reglab/statecodes huggingface dataset:
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 480 - HOME AND COMMUNITY-BASED SERVICES › Chapter 3 - PARTICIPANT ACCESS AND REQUIREMENTS › Section 480-3-004 - TARGETED CASE MANAGEMENT

Current through June 17, 2024
Targeted case management will be provided by Department staff or a
	 designee. Regulatory references addressing participation by the services
	 coordinator are also intended to allow participation by the services
	 coordinator's supervisor, if necessary.
004.01
WAIVER
  CONSENT.
If the participant accepts Waiver services, the
  participant or legal guardian must sign the Waiver consent form. The Waiver
  consent form must be updated any time there is a change in the legal ability of
  the participant or legal guardian to consent to Waiver services. The Waiver
  consent form is not valid until the date the participant's eligibility for
  Medicaid has been determined. The participant's Waiver services may not be
  authorized until the participant signs the Waiver consent form and Medicaid
  eligibility is approved.
004.02
MONITORING.
Monitoring of Waiver services includes:
(A) Monthly contact between the participant
  and the services coordinator. Contact may be more frequent based on participant
  need. In-person visits must occur at least quarterly, and may occur more often
  if determined to be necessary by the services coordinator. All in-person
  contacts will be at a time, date, and location convenient to the participant.
  Each participant contact includes the following:
(i) Confirmation services being provided by
  both formal and informal supports and services continue to meet the
  participant's needs based on participant interview and observation;
(ii) Review of service usage and
  cost;
(iii) Review of the
  participant's desired outcomes;
(iv) Review the participant's satisfaction
  with the services provided;
(v)
  Review of the participant's overall health status;
(vi) Review of medical information;
  and
(vii) Verification that
  providers comply with the requirements of service provision.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 480 - HOME AND COMMUNITY-BASED SERVICES › Chapter 4 - PROVIDER REQUIREMENTS › Section 480-4-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
The regulations govern the services provided under Nebraska's Medicaid
	 program as defined by Nebraska Revised Statutes (Neb. Rev. Stat.) §§
									68-901
	 Et seq. (the Medical Assistance Act).
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 480 - HOME AND COMMUNITY-BASED SERVICES › Chapter 4 - PROVIDER REQUIREMENTS › Section 480-4-004 - PROVIDER ENROLLMENT

Current through June 17, 2024
Refer to 471 NAC
	 2-000 for guidance regarding provider
	 enrollment. Additional standards applicable to providers of Medicaid Home and
	 Community-Based Waiver services follow.
004.01
PROVIDER
  SCREENING.
In addition to requirements for provider screening
  found in 471 NAC
  2-000, Department staff, or a designee
  of the Department, must conduct an in-person interview with each potential
  provider upon initial application and annually to review compliance with
  current service specific program standards. Monitoring visits will occur if a
  potential provider is approved. If the provider does not meet service specific
  standards at the time of the interview, but is willing to correct the
  deficiency within 30 days, staff will continue the interview when proof of
  compliance is received. If the provider is not willing to correct deficiencies
  within 30 days the provider will be denied or terminated.
004.02(A)
DEPARTMENT STAFF
  RELATIVES AS PROVIDERS.
In situations where a Department staff
  person's relative is the only resource, staff will obtain administrative
  approval. Department staff cannot approve, reapprove, evaluate, or negotiate
  provider agreements with, or authorize service provision from, providers to
  whom they are related.
004.02(B)
PARTICIPANT RELATIVES AS PROVIDERS.
A provider may not
  provide services for a relative participant that the provider has a legal
  responsibility to support.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 480 - HOME AND COMMUNITY-BASED SERVICES › Chapter 5 - AGED AND DISABLED WAIVER SERVICE REQUIREMENTS › Section 480-5-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
The regulations govern the services provided under Nebraska's Medicaid
	 program as defined by Nebraska Revised Statutes §§
									68-901
	 et seq. (the Medical Assistance Act).
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 480 - HOME AND COMMUNITY-BASED SERVICES › Chapter 5 - AGED AND DISABLED WAIVER SERVICE REQUIREMENTS › Section 480-5-002 - GENERAL SERVICE REQUIREMENTS.

Current through June 17, 2024
002.01
PARTICIPANT ELIGIBILITY.
Prior to initiation of
  services, all requirements outlined in 480 NAC
  3-000 must be finalized.
002.02
SERVICE
  NEEDS.
The need for each of the covered Waiver Services outlined
  in 480 Nebraska Administrative Code (NAC)
  5-000 must be reflected in one or more
  assessment areas of the participant's person-centered plan (PCP).
002.03
SERVICE
  DUPLICATION.
Medicaid does not cover Waiver services
  simultaneously provided by two or more paid caregivers for the same service.
  Services that are available under the State Plan cannot be duplicated by this
  Waiver.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 480 - HOME AND COMMUNITY-BASED SERVICES › Chapter 5 - AGED AND DISABLED WAIVER SERVICE REQUIREMENTS › Section 480-5-003 - COVERED WAIVER SERVICES

