The Case Manager will evaluate the enrollee’s health care needs to determine the appropriate residential setting, Level of Care (LOC) and services necessary to safely maintain the enrollee in the least restrictive environment. All LTC services require prior notification by the UnitedHealthcare Community Plan Case Manager.
All facility settings require the appropriate registration, licensure and insurance liability coverage. All
providers are required to send copies of updated licenses and certificates upon renewal. Failure to provide this information may result in non- payment of rendered services and termination of your UnitedHealthcare Community Plan Agreement. Case Managers will conduct on-site assessments of enrollees to ensure the appropriateness of the caregiver and of the type and amount of services being rendered to the UnitedHealthcare Community Plan enrollee. If UnitedHealthcare Community Plan has been made aware that a provider’s performance is unsatisfactory, it will contact the provider with the findings and care issues. The provider is responsible to address the issues and follow up with UnitedHealthcare Community Plan promptly. If a Quality Management issue becomes evident, UnitedHealthcare Community Plan will follow appropriate procedures to ensure the highest quality of care is provided to the enrollee.
Enrollees residing in nursing facilities or assisted living facility settings are responsible for the Enrollee Share of Cost (MSOC) or Room and Board (R&B) payment as applicable. There are three long-term care settings:
1. Nursing Facility – Case Management enrollee
evaluations are completed every 180 days or as enrollee conditions change. Nursing facility placements must be prior authorized by the
Case Manager.
• Nursing facilities, including skilled nursing. • Behavioral Health Level 1.
• Inpatient Psychiatric Residential, only for enrollees under 21 years of age.
• Institution for Mental Disease.
2. Assisted Living Facility – Case Management
enrollee evaluations are completed every 90 days or as enrollee conditions change. See “HCBS Alternative Residential Settings” of this chapter for more details. In some instances, an enrollee may be eligible to receive HCBS services while residing in an Assisted Living Facility. The Case Manager will evaluate the enrollee’s health care needs and determine if an HCBS services is appropriate. Assisted Living Facility placement must be prior authorized by the Case Manager.
3. Home and Community Base
Services (HCBS) – Case Management
enrollee evaluations are completed every 90 days or as enrollee conditions change. Enrollees residing in a private home or apartment may receive the following services based upon the Case Manager’s evaluation and authorization of services:
• Adult Day Health Care – includes
supervision, medication assistance, recreations and socialization, personal living skills training, health monitoring and preventive, therapeutic and restorative services. This service may be available to enrollees residing in ALTCS approved alternative residential settings upon the Case Managers evaluation and approval for the service.
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• Attendant Care – includes supervision, bathing
assistance, food preparation and feeding assistance, housekeeping services, medication reminders, recreation and socialization.
• Behavioral Management Services –
See the Behavioral Health chapter of this Provider Manual.
• Community Transition Service – The
Community Transition Service is a fund to assist ALTCS-institutionalized members to reintegrate into the community by providing financial assistance to move from an ALTCS Long Term Care (LTC) institutional setting to their own home.
• Durable Medical Equipment – Custom
and standard items require an order by the enrollee’s physician and must be prior authorized by the enrollee’s UnitedHealthcare Community Plan Case Manager and/or the Prior Authorization Department. This service is limited to a one-time benefit per five years per member.
• Emergency Alert System – Monitoring
devices for enrollee’s who live alone, are at risk of emergent care and are unable to access emergency assistance. Emergency alert system equipment may not be provided without orders from the member’s PCP. A physician order is also required to discontinue the provision of the Emergency Alert System.
• Group Respite – An alternative to adult day
health care.
• Habilitation – Provision of training independent
living skills or special developmental skills: sensory-motor development; orientation and mobility and behavior intervention. Physical, occupational or speech therapies may be provided as a part of or in conjunction with other habilitation services.
• Home Delivered Meals – Provides nutritious
food to enrollees who live in their own home but are in jeopardy of not eating adequate amounts of nutritious food to maintain good health. Only one meal may be approved for an enrollee on any given day. Provider of home-delivered meals, and those employed, must have applicable food handling/preparation permits.
– Menus: Must be planned for a minimum
of four consecutive weeks and rotated three times before changing menus, taking seasonal foods into consideration; must be available for audit at the providers place of business for at least one year following meal services; must be available in the predominant languages of the group serviced, with reflection of ethnic choices; must be approved by a registered
dietician prior to posting – any possible substitutions must be included.
– Meals: Must reflect 1/3 of the current
recommended daily allowance of nutrients dietary recommendations for sugar, salt and fat intake must be maintained; must be delivered in a safe and sanitary manner directly to the enrollee; frozen meals may be provided in advance for days when no delivery is available; enrollee must have the ability to store three meals; must be prepared therapeutically in accordance with the PCP order if a special diet is ordered; must be signed for upon delivery. – Other: Case records must be maintained
confidentially; services not provided are documented with reasoning; printed educational materials must be delivered to enrollees with meals at least two times per quarter; provider must respond to consultant concerns and initiate corrective action within three weeks.
