405 Ind. Admin. Code 14-6-4

Current through October 9, 2024

Section 405 IAC 14-6-4 - LTSS functional eligibility

Authority: IC 12-15-1-10

Affected: IC 12-10-11.5-4; IC 12-15-12

Sec. 4.

(a) In addition to meeting general Medicaid eligibility criteria, otherwise eligible individuals receiving long term services and supports (LTSS) must have a nursing facility level of care, as determined by the InterRAI assessment, and meet the requirements under IC 12-10-11.5-4.

(b) Initial level of care assessment is completed using the interRAI assessment by the office's LOCA and shall not be conducted by an MCO.

(c) The LOCA shall provide information about the available HCBS and LTSS services the State offers, describing the program, including;

(1) how managed care works;

(2) covered benefits; and

(3) provider networks; and supporting individuals in connecting with the enrollment broker, for each individual referred for a level of care assessment, at least sixty (60) years of age and either Medicaid enrolled or determined to be likely eligible for Medicaid.

(d) After an enrollee's enrollment with an MCO under PathWays, the enrollee's assigned MCO is responsible for ensuring the enrollee has a current and accurate level of care as determined by the interRAI Assessment under the MCO's contract with the office.

(e) The MCO responsibility in subsection (d) includes at least an annual redetermination of an enrollee's level of care for any enrollee receiving LTSS. It may also include a postenrollment redetermination shortly after enrollment, or a redetermination required by a change in the enrollee's condition.

(f) For an individual receiving LTSS and admitted to a nursing facility and is reasonably expected to no longer meet nursing facility level of care criteria within a period of thirty (30), sixty (60), ninety (90), or one hundred twenty (120) days, the MCO shall ensure the enrollee's level of care is reassessed during the respective period.

(g) The enrollee's MCO shall not complete the level of care determination or reassessment but shall work with the office's LOCA and the enrollee to ensure the level of care is determined at least annually, and as otherwise required in subsections (d) through (g).

405 IAC 14-6-4

Office of the Secretary of Family and Social Services; 405 IAC 14-6-4; filed 8/30/2024, 11:42 a.m.: 20240925-IR-405240180FRA