Current through June 17, 2024
Medicaid services available to persons eligible for this Home and
	 Community-Based Waiver program are:
(A) Adult Day Health Services
  (ADHS);
(B) Assisted Living Service
  (AL);
(C) Assistive Technology and
  Supports, and Home and Vehicle Modifications (ATS, H/VM);
(D) Chore;
(E) Extra Care for Children with
  Disabilities;
(F) Home
  Again;
(G) Home-Delivered
  Meals;
(H) Independence Skills
  Building;
(I) Non-Medical
  Transportation;
(J) Personal
  Emergency Response System (PERS); and
(K) Respite Care
003.01
ADULT DAY HEALTH SERVICES
  (ADHS).
003.01(A)
SERVICE DESCRIPTION.
Adult Day Health Services (ADHS)
  is a service which allows for structured social, and health activities. It may:
(i) Offer socialization;
(ii) Aid in transition from one living
  arrangement to another;
(iii)
  Provide a supervised environment while the regular caregiver is working or
  otherwise unavailable; or
(iv)
  Provide a setting for receipt of multiple health services in a coordinated
  setting.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 480 - HOME AND COMMUNITY-BASED SERVICES › Chapter 6 - TRAUMATIC BRIAN INJURY (TBI) WAIVER SERVICE REQUIREMENTS › Section 480-6-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
The regulations govern the services provided under Nebraska's Medicaid
	 program as defined by Nebraska Revised Statutes (Neb. Rev. Stat.) §§
									68-901
	 Et seq. (the Medical Assistance Act).
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 480 - HOME AND COMMUNITY-BASED SERVICES › Chapter 6 - TRAUMATIC BRIAN INJURY (TBI) WAIVER SERVICE REQUIREMENTS › Section 480-6-002 - PARTICIPANT ACCESS AND REQUIREMENTS

Current through June 17, 2024
002.01
PARTICIPANT ELIGIBILITY.
In addition to the criteria
  outlined in 480 Nebraska Administrative Code (NAC)
  3-000, to be eligible for Traumatic
  Brain Injury (TBI) Waiver services, an individual must:
(A) Be an adult, ages 18 - 64 years old, with
  a medically documented diagnosis of traumatic brain injury (TBI);
(B) Have needs which require the type of care
  necessary to treat the conditions and criteria identified in the definition of
  a Specialized Assisted Living (SAL); and
(C) Utilize available waiver capacity. If a
  statewide waiting list is required due to limited statewide capacity, the next
  available opening is assigned based upon this priority order:
(i) The participant has been residing in a
  nursing facility, hospital, or other institution for longer than 90
  days;
(ii) The participant is in a
  crisis or high stress situation and is at risk for institutional
  placement;
(iii) The participant is
  a person who has had a substantiated report of abuse or neglect, and it is
  determined that the applicant can be appropriately supported with waiver
  services; and
(iv) Any other
  situation where the participant is eligible for waiver services.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 480 - HOME AND COMMUNITY-BASED SERVICES › Chapter 6 - TRAUMATIC BRIAN INJURY (TBI) WAIVER SERVICE REQUIREMENTS › Section 480-6-003 - SPECIALIZED ASSISTED LIVING (SAL) PROVIDER REQUIREMENTS

Current through June 17, 2024
In addition to all requirements applicable to an assisted living
	 provider in 480 NAC Chapters
	 2-000,
	 4-000 and 5000, each assisted living
	 (AL) provider providing traumatic brain injury (TBI) services will be licensed
	 as a specialized assisted living (SAL) provider per 175 NAC Chapter
	 4-000.
003.01
SPECIALIZED ASSISTED
  LIVING (SAL) PROVIDER RATES.
Specialized assisted living (SAL)
  providers are provided an increased rate relative to the rates outline in 480
  NAC
  4-000. This increased rate is based on
  participant condition and complexity of providing services.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 480 - HOME AND COMMUNITY-BASED SERVICES › Chapter 6 - TRAUMATIC BRIAN INJURY (TBI) WAIVER SERVICE REQUIREMENTS › Section 480-6-004 - SERVICE REQUIREMENTS

Current through June 17, 2024
The service available to eligible persons under Nebraska's traumatic
	 brain injury (TBI) Waiver is described in this section. The need for each
	 Waiver service must be identified in one or more assessment areas and addressed
	 in the participant's person centered plan (PCP).
004.01
SPECIALIZED ASSISTED
  LIVING (SAL) SERVICE.
004.01(A)
SERVICE DESCRIPTION.
Specialized assisted living (SAL)
  is an array of support services for the Home and Community-Based Services
  (HCBS) Waiver population which includes assistance with or provision of
  personal care activities, activities of daily living (ADL), instrumental
  activities of daily living (IADL), and health maintenance activities.
004.01(B)
SERVICE
  COMPONENTS.
Specialized assisted living (SAL) providers must offer
  and make available each of the service components identified and outlined in
  480 NAC
  5-000.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 481 - COMMUNITY SERVICES BLOCK GRANT PROGRAM › Chapter 1 - PROGRAM REQUIREMENTS › Section 481-1-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
These regulations govern the Community Services Block Grant (CSBG)
	 Program. The Community Services Block Grant Program was created by the Economic
	 Opportunity Act of 1964 and amended by Public
				  Law 105-285, cited as the Coats Human Services Reauthorization Act of
	 1998.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 481 - COMMUNITY SERVICES BLOCK GRANT PROGRAM › Chapter 1 - PROGRAM REQUIREMENTS › Section 481-1-002 - DEFINITIONS

Current through June 17, 2024
The following definition of terms will apply unless the context denotes
	 otherwise:
002.01.
DEPARTMENT
The Nebraska Department of Health and Human Services.
002.02
ELIGIBLE ENTITY.
An eligible entity as defined in the Community Services Block
  Grant Act.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 481 - COMMUNITY SERVICES BLOCK GRANT PROGRAM › Chapter 1 - PROGRAM REQUIREMENTS › Section 481-1-003 - ELIGIBILE ENTITY REQUIREMENTS

Current through June 17, 2024
Eligible entities receiving funds under the Community Services Block
	 Grant Program must comply with federal statutes and regulations, state
	 regulations, and the sub-award.
003.01
NONDISCRIMINATION AND EQUAL OPPORTUNITY.
An eligible
  entity must not discriminate on the basis of race, color, national origin,
  religion, sex, familial status, disability, or age. The eligible entity must
  make known that use of the facilities and services are available to all on a
  nondiscriminatory basis. The eligible entity must have procedures to make known
  their policy of nondiscrimination. Eligible entities and recipients must also
  adopt procedures, which must be made available to interested persons, that
  contain information concerning the location of services and facilities that are
  accessible to persons with disabilities.
003.02.
CONFIDENTIALITY.
All eligible entities must adopt written policies to protect the
  confidentiality of all persons served. Confidentiality policies regarding
  persons served must be framed in the best interests of the client, and must
  include disclosure to the client of any potential sharing of
  information.
003.03
ACCESS TO RECORDS.
All eligible entities must adopt
  written policies that identify those records which are available to the public,
  those records which are not available to the public, and the conditions under
  which records may be made available. The Department's intent is that
  information regarding the eligible entity's policies, financial operations, and
  operating effectiveness must be available to the public under reasonable
  conditions.
003.04
APPEALS PROCESS.
All eligible entities must have a
  written appeals process through which clients or potential clients may appeal
  denials of service or improper provision of service. The appeals process should
  extend at least to the eligible entity's governing board
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 481 - COMMUNITY SERVICES BLOCK GRANT PROGRAM › Chapter 1 - PROGRAM REQUIREMENTS › Section 481-1-004 - ADMINISTRATIVE REQUIREMENTS

Current through June 17, 2024
The Community Services Block Grant Program is administered in
	 accordance with the federal statutes and regulations governing the program and
	 the Department's approved state plan. Eligible entities seeking to participate
	 and receive funding, must complete and submit a Community Action Plan for
	 evaluation and approval by the Department.
004.01
SELECTION AND COMPOSITION
  OF BOARD OF DIRECTORS.
The eligible entity must ensure that a
  process is in place for the selection of members of the board in accordance
  with the Community Services Block Grant Act.
004.01(A)
BOARD
  POWERS.
The board must have all of the powers required under
  Nebraska Revised Statute, Chapter 21, Article 19, (The Nebraska Nonprofit
  Corporation Act) and its successors.
004.01(B)
SELECTING
  REPRESENTATIVES OF THE SECTORS.
The board must adopt a written plan
  which describes the procedures for selecting representatives for each of the
  three sectors of the board.
004.01(C)
LIMITATIONS ON LENGTH
  OF SERVICE.
The board must develop policies as to the length of
  time members may serve on the board
004.01(D)
CONFLICT OF
  INTEREST.
The following individuals are considered to have a
  conflict of interest and must not serve on the board of directors.
(1) A person who is an officer or an employee
  of an organization contracting to perform a component of the work program
  funded by Community Services Block Grant;
(2) A paid employee of the eligible entity;
  and
(3) An employee of the
  Department.
004.01(D)(i)
RESTRICTIONS.
These restrictions may be waived by the
  Department.
004.01(E)
PETITION FOR REPRESENTATION ON THE BOARD.
Eligible
  entities must establish procedures allowing a petition for adequate
  representation if a low income individual, community organization, religious
  organization, or representative of low income individuals feels
  under-represented on the board.
004.01(F)
ALTERNATES.
The board may allow alternates to
  substitute for members. If alternates are allowed, the board must maintain
  written policies which specify.
(i) How
  alternates are selected;
(ii) The
  powers given alternates; and
(iii)
  The limitations placed on alternates.
004.01(G)
FILLING
  VACANCIES.
The board must maintain written policies that describe
  the procedures to be used in filling vacancies.
004.01(H)
COMPENSATION.
Although expense allowances for low
  income individuals and reimbursements to all members of the board for expenses
  are permitted, regular compensation to all members for their service on the
  board is not permitted.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 481 - COMMUNITY SERVICES BLOCK GRANT PROGRAM › Chapter 1 - PROGRAM REQUIREMENTS › Section 481-1-005 - FINANCIAL ADMINISTRATION

Current through June 17, 2024
The expenditures of all Community Services Block Grant funds must be
	 accounted for in accordance with generally accepted accounting principles, as
	 per 45 C.F.R. Part 75.
005.01
ACCESS TO INFORMATION AND DOCUMENTS.
Eligible entities
  and contractors must provide access to any books, documents, papers, or records
  that duly authorized representatives of the Department, the Secretary of the
  United States Health and Human Services, and the State Auditor determine are
  pertinent to an approved project plan. Eligible entities must comply with the
  Privacy Act of 1974, 5 United States Code (U.S.C.) 552a. An eligible entity
  must not establish restrictions which limit public access to the eligible
  entity's records or to the records of its contractors, except when the records
  must remain confidential for any of the following reasons:
(A) To prevent a clearly unwarranted invasion
  of personal privacy;
(B) To comply
  with an executive order or statute which specifically requires the records to
  be kept secret;
(C) To protect
  commercial or financial information which was obtained from a person or a firm
  on a privileged or confidential basis;
(D) To protect information which can be
  improperly exploited for personal gains;
(E) To comply with the Health Insurance
  Portability and Accountability Act (HIPAA) of 1996;
(F) To protect the confidentiality of
  individual program participant information; or
(G) To protect the confidentiality of
  employee personnel records.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 1 - INTRODUCTION AND DEFINITIONS › Section 482-1-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
These regulations govern services provided under the Medical
	 Assistance Act, Nebraska Revised Statute (Neb. Rev. Stat.) §§
									68-901
	 et seq.
001.01
LEGAL
  BASIS.
The Nebraska Medicaid program is authorized by the Medical
  Assistance Act to deliver services through managed care. The Section 1915(b)
  waiver permits Nebraska Medicaid to operate the managed care program.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 1 - INTRODUCTION AND DEFINITIONS › Section 482-1-002 - DEFINITIONS

Current through June 17, 2024
The following definitions apply:
002.01
ACTION.
Action means the:
(A) Denial or limited
  authorization of a requested service, including the type or level of
  service;
(B) Reduction, suspension,
  or termination of a previously authorized service;
(C) Denial, in whole or in part, of payment
  for a service;
(D) Failure to
  provide services in a timely manner, as defined by Medicaid;
(E) Failure of the managed care organization
  to act within the timeframes; or
(F) For a rural area resident with only one
  managed care organization to choose from, the denial of a Medicaid enrollee's
  request to obtain services outside the network:
(i) From any other provider (in terms of
  training, experience, and specialization) not available within the network;
(ii) From a provider not part of
  the network who is the main source of a service to the recipient - provided
  that the provider is given the same opportunity to become a participating
  provider as other similar providers. If the provider does not choose to join
  the network or does not meet the qualifications, the enrollee is given a choice
  of participating providers and is transitioned to a participating provider
  within 60 days;
(iii) Because the
  only plan or provider available does not provide the service because of moral
  or religious objections;
(iv)
  Because the recipient's provider determines that the recipient needs related
  services that would subject the recipient to unnecessary risk if received
  separately and not all related services are available within the network;
  or
(v) Medicaid determines that
  other circumstances warrant out-of-network treatment.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 2 - MEMBER PARTICIPATION AND ENROLLMENT › Section 482-2-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
These regulations govern services provided under the Medical Assistance
	 Act, Nebraska Revised Statute (Neb. Rev. Stat.) §§
									68-901
	 et seq.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 2 - MEMBER PARTICIPATION AND ENROLLMENT › Section 482-2-002 - HERITAGE HEALTH PLAN MANDATORY AND EXCLUDED MEMBERS

Current through June 17, 2024
The following outlines those clients who are mandatory or excluded
	 members. The member's status (mandatory or excluded) is determined by an
	 automated interface between Medicaid's eligibility system and each Heritage
	 Health plan's system based on information entered on the Medicaid eligibility
	 system known at the time of the interface.
002.01
HERITAGE HEALTH PLAN
  MANDATORY MEMBERS.
Unless excluded, the following clients are
  required to participate as members in Nebraska Medicaid managed care program
  for physical health, behavioral health, and pharmacy benefits:
(A) Families, children, and pregnant women
  eligible for Medicaid under Section 1931 of the federal Social Security Act, as
  amended ("Section 1931"), or related coverage groups.
(B) Members who are eligible for Medicaid due
  to blindness or disability;
(C)
  Members who are sixty-five (65) years of age or older and not members of the
  blind and disabled population or members of the Section 1931 adult
  population;
(D) Low-income children
  who are eligible to participate in Medicaid under Title XXI of the federal
  Social Security Act, as amended (the "Children's Health Insurance
  Program");
(E) Members who are
  receiving foster care or subsidized adoption assistance under Title IV-E of the
  federal Social Security Act, as amended; are in foster care; or, are otherwise
  in an out-of-home placement;
(F)
  Members who participate in a Home and Community-Based Waiver Services program.
  This includes groups covered by the State's Section 1915(c) waiver under the
  federal Social Security Act, as amended;
(G) Individuals who are eligible for Medicaid
  through the Breast and Cervical Cancer Prevention and Treatment Act of
  2000;
(H) Medicaid beneficiaries
  during a period of retroactive eligibility, when mandatory enrollment for
  Heritage Health has been determined;
(I) Members eligible during a period of
  presumptive eligibility;
(J)
  Members eligible for the State Disability program under Neb. Rev. Stat. §
										68-1005;
(K) Members eligible for the Refugee
  Resettlement program under Title IV of the Immigration and Nationality Act;
  and
(L) Members with continuous
  eligibility who have a share of cost.
(M) Members who are eligible in the Heritage
  Health Adult group as described in 477 Nebraska Administrative Code (NAC) 29
  under Section 1902(a)(10)(A)(i)(VIII) of the Social Security Act
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 2 - MEMBER PARTICIPATION AND ENROLLMENT › Section 482-2-003 - ENROLLMENT ACTIVITIES IN A HERITAGE HEALTH PLAN

