Section 482-2-005 - WAIVER OF ENROLLMENTWaiver 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.
005.01WAIVER 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.005.02HOSPITALIZATION RELATED WAIVER OF ENROLLMENT. Waiver of enrollment from Heritage Health plans will occur automatically in the following situations due to a change in mandatory status for Heritage Health plans. If the Heritage Health plan member is receiving inpatient hospital services at the time of waiver, the following rules apply: (A) When a Heritage Health plan member is receiving inpatient acute or rehabilitation hospital services on the first day of a month that the member is no longer eligible for Medicaid benefits, the Heritage Health plan is not responsible for services effective the first day of the month the member is no longer Medicaid eligible; or(B) When a Heritage Health plan member is receiving inpatient for acute hospital services and has enrollment waived from Heritage Health due to an eligibility status change, the Heritage Health plan is responsible for the hospitalization and services provided in the core benefits package until waiver of enrollment occurs.005.03ADMISSION TO NURSING FACILITY CARE. Admission to a nursing facility may affect the Heritage Health plan member's enrollment in the Heritage Health plan. Skilled nursing services are those nursing facility services provided to eligible members which are skilled or rehabilitative in nature as defined by Medicare and the nursing facility admission is expected to be short term. Custodial services are those nursing facility services as defined in Title 471 NAC and the nursing facility admission is expected to be of long term or permanent duration. The following rules apply: (A) When a member is admitted to a nursing facility, the Heritage Health plan must determine if the level of care the member requires is skilled or rehabilitative using Medicare's definition of skilled care.(B) When the level of care the member requires is skilled or rehabilitative, the Heritage Health plan is responsible for payment of services for the member while receiving skilled level of care services.(C) When the member is admitted to a nursing facility for custodial care, long-term care, Medicaid fee-for-service will assume financial responsibility for the facility charges beginning on the date the custodial level of care determination is made. (i) Payment for all services included in the core benefits package will be the responsibility of the Heritage Health plan.(D) When the member is admitted to a nursing facility for custodial care and the member's primary care provider does not see patients at the facility, the Heritage Health plan must work cooperatively with the member and the nursing facility to locate a primary care provider for the member. (i) The Heritage Health plan must make arrangements to ensure reimbursement of primary care provider services provided by the member's nursing facility physician, for referrals, and for all services included in the core benefits package.482 Neb. Admin. Code, ch. 2, § 005
Amended effective 7/29/2020Amended effective 9/27/2021