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• Home/Environmental Modifications –
Allows modifications to enrollee’s existing residences to enable an enrollee to function safely and as independently as possible in the community. UnitedHealthcare Community Plan Case Managers will conduct on site assessments to determine the appropriateness of an environmental modification or repair. • Home Health Services – Includes home
health aides, home health skilled nursing, private-duty nurses for ventilator dependent enrollees only, medically necessary supplies and therapy services. See “Medical Supplies Included in FFS Home Health Nursing Visits” for supplies that are included in the agencies Fee-For-Service (FFS) rate, at the end of the chapter.
• Home Health Aide – Provides nursing-related
services under the direction of a registered nurse or physician. These services must be ordered by the PCP and authorized by the Case Manager. Home Health Aides must have current certification through the Arizona Board of Nursing, CPR and First Aid. A Home Health Aide visit may include one or more of the following:
– Assessment of the enrollee’s health or functional level.
– Monitoring and documentation of vital signs.
– Assistance with contingency orosmotic programs.
– Assistance with self-administration of medications.
– Assistance with feeding.
– Assistance with ambulation, transfer, range of motion and use of equipment. – Assistance with Activities of Daily Living. – Enrollee or family training of health
care tasks.
• Home Health Nurse – Provides skilled
nursing services ordered by the PCP and must be provided by a licensed nurse under the supervision of a physician. These services can only be provided on an intermittent basis. These services are considered as skilled. If a licensed/Medicare certified home health agency is not available in an enrollee’s community, does not have adequate staff, or will not provide services through UnitedHealthcare Community Plan, a licensed home health agency that is non-Medicare certified or an independent RN may provide skilled nursing services. RNs providing these services will be required to provide documentation of services performed via PCP orders. UnitedHealthcare Community Plan will monitor the service deliver and quality of care.
Skilled nursing assessments and care for enrollees with pressure sores, surgical wounds, tube feedings, etc., must be provided by a Medicare-certified home health agency or independent nurse. Written monthly reports must be submitted to the PCP and UnitedHealthcare Community Plan Case Manager. Skin assessments must be performed at least monthly for enrollees prone to breakdown of skin integrity due to their health status or care needs.
• Private Duty Nurse – Home Health Private
Duty Nurse services are provided on a continuous basis to avoid hospitalization or institutionalization when care cannot be safely managed intermittently. Private Duty services must be ordered by the PCP and authorized by UnitedHealthcare Community Plan. If a LPN provides services, a physician must provide supervision. Home Health Private Duty Nursing services are only available to ventilator dependent enrollees.
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• Homemaker Services – May be provided
to preserve or improve upon the safety and sanitation of an enrollee’s living condition, nutritional value of meals and to maintain or increase the enrollee’s self-sufficiency. A homemaker is only to provide services that pertain to the enrollee. A homemaker may clean the enrollee’s living space, such as his or her bedroom; conduct meal planning, shopping, and food preparation with clean up; and clean and put away the enrollee’s laundry.
• Home Maintenance Program – If an
enrollee’s restoration potential is evaluated as insignificant or at a plateau, a Home Maintenance Program can be initiated. A licensed therapist, the enrollee, family, caregiver or non-skilled personnel is trained to help to maintain the enrollee’s functioning level. UnitedHealthcare Community Plan will authorize the initial establishment of the Home Maintenance Program via a licensed therapist if the service is determined appropriate by the PCP, UnitedHealthcare Community Plan Medical Director, and UnitedHealthcare Community Plan Utilization Management.
• Hospice – Includes physician services, nursing
services, medication for the terminal illness, therapies, aid services, homemaker services, medical social services, medical supplies and appliances, short-term respite and counseling including bereavement and support. The
enrollee’s physician must certify that the enrollee is terminally ill with a prognosis of six (6) months or less, and enrollee desires palliative versus curative treatment. Hospice is a prior-authorized service. If the enrollee is receiving services under Medicare, the services do not require PCP orders or UnitedHealthcare Community Plan Case Management prior authorization. However, the UnitedHealthcare Community Plan Case Manager is responsible to monitor the enrollee’s care, therefore the hospice provider
must notify the UnitedHealthcare Community Plan Case Manager of the hospice election. Hospice services must be provided through a Medicare-certified agency. If the enrollee has Medicare, hospice benefits must be chosen instead of regular Medicare benefits. • Partial Care – Structured, coordinated
programs designed to provide therapeutic activities that promote coping, problem solving, and socialization skills.
• Personal Care – Includes bathing assistance,
food preparation and feeding assistance, homemaker services, medication reminders, and recreation and socialization. Personal Care services may assist with bathing, toileting, dressing, nail care and feeding; assistance with transferring, ambulating and use of special equipment; and conduct training of family/caregivers.
• Respite Care – Is provided in both inpatient
and outpatient settings for a short-term period to relieve the family. Respite services can be available up to 24-hours-a-day and is limited to 600 hours per fiscal year up to 25 days.
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