Current through June 17, 2024
The enrollment broker has the responsibility to enroll a member in a
	 Heritage Health plan.
003.01
MEMBER CHOICE.
A member may choose a Heritage Health
  plan and primary care provider or the member may be auto-assigned by the
  enrollment broker to a Heritage Health plan. The member must have the
  opportunity to choose the health plan and primary care provider of their
  choice, to the extent possible and appropriate.
(A) The Heritage Health plan is responsible
  for the assignment of the primary care provider for members who do not
  voluntarily enroll.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 2 - MEMBER PARTICIPATION AND ENROLLMENT › Section 482-2-004 - DISENROLLMENT OR TRANSFERS

Current through June 17, 2024
A disenrollment or transfer may be made at the member's request (Title
	 482 NAC
	 2-004.01) or at the primary care
	 provider's or Heritage Health plan's request (Title 482 NAC
	 2-004.04). A transfer may also be
	 made because the member requires an interim primary care provider (Title 482
	 NAC
	 2-004.03E).
004(A)
TRANSFERS.
Transfer for the purposes of this section is a change in a member's assignment
  from one primary care provider to another primary care provider or one dental
  home to another dental home.
004(B)
DISENROLLMENT.
Disenrollment for the purposes of this
  section is a change in a member's enrollment from one Heritage Health plan to
  another.
004.01
TRANSFER REQUESTS.
The member must contact the
  Heritage Health plan or Dental Benefits Manager to request a primary care
  provider or dental home transfer, respectively. A member may request a transfer
  from one primary care provider to another primary care provider or from one
  dental home to another dental home at any time. The health plan must document
  all member transfer requests and the reason.
004.01(A)
ASSISTANCE WITH
  SELECTING A NEW PRIMARY CARE PROVIDER.
The Heritage Health plan
  must assist the member in selecting a new primary care provider by:
(i) Discussing the reasons for transfer with
  the member and attempting to resolve any conflicts when in the member's best
  interest;
(ii) Reviewing the
  member's needs to facilitate the member's choice of primary care
  provider;
(iii) Processing the
  member request; and
(iv) Notifying
  the Department of the primary care provider transfer via the primary care
  provider transfer file. The primary care provider transfer will be updated on
  the member's managed care file,
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 2 - MEMBER PARTICIPATION AND ENROLLMENT › Section 482-2-005 - WAIVER OF ENROLLMENT

Current through June 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.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 3 - ENROLLMENT BROKER › Section 482-3-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
These regulations govern the services provided under Nebraska's
	 Medicaid program as defined by Neb. Rev. Stat. §§
									68-901 et. Seq. the Medical
	 Assistance Act.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 3 - ENROLLMENT BROKER › Section 482-3-002 - DEFINITIONS

Current through June 17, 2024
The following definitions apply:
002.01
ENROLLMENT
  BROKER.
The enrollment broker is a contracted entity that performs
  unbiased choice counseling and enrollment activities for health plan
  members.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 3 - ENROLLMENT BROKER › Section 482-3-003 - ENROLLMENT MATERIALS

Current through June 17, 2024
The enrollment broker must distribute enrollment information and
	 marketing materials to managed care members and potential members. The
	 enrollment broker must develop the materials in coordination with the health
	 plans, with Medicaid's approval, and meet the following guidelines:
(A) Written materials use easily understood
  language and format;
(B) Written
  materials are available in the prevalent non-English languages, as specified by
  Medicaid;
(C) Written materials are
  available in alternative formats that take into consideration the special needs
  of members;
(D) Materials on all
  Heritage Health service components are distributed equitably and without bias
  to any particular health plan;
(E)
  All enrollment notices, information, and instructional materials are available
  upon request;
(F) Materials clearly
  state information about Heritage Health, ensure the member has adequate
  information to make an informed selection; and
(G) Materials are reviewed and approved by
  Medicaid.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 3 - ENROLLMENT BROKER › Section 482-3-004 - MEMBER WEBSITE

