Neb. Admin. Code tit. 482 — Nebraska Medicaid Managed Care

Chapter 1 Introduction and Definitions

Neb. Admin. Code tit. 482, ch. 1 Introduction and Definitions {#sec-482-nac-1 omnilex-key=us-ne-regs-official--title-482--482 NAC 1}

001. SCOPE AND AUTHORITY . 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.

002. DEFINITIONS . 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;

(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.

002.02 ADVERSE BENEFIT DETERMINATION. An action by a health plan that includes:

(A) Denial or limited authorization of a requested service, including the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit;

(B) Reduction, suspension, or termination of a previously authorized service;

(D) Failure to provide services in a timely manner;

(E) Failure of a health plan to act within grievance and appeal process timelines;

(F) Denial of a members request to exercise his or her right to obtain services outside the network (for a resident of rural area with only one health plan); and

(G) Denial of a member’s request to dispute a financial liability.

002.03 AMERICANS WITH DISABILITIES. The Americans with Disabilities Act of 1990 as amended, 42 United States Code (U.S.C.) 12101 et seq.

002.04 APPEAL. A request for review of an action.

002.05 AUTO-ASSIGNMENT. The process of the enrollment broker automatically assigning a member to a health plan or a primary care provider.

002.06 CAPITATION PAYMENT. A monthly payment by Medicaid to a health plan on behalf of each member of a health plan for the provision of covered services under the contract, regardless of whether any particular member receives services during the period covered by the payment.

002.07 CARVE-OUT. The services not included in the core benefits package of managed care.

002.08 CHOICE COUNSELING. The provision of information available regarding the available health plans and unbiased decision support for selection of a health plan by the enrollment broker for Medicaid members.

002.09 CLAIM. A bill for services, a line item of service, or all services for one client within a bill.

002.10 CLEAN CLAIM. A claim, received by a health plan for adjudication, that requires no further information, adjustment, or alteration by the provider of the services, or by a third party, in order to be processed and paid by the health plan.

(A) It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity.

002.11 CENTERS FOR MEDICARE AND MEDICAID SERVICES. A division within the federal Department of Health and Human Services responsible for administering the Medicare, Medicaid, and Children's Health Insurance programs.

002.12 CLIENT. An individual receiving benefits under Title XIX or XXI of the Social Security Act, and under Medicaid as defined in the Nebraska Administrative Code (NAC).

002.13 COLD CALL MARKETING. Any unsolicited personal contact by a health plan with a potential member for the purpose of marketing.

002.14 CONTRACT. The legal and binding agreement between the Nebraska Department of Health and Human Services, Division of Medicaid and Long-Term Care and any of the vendors participating in Heritage Health.

002.15 CORE BENEFIT PACKAGE. The minimum package of services to which a member is entitled under the Nebraska Medicaid State Plan and that the health plan must provide to members enrolled in the health plan.

002.16 DEPARTMENT. The Nebraska Department of Health and Human Services.

002.017 DESIGNATED SPECIALTY CARE PHYSICIAN. A specialty care physician who has enhanced responsibilities for members with special health care needs, designated upon review and concurrence by the primary care provider (PCP) and the health plan providing the core benefits package.

(A) The designation of the specialty care physician allows for greater continuity of care between the primary care provider (PCP) and specialty care physician. This may include, but is not limited to, open referrals and shared primary care provider (PCP) responsibilities.

002.18 DISENROLLMENT. A change in the status of a member from being enrolled with a specific health plan to being enrolled with a different health plan, or a change from being considered mandatory for participation in managed care to being ineligible for participation in managed care.

002.19 EMERGENCY MEDICAL CONDITION. A medical condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, who possesses an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in:

(A) Placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;

(B) Serious impairment to bodily functions; or

002.20 EMERGENCY SERVICES. Covered inpatient and outpatient services that are either furnished by a provider qualified to furnish these services under Title 42 of the Code of Federal Regulations or the services needed to evaluate or stabilize an emergency medical condition.

002.21 ENCOUNTER DATA. Line-level utilization and expenditure data for services furnished to members through the health plan.

002.22 ENROLLMENT. The process of a member selecting a health plan, whether by an active choice or through auto assignment.

