What is hospice care and length of the stay

Hospice

The term “hospice care” means the following items and services provided to a terminally ill individual by, or by others under arrangements made by, a hospice program under a written plan (for providing such care to such individual) established and periodically reviewed by the individual's attending physician and by the medical director (and by the interdisciplinary group described in paragraph (2)(B)) of the program—

•    (A) nursing care provided by or under the supervision of a registered professional nurse,

•    (B) physical or occupational therapy, or speech-language pathology services,

•    (C) medical social services under the direction of a physician,

•    (D)(i) services of a home health aide who has successfully completed a training program approved by the Secretary and o    (ii) homemaker services,

•    (E) medical supplies (including drugs and biologicals) and the use of medical appliances, while under such a plan,

•    (F) physicians' services,

•    (G) short-term inpatient care (including both respite care and procedures necessary for pain control and acute and chronic symptom management) in an inpatient facility meeting such conditions as the Secretary determines to be appropriate to provide such care, but such respite care may be provided only on an intermittent, nonroutine, and occasional basis and may not be provided consecutively over longer than five days,

•    (H) counseling (including dietary counseling) with respect to care of the terminally ill individual and adjustment to his death, and

•    (I) any other item or service which is specified in the plan and for which payment may otherwise be made under this title.

The care and services described in subparagraphs (A) and (D) may be provided on a 24-hour, continuous basis only during periods of crisis (meeting criteria established by the Secretary) and only as necessary to maintain the terminally ill individual at home.

SIMPLY Healthcare plans will no longer available county details

Simply Healthcare Plans and its affiliates, Better Health and Clear Health Alliance continue to serve more than 190,000 Medicare and Medicaid members throughout Florida. Our commitment to provide value to both our members and providers is of the atmost importance. Through Simply Healthcare Medicare Advantage Plans alone, we deliver healthcare coverage to over 20,000 Medicare Beneficiaries in Miami-Dade, Polk, Orange, Osceola and Seminole counties.

As of January 1st, 2015, Simply Healthcare Plans will no longer be available to Medicare beneficiaries residing in Broward, Palm Beach, Duval, Clay, Brevard, Hillsborough, Hernando, Pasco and Pinellas counties in Florida.

This is to advise you that your Medicare patients will be receiving a formal notice from Simply Healthcare dated Oct. 2, 2014. The CMS approved letter will be sent to the affected members which will provide information to help them make informed decisions about their Medicare coverage options for 2015. These members will also receive instructions about their eligibility to enroll in another Medicare health plan. If your Medicare patients do not sign up for a new plan by the end of 2014, their current coverage will end Dec, 31, 2014. Your Medicare patients will then be covered through Original Medicare beginning Jan 1, 2015. 

The status of your Simply Healthcare Provider Agreement will not be affected. We are continuously evaluating our Medicare Advantage products to ensure that they meet our member needs for access, cost and quality.

Managed Medical Assistance (MMA) Program

Managed Medical Assistance (MMA) Program - Mandatory Recipients Only: For those who are required to enroll in a plan. 

1.    What if my current plan will not participate in the MMA program? 

If your current plan will not participate in the MMA program, you must pick a different plan. The plan you pick must cover your services with your current providers for up to 60 days while you move to new providers in the plan’s network. You may want to pick the plan that has most of the doctors and service providers that are important to you. 

2.    What if I do not choose an MMA plan? 

If you do not choose an MMA plan in time, the State will choose one for you. Your packet includes the name of the MMA plan that would be chosen for you and the MMA plan’s start date. Also keep in mind that you will have 90 days to change your MMA plan from the date your enrollment in the plan begins. After 90 days, you may only change your plan during Open Enrollment or with a State-approved reason. Open Enrollment is a period of time, once a year, that allows you to change plans without a State-approved good cause reason. 

3.    If I am enrolled in a Long-term Care plan do I need to enroll in an MMA plan, too? 

Yes. If you or your family member are enrolled in a Long-term Care plan, you will need to choose an MMA plan for medical services covered by Medicaid. 

Managed Medical Assistance (MMA) Program FAQs

1.    What if I want to change plans?

If you have been approved for Medicaid, you may change your plan during the first 90 days of your enrollment. After the 90 days you will only be able to change your plan during your open enrollment period or with a State-approved good cause reason. 

2.    What is open enrollment? 

Open Enrollment is the 60-day period each year when you can change plans without state approval. Open Enrollment occurs yearly on the anniversary date of your first enrollment into the plan. 

3.    What is the no change period? 

The no change period is the time period between the end of your initial first 90 days of enrollment and your 60-day annual open enrollment period. No change period also exists between your 60-day open enrollment periods going forward. Please refer to the below chart for reference. You will receive reminder letters assisting you with these time periods.

4.  What is "good cause"?

This is a State-approved reason to change plans during the no change period. 

5.    What happens to my plan if I relocate or my address changes? 

If your address changes, you may need to select another plan if your region has changed. You may need to contact the Department of Children and Families (DCF) at 1-866-762-2237 or the Social Security Administration (SSA) at 1-800-772-1213 to report a change in address. 

6.    Will enrolling into the MMA program cancel my Medicare? 

No, the MMA program will not cancel your Medicare. You are allowed to be enrolled in this program and Medicare at the same time because they cover different services. 

7.    Will my current providers, including doctors, hospital, mental health or transportation to covered services, be available in the new program? 

Each plan must cover all of the Medicaid services listed in the Program Information page of this website. However, each plan will have its own network of providers, which may include your current providers and or facilities. When you receive your enrollment packet, review the list of services provided by each plan. You may want to pick the plan that has most of the doctors and service providers that are important to you. 

8.    What if no Managed Medical Assistance (MMA) plans include all of my current providers? 

The plan you pick will be required to cover your services with your current providers for up to 60 days while you move to new providers in your new plan’s network. You may want to pick the plan that has most of the doctors and services that are important to you. 

Medicare Payment Floor Standards detailed review

The “payment floor” establishes a waiting period during which time the contractor may not pay, issue, mail, or otherwise finalize the initial determination on a clean claim. The “payment floor date” is the earliest day after receipt of the clean claim that payment may be made.

The payment floor date is determined by counting the number of days since the day the claim was received, i.e., the count begins the day after the day of receipt.

There are different waiting periods, and thus different payment floor dates, for electronic claims and paper claims. The waiting periods are 13 days for electronic claims and 26 days for paper claims. For the purpose of implementing the payment floor, the following definitions apply:

An “electronic claim” is a claim submitted via central processing unit (CPU) to CPU transmission, tape, direct data entry, direct wire, or personal computer upload or download. A claim that is submitted via digital FAX/OCR, diskette, or touch-tone telephone is not considered as an electronic claim.

A “paper claim” is submitted and received on paper, including fax print-outs. This also includes a claim that the contractor receives on paper and then reads electronically with OCR technology

Also, for the purpose of implementing the payment floor, effective 7/1/04 and for the duration of the HIPAA contingency plan implementation, an electronic claim that does not conform to the requirements of the standard implementation guides adopted for national use under HIPAA, including electronic claims submitted electronically using pre-HIPAA formats supported by Medicare, is considered to be a paper claim.

Based on the waiting periods, the payment floor dates are as follows:

Claim Receipt Date                     Payment Floor Date

10-01-93 through 6/30/04       14th day for EMC 27th day for paper claims

07-01-04 and later                  14th day for HIPAA-compliant EMC

                    27th day for paper and non-HIPAA EMC

01/01/2006 and later  29th day for paper

Except as noted below, the payment floor applies to all claims. The payment floor does not apply to: “no-payment claims, RAPs submitted by Home Health Agencies, and claims for PIP payments.