Current through June 17, 2024
The enrollment broker website must include general and up-to date
	 information about Heritage Health, the enrollment broker, and health plans. The
	 enrollment broker website will remain compliant with applicable privacy and
	 security requirements, including but not limited to the Health Insurance
	 Portability and Accountability Act of 1996 (HIPAA), when providing member
	 eligibility or identification information on its website. The enrollment broker
	 website must include the following:
(A) Current version of the enrollment broker
  outreach packet, notice of anniversary letter, provider directory, health plan
  matrix, and all other mailings provided by the enrollment broker;
(B) Telephone contact information for the
  enrollment broker;
(C) Real time,
  searchable provider directory for each health plan; to include open and closed
  panels;
(D) Links to health plan
  websites and toll-free numbers;
(E)
  A link to the Medicaid eligibility website;
(F) Information on how to select a health
  plan and primary care provider, report family and demographic changes, and file
  grievances and appeals; and
(G)
  Secure online portal to facilitate member health plan enrollment and primary
  care provider selection.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 3 - ENROLLMENT BROKER › Section 482-3-005 - ENROLLMENT ACTIVITIES AND CHOICE COUNSELING

Current through June 17, 2024
The enrollment broker must complete the following enrollment and choice
	 counseling activities for mandatory and potential mandatory members in
	 coordination with the health plans and Medicaid:
(A) Educate members concerning Heritage
  Health including:
(i) A general explanation of
  Heritage Health;
(ii) Mandatory and
  excluded members; and
(iii) The
  role of the health plans in coordinating care.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 4 - THE HERITAGE HEALTH MANAGED CARE CORE BENEFITS PACKAGE › Section 482-4-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
These regulations govern the responsibilities of the health plan in
	 delivering the core benefits package to the Heritage Health member. The
	 Department, assumes primary administrative and operational responsibility for
	 the implementation of the Heritage Health programmatic requirements. The health
	 plan must incorporate the information contained in this Title, as well as Title
	 471 Nebraska Administrative Code (NAC), which defines in detail the minimum
	 service provisions required for the physical health, behavioral health, and
	 pharmacy services under Medicaid.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 4 - THE HERITAGE HEALTH MANAGED CARE CORE BENEFITS PACKAGE › Section 482-4-003 - HEALTH CHECK EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT

Current through June 17, 2024
The health plan must develop a program to ensure the delivery of Health
	 Check Early and Periodic Screening, Diagnosis and Treatment services.
003.01
CONTACT WITH ELIGIBLE
  FAMILIES.
The health plan must contact eligible families who have
  children age twenty (20) and younger within sixty (60) days of enrollment and
  encourage them to make an appointment for the required components of Health
  Check Early and Periodic Screening, Diagnosis and Treatment. The health plan
  must also counsel the family regarding the importance of health supervision and
  regular check-ups and assist in removing barriers to care. If necessary, the
  health plan must assist families with appointment scheduling and arranging
  transportation.
003.01(A)
REQUIRED COMPONENTS.
The required components are
  health screening, including medical, vision, hearing and dental screening (see
  471 NAC
  33-000).
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 4 - THE HERITAGE HEALTH MANAGED CARE CORE BENEFITS PACKAGE › Section 482-4-005 - CORE BENEFITS PACKAGE GENERAL PROVISIONS

Current through June 17, 2024
All services provided under managed care must meet the requirements of
	 Title 471 NAC unless specifically waived by the Department. The health plan
	 must apply the same guidelines for determining coverage of services for the
	 Heritage Health member as the Department applies for other Medicaid members.
	 The plan must base the actual provision of a service included in the core
	 benefits package on whether the service could have been covered under Medicaid
	 fee-for-service basis under Title 471 NAC.
005.01
PRIOR
  AUTHORIZATIONS.
Family planning services (see 482 NAC
  4-005.04), emergency services, and
  Native Americans seeking tribal clinic or Indian Health hospital services do
  not require prior authorization or provision by the primary care physician or
  participating network provider. All covered emergency services (see 482 NAC
  4-005.05) must be available
  twenty-four (24) hours per day, seven (7) days per week, and are not to be
  limited to plan-network providers. The member may access these services from
  any Medicaid-enrolled provider of their choice, and the member may access these
  services without a referral.
005.01(A)
REIMBURSEMENT.
The Department requires the health plan
  to reimburse providers, network and out-of-network, for appropriate medical
  screening performed during an emergency room visit. The payment of claims to
  out-of-network providers are subject to the requirements in 482 NAC
  4-006.07(A).
  Electronic referral and authorization must be provided in accordance with the
  standards set forth in the Health Insurance Portability and Accountability Act
  of 1996.
005.01(B)
EXCEPTION.
In addition to the health plans provision,
  abortions must be prior authorized by the Department.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 5 - THE DENTAL BENEFITS PACKAGE › Section 482-5-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
These regulations govern services provided under the Medical Assistance
	 Act, Nebraska Revised Statute (Neb. Rev. Stat.) §§
									68-901
	 et seq.
001.01
INTRODUCTION.
This chapter sets forth the
  responsibilities of the Dental Benefits Manager, a Prepaid Ambulatory Health
  Plan, in delivering the dental benefits package to their managed care members.
  While the provider is responsible for providing services to the member, the
  Dental Benefits Manager, as the contracting entity with the Department, assumes
  primary administrative and operational responsibility for the development and
  implementation of the managed care requirements. In developing its program for
  the delivery of the dental benefits package, the Dental Benefits Manager must
  incorporate the information contained in this Title, as well as 471 Nebraska
  Administrative Code (NAC) 6, which defines in detail the minimum service
  provisions required for dental services under Nebraska Medicaid.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 5 - THE DENTAL BENEFITS PACKAGE › Section 482-5-002 - DENTAL BENEFITS PLAN