002.23 ENROLLMENT BROKER. A contracted entity responsible for enrollment activities and choice counseling.

002.24 ENROLLMENT FILE. A proprietary data file provide by Medicaid or the enrollment broker to a health plan. The enrollment file is the basis for monthly payments to the health plan.

002.25 ENROLLMENT MONTH. The enrollment period for a member effective the first of the month through the end of the month.

002.26 ENTITY. A generic term used to reference any of the contracted vendors participating in Nebraska’s managed care program.

002.27 EXTERNAL QUALITY REVIEW ORGANIZATION. An organization that meets the competence and independence requirements to perform analysis and evaluation of aggregated information on quality, timeliness, and access to the health care services that a health plan furnishes to Medicaid members.

002.28 FAMILY PLANNING SERVICES. Services to prevent or delay pregnancy, including counseling services and patient education, examination and treatment by medical professionals, laboratory examinations and tests, medically approved methods, procedures, pharmaceutical supplies and devices to prevent conception.

002.29 FEE-FOR-SERVICE. Payment of a fee for each service provided to a client who is not enrolled in managed care or for services excluded from the core benefits package.

002.30 GRIEVANCE. An expression of dissatisfaction about any matter other than an adverse benefit determination as defined above. The term also refers to the overall system that includes grievances and appeals handled at the health plan level and access to the Medicaid administrative hearing process.

002.31 HEALTHCARE EFFECTIVENESS DATA AND INFORMATION SET. The most widely used set of standardized performance measures used in the managed care industry, designed to allow reliable comparison of the performance of health plans. The National Committee of Quality Assurance sponsors, supports, and maintains the Healthcare Effectiveness Data and Information Set.

002.32 HEALTH CARE PROFESSIONAL. A physician or any of the following: a podiatrist, optometrist, chiropractor, psychologist, dentist, physician’s assistant, physical or occupational therapist, therapist assistant, speech-language pathologist, audiologist, registered or practical nurse (including nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, and certified nurse midwife), licensed and certified social worker, registered respiratory therapist, and certified respiratory therapy technician.

002.33 HEALTH PLAN. A generic term used to reference any of the contracted plans participating in Heritage Health. A healthcare entity that meets the definition of a managed care organization for the provision of the core benefits package.

002.34 HERITAGE HEALTH. Nebraska’s Medicaid managed care program.

002.35 INTERIM PRIMARY CARE PROVIDER. A primary care provider designated by the physical health plan when the member’s chosen or assigned primary care provider is not available and the duration is only applicable until the member requests a different primary care provider.

002.36 MANAGED CARE ORGANIZATION. An organization that has or is seeking to qualify for a comprehensive risk contract to provide services to managed care enrollees. An entity that has, or is seeking to qualify for a comprehensive risk contract that is:

(A) A federally qualified Health Maintenance Organization that meets the advance directives requirement of 42 Code of Federal Regulations (CFR) 489.100 et seq.; or

(B) Any public or private entity that meets the advance directives requirements and is determined to also meet the following conditions:

(i) Makes the services it provides to its Medicaid members as accessible (in terms of timeliness, amount, duration, and scope) as those services are to other Medicaid recipients within the area served by the entity; and

(ii) Meets the solvency standards of 42 CFR 438.116.

002.37 MEDICAID. Nebraska’s Medicaid program as defined by Neb. Rev. Stat. § 68-901 et. Seq. (the Medical Assistance Act).

002.38 MEDICAL HOME. A community-based primary care setting which provides and coordinates high quality, planned, and family-centered: health promotion, acute illness care and chronic condition management.

002.39 MEDICAL NECESSITY. Health care services and supplies which are medically appropriate and:

(A) Necessary to meet the basic health needs of the client;

(B) Rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the covered service;

(C) Consistent in type, frequency, duration of treatment with scientifically based guidelines of national medical, research, or health care coverage organizations or governmental agencies;

(D) Consistent with the diagnosis of the condition;

(E) Required for means other than convenience of the client or his or her physician;

(F) No more intrusive or restrictive than necessary to provide a proper balance of safety, Effectiveness, and efficiency;

(G) Of demonstrated value; and

(H) The least intense level of service that can be safely provided.

The fact that the physician has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for a particular injury, sickness, or mental illness does not mean that it is covered by Medicaid. Services and supplies that do not meet the definition of medical necessity set out above are not covered.

