2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

Behavioral Health10. Long-Term Care10. Long-Term CareLong-term care is the overarching term that refersto the Community Benefit, the services of a nursingfacility, and the services of an institutional facility.With the creation of Centennial Care, the NewMexico Human Services Department (HSD) nowcontracts with four Managed Care Organizations(MCOs) including Presbyterian to deliver the fullrange of physical health, behavioral health, andlong-term care in a comprehensive and integratedmanner.Presbyterian Centennial Care’s goal is to provideeach of our members with access to the servicesand support necessary to maintain the highest levelof function and independence in their community.For members residing in nursing facilities or otherinstitutions, our goal is to ensure quality health careand reduce the number of acute inpatientadmissions through effective care coordination andsuccessful care transitions. Please note that thischapter applies specifically to the Centennial Careprogram.Patient EligibilityGeneral EligibilityThe state determines eligibility for enrollment in aCentennial Care program. Continued eligibility isassessed annually and includes a re-assessmentby the state or its designee. All individualsassessed as Medicaid-eligible are required toparticipate in Centennial Care unless specificallyexcluded by a 1115(a) Waiver.Recipients in the Developmental Disabilities1915(c) Waiver and recipients with developmentaldisabilities in the Mi Via 1915(c) Waiver continue toreceive home- and community-based services(HCBS) through those waivers for a limited periodof time, but are required to enroll in CentennialCare for all non-HCBS. Recipients in the MedicallyFragile 1915(c) Waiver continue to receive HCBSthrough that waiver unless and until such servicesare transitioned to Centennial Care. Recipients inthe Medically Fragile 1915(c) Waiver are requiredto enroll in a Centennial Care MCO for all non-HCBS.Native American Member EligibilityNative American members may self-refer to anIndian Health Service (IHS) or Tribal Health Centerfor long-term care services. PresbyterianCentennial Care allows members who are NativeAmerican to seek care from any IHS or tribalprovider defined in the Indian Health CareImprovement Act, 25 United States Code (USC)§§1601, et seq., whether or not the providerparticipates in Presbyterian’s provider network. Tofurther promote access for our Native Americanmembers, Presbyterian Centennial Care does notrequire prior authorization for services providedwithin the IHS and Tribal 638 network and accepts10-12014 Practitioner and Provider Manual - Ver. 3