Current through June 17, 2024
Medicaid managed care delivers the dental benefits package to eligible
	 Medicaid members through a Prepaid Ambulatory Health Plan. The following
	 provisions describe the Dental Benefits Manager's responsibilities in Managed
	 Care.
002.01
GENERAL
  REQUIREMENTS.
The Dental Benefits Manager is responsible for
  establishing a statewide system of dental services. The Dental Benefits Manager
  is required to comply with, but is not limited to, the following general
  requirements:
(A) Credential only providers
  enrolled in Nebraska Medicaid;
(B)
  Provide a full array of services along a continuum of care in accordance with
  471 NAC 6;
(C) Provide access to
  dental services and necessary referrals twenty-four (24) hours per day, seven
  (7) days per week;
(D) Provide a
  client handbook, a comprehensive list of providers, and other informational
  materials about the dental benefits package to its members. The Dental Benefits
  Manager must not perform any direct solicitation to individual Medicaid
  members. The Department must approve any general marketing to Medicaid members
  prior to use and must comply with applicable marketing
  guidelines7;
(E) Comply with Medicaid's continuous Quality
  Assessment and Performance Improvement, provide dental services meeting
  Medicaid's quality standards, and comply with all requests for reports and data
  to ensure that the Quality Assessment and Performance Improvement requirements
  are met (See 482 NAC 6);
(F)
  Coordinate activities with Medicaid, other managed care contractors, and other
  providers for services, as appropriate, to meet the needs of the member, and
  ensure systems are in place to promote well-managed patient care;
(G) Maintain, at all times, an appropriate
  certificate of authority to operate issued by the Nebraska Department of
  Insurance;
(H) Prohibit hiring,
  employing, contracting with or otherwise conducting business with individuals
  or entities barred from participation in Medicaid or Medicare;
(I) Allow members with chronic, severe
  conditions, or experience-sensitive conditions to go directly to a qualified
  provider within the Dental Benefits Manager's network;
(J) Report all fraud and abuse information to
  Medicaid in a timely manner; and
(K) Make available twenty-four (24) hour,
  seven (7) days per week access by telephone to a live voice (an employee of the
  plan or an answering service) so that referrals can be made for non-emergency
  services or so information can be given about accessing services or how to
  handle medical problems during non-office hours.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 5 - THE DENTAL BENEFITS PACKAGE › Section 482-5-003 - DENTAL BENEFITS PACKAGE GENERAL PROVISION

Current through June 17, 2024
All services provided under managed care must meet the requirements of
	 471 NAC unless specifically waived by the Department.
003.01
GUIDELINES.
The provider and Dental Benefits Manager must apply the same guidelines for
  determining coverage of services for the managed care member as Medicaid
  applies to non-managed care members.
(A)
  Actual provision of a service included in the dental benefits package must be
  based on whether the service could have been covered by Nebraska Medicaid on a
  fee-for-service basis under Title 471 NAC.
(B) All services in the dental benefits
  package must be provided or approved by the Dental Benefits Manager.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 5 - THE DENTAL BENEFITS PACKAGE › Section 482-5-004 - SERVICES IN THE DENTAL BENEFITS PACKAGE

Current through June 17, 2024
The Dental Benefits Manager must provide the services listed in the
	 Nebraska Medicaid Dental Fee Schedule in amount, duration and scope defined by
	 Medicaid in 471 NAC 6.
004.01
DENTAL BENEFITS MANAGER AND ACCESS STANDARDS.
The
  Dental Benefits Manager is responsible for ensuring the eligible member has
  access to all services when medically necessary.
004.01(A)
ACCESSIBILITY.
The Dental Benefits Manager must ensure
  services provided to the member are accessible, in terms of timeliness, amount,
  duration, and scope, as those services provided to the non-managed care
  member.
004.01(B)
LIMITATIONS.
The Dental Benefits Manager may place
  appropriate limits on services based on medical necessity or utilization
  control.
004.01(C)
ADDITIONAL AND SUBSTITUTE SERVICES.
The Dental
  Benefits Manager is allowed to provide additional medically necessary services
  than those covered by Medicaid. The Dental Benefits Manager is also allowed to
  provide substitute dental services when the Dental Benefits Manager determines
  the service is more cost effective than the covered service and the health
  status of the member is expected to improve or stabilize.
(i) If the Dental Benefits Manager provides
  additional or substitute dental services, the Department will not adjust the
  rate or total payment to the Dental Benefits Manager as the contract between
  the two parties dictate. The rate will remain within the rate range that the
  Centers for Medicare and Medicaid Services approved and certified.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 5 - THE DENTAL BENEFITS PACKAGE › Section 482-5-005 - SERVICES FOR EMERGENCY MEDICAL CONDITIONS