002.40 MEMBER. A Medicaid client who is currently enrolled with a specific health plan.

002.41 NEBRASKA MEDICAID ELIGIBILITY SYSTEM. The automated eligibility verification system for use by Medicaid service providers.

002.42 PATIENT-CENTERED MEDICAL HOME. An enhanced model of primary care in which a patient establishes an ongoing relationship with a primary care provider and a primary care provider-directed team of health care providers. This team coordinates all aspects of a patient's physical and mental health care needs, including prevention and wellness, acute care and chronic care, across the health care system in order to improve access and health outcomes in a cost effective manner.

002.43 PRIMARY CARE PHYSICIAN TRANSFER. A change in a client's assignment from one establishes an ongoing relationship with a primary care provider to another primary care provider.

002.44 PEER REVIEW ORGANIZATION. An organization under contract with Medicaid to perform a review of health care practitioners of services ordered or furnished by other practitioners in the same professional fields.

002.45 PER MEMBER PER MONTH. The basis of capitation payment for a health plan.

002.46 PREPAID AMBULATORY HEALTH PLAN. An entity as defined in 42 CFR 438.2 that:

(A) Provides services to enrollees under contract with the State, and on the basis of capitation payments, or other payment arrangements that do not use State plan payment rates.

(B) Does not provide or arrange for, and is not otherwise responsible for the provision of any inpatient hospital or institutional services for its enrollees; and

002.47 PRIMARY CARE PROVIDER. A medical professional chosen by the member or assigned to provide primary care services. Provider types that can be primary care providers are licensed medical doctors or doctors of osteopathy from any of the following practice areas: general practice, family practice, internal medicine, pediatrics, and obstetrics and gynecology. Primary care providers may also include advanced practice registered nurses and physician assistants when practicing under the supervision of a physician specializing in family practice, internal medicine, pediatrics, or obstetrics/gynecology who also qualifies as a primary care provider under the health plans.

002.48 PRIMARY CARE SERVICES. All health and laboratory services customarily furnished by or through a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, or pediatrician, to the extent the furnishing of those services is legally authorized in the State in which the practitioner furnishes them.

002.49 PROVIDER. Any individual or entity that is engaged in the delivery of health care services under agreement with Medicaid and is legally authorized to do so by the State in which it delivers the services.

002.50 PROVIDER AGREEMENT. Any written agreement between the provider and Medicaid, for the purpose of enrolling as a Medicaid provider, or between the health plan and the provider for the purpose of participating in Heritage Health.

002.51 RESTRICTED SERVICES. A method used by Medicaid to provide safeguards when a client has been determined to be abusing or inappropriately utilizing services provided by Medicaid or a health plan.

002.52 RETURNED CLAIM. A claim that has not been adjudicated because it has a material defect or impropriety.

002.53 RISK CONTRACT. A contract under which the contractor:

(A) Assumes risk for the cost of the services covered under the contract; and

(B) Incurs loss if the cost of furnishing the services exceeds the payments under the contract.

002.54 SUBCONTRACT. Any written agreement between the health plan and another party to fulfill the requirements of title 482 of the NAC, except provider agreements as defined above.

002.55 SYSTEM CUT OFF. The last day in which data must be entered into the Medicaid eligibility system in order for changes to be effective the first of the next month.

002.56 THIRD PARTY RESOURCE. Any individual, entity, or program that is, or may be liable to pay all or part of the cost of medical services furnished to a client.

002.57 VALUE-ADDED SERVICES. Those services a health plan provides in addition to a service covered under a contract because the health plan has determined that the health status and quality of life for the member will be the same or better using the value-added health service as it would be using the covered service.

002.58 WAIVER OF ENROLLMENT. A change in the status of a member from being considered mandatory for participation in managed care to being not mandatory for participation in managed care.

History

Effective 2020-07-29

Chapter 2 Member Participation and Enrollment

Neb. Admin. Code tit. 482, ch. 2 Member Participation and Enrollment {#sec-482-nac-2 omnilex-key=us-ne-regs-official--title-482--482 NAC 2}

001. SCOPE AND AUTHORITY . These regulations govern services provided under the Medical Assistance Act, Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68-901 et seq.

002. HERITAGE HