Illinois Compiled Statutes 305 ILCS 5/5F-30 – Continuity of care
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When a nursing home resident first transitions to a managed care organization from the fee-for-service system or from another managed care organization, the managed care organization shall honor the existing care plan and any necessary changes to that care plan until the MCO has completed a comprehensive assessment and new care plan, to the extent such services are covered benefits under the contract, which shall be consistent with the requirements of the RAI Manual.
When an enrollee of a managed care organization is moving from a community setting to a nursing home, and the MCO is properly notified of the proposed admission by a network nursing home, and the managed care organization fails to participate in developing a care plan within the time frames required by nursing home regulations, the MCO must honor a care plan developed by the nursing home until the MCO has completed a comprehensive assessment and a new care plan to the extent such services are covered benefits under the contract, consistent with the requirements of the RAI Manual.
A nursing home shall have the ability to refuse admission of an enrollee for whom care is required that the nursing home determines is outside the scope of its license and healthcare capabilities.
When an enrollee of a managed care organization is moving from a community setting to a nursing home, and the MCO is properly notified of the proposed admission by a network nursing home, and the managed care organization fails to participate in developing a care plan within the time frames required by nursing home regulations, the MCO must honor a care plan developed by the nursing home until the MCO has completed a comprehensive assessment and a new care plan to the extent such services are covered benefits under the contract, consistent with the requirements of the RAI Manual.
Terms Used In Illinois Compiled Statutes 305 ILCS 5/5F-30
- Contract: A legal written agreement that becomes binding when signed.
- Enrollee: means an individual who resides in a nursing home or is qualified to be admitted to a nursing home and is enrolled with a managed care organization participating in the Demonstration Project. See Illinois Compiled Statutes 305 ILCS 5/5F-15
- MCO: means an entity that meets the definition of health maintenance organization as defined in the Health Maintenance Organization Act, is licensed, regulated and in good standing with the Department of Insurance, and is authorized to participate in the nursing home component of the Medicare-Medicaid Alignment Initiative Demonstration Project by a 3-way contract with the Department of Healthcare and Family Services and the Centers for Medicare and Medicaid Services. See Illinois Compiled Statutes 305 ILCS 5/5F-15
- Nursing home: means a facility licensed under the Nursing Home Care Act. See Illinois Compiled Statutes 305 ILCS 5/5F-15
- RAI Manual: means the most recent Resident Assessment Instrument Manual, published by the Centers for Medicare and Medicaid Services. See Illinois Compiled Statutes 305 ILCS 5/5F-15
- Resident: means an enrollee who is receiving personal or medical care, including, but not limited to, mental health treatment, psychiatric rehabilitation, physical rehabilitation, and assistance with activities of daily living, from a nursing home. See Illinois Compiled Statutes 305 ILCS 5/5F-15
A nursing home shall have the ability to refuse admission of an enrollee for whom care is required that the nursing home determines is outside the scope of its license and healthcare capabilities.