member is receiving inpatient for acute hospital services and has enrollment
waived from Heritage Health due to an eligibility status change, the Heritage
Health plan is responsible for the hospitalization and services provided in the
core benefits package until waiver of enrollment occurs.
005.03
ADMISSION TO NURSING
FACILITY CARE. Admission to a nursing facility may affect the
Heritage Health plan member's enrollment in the Heritage Health plan. Skilled
nursing services are those nursing facility services provided to eligible
members which are skilled or rehabilitative in nature as defined by Medicare
and the nursing facility admission is expected to be short term. Custodial
services are those nursing facility services as defined in Title 471 NAC and
the nursing facility admission is expected to be of long term or permanent
duration. The following rules apply:
(A) When
a member is admitted to a nursing facility, the Heritage Health plan must
determine if the level of care the member requires is skilled or rehabilitative
using Medicare's definition of skilled care.
(B) When the level of care the member
requires is skilled or rehabilitative, the Heritage Health plan is responsible
for payment of services for the member while receiving skilled level of care
services.
(C) When the member is
admitted to a nursing facility for custodial care, long-term care, Medicaid
fee-for-service will assume financial responsibility for the facility charges
beginning on the date the custodial level of care determination is made.
(i) Payment for all services included in the
core benefits package will be the responsibility of the Heritage Health
plan.
(D) When the
member is admitted to a nursing facility for custodial care and the member's
primary care provider does not see patients at the facility, the Heritage
Health plan must work cooperatively with the member and the nursing facility to
locate a primary care provider for the member.
(i) The Heritage Health plan must make
arrangements to ensure reimbursement of primary care provider services provided
by the member's nursing facility physician, for referrals, and for all services
included in the core benefits package.