Current through June 17, 2024
Prior approval by the member's Dental Benefits Manager is not required
	 for receipt of emergency dental services.
005.01
EMERGENCY SERVICES
  PROVIDED.
The Dental Benefits Manager must cover and pay for
  emergency dental services regardless of whether the provider that furnishes the
  services participates in the Dental Benefits Manager network.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 5 - THE DENTAL BENEFITS PACKAGE › Section 482-5-006 - COORDINATION OF SERVICES

Current through June 17, 2024
The following rules apply when coordination of services is required
	 between the physical health plan responsible for the core benefits package and
	 the Dental Benefits Manager responsible for the dental benefits package, as
	 addressed by the Department in regulations governing both components of managed
	 care. In situations where the individual is only a member of a health plan or
	 the Dental Benefits Manager, but not both, the payment of the associated
	 service is coordinated with the Department on a fee-for-service basis.
006.01
INPATIENT CARE AND
  SERVICES.
The member's Heritage Health plan will be responsible
  for reimbursing all inpatient services. The Dental Benefits Manager will not be
  responsible for reimbursing any inpatient or related services.
006.02
ANESTHESIOLOGY ASSOCIATED
  WITH DENTAL SERVICES.
Anesthesiology services associated with
  dental services, authorized by the Dental Benefits Manager, are the
  responsibility of the Heritage Health plan if the member is also a member of a
  health plan.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 5 - THE DENTAL BENEFITS PACKAGE › Section 482-5-007 - FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS

Current through June 17, 2024
The Dental Benefits Manager must offer to contract with all Federally
	 Qualified Health Centers and Rural Health Clinics in the State.
007.01
NOTIFICATION TO THE
  DEPARTMENT.
If the Dental Benefits Manager and a Federally
  Qualified Health Center or Rural Health Clinic cannot agree upon a contract,
  the Dental Benefits Manager must notify the Department.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 5 - THE DENTAL BENEFITS PACKAGE › Section 482-5-008 - INDIAN HEALTH PROTECTIONS

Current through June 17, 2024
The Dental Benefits Manager must reimburse Indian Health Services,
	 Tribal 638, and Urban Indian Health providers, whether participating in the
	 network, payment for covered services provided to Indian members who are
	 eligible to receive services from these providers.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 5 - THE DENTAL BENEFITS PACKAGE › Section 482-5-009 - PAYMENT FOR SERVICES

Current through June 17, 2024
The Department pays the Dental Benefits Manager a capitated payment for
	 the services it provides. The Department pays a monthly capitation fee to the
	 Dental Benefits Manager for each enrolled member. The monthly capitation fee
	 includes payment for all services in the dental benefits package.
009.01
CAPITATION
  RATES.
The capitation payment rates are actuarially determined and
  are based on the member's age. The Department may adjust rates when it is
  determined appropriate.
009.02
PAYMENT IN FULL.
Payment to the Dental Benefits
  Manager is payment in full for all services included in the dental benefits
  package. The Dental Benefits Manager must not request additional payment from
  the Department or a member.
009.02(A)
BILLING THE CLIENT.
The Dental Benefits Manager must
  not bill a member for a coverable service, regardless of circumstances. A
  provider of a service may only bill the client pursuant to 471 NAC.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 6 - QUALITY › Section 482-6-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
This chapter sets forth the requirements of the Nebraska Medicaid
	 Managed Care Quality Strategy (See 480-000-10). This chapter also establishes
	 the Department's expectation for each of the health plans and the dental plan
	 (collectively referred to as plans), in effectively managing and monitoring the
	 quality of care provided to members. In addition to abiding to all provisions
	 in this chapter, the plans must abide by the provisions found in 42 Code of
	 Federal Regulations (CFR) 438, Subpart D.
001.01
QUALITY ASSESSMENT AND
  PERFORMANCE IMPROVEMENT REQUIREMENT.
The contract between the
  Department and each plan requires the plan to have an ongoing quality
  assessment and performance improvement program that Medicaid must
  approve.
001.02
EVALUATION REQUIREMENTS.
The Department, its
  contracted entities or designees, or the Centers for Medicare and Medicaid
  Services officials may evaluate, through inspection or other means, the
  quality, appropriateness, and timeliness of services performed under managed
  care.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 6 - QUALITY › Section 482-6-002 - CONTINUOUS QUALITY ASSURANCE AND QUALITY IMPROVEMENT

Current through June 17, 2024
The departments quality strategy includes continuous assessment of how
	 well the managed care program is meeting the quality objectives, how , based on
	 the results of the assessment activities, the Department will attempt to
	 improve the quality of care delivered by the health plans (based on the results
	 of the assessment activities), and how the Department reviews the effectiveness
	 of the quality strategy and revises it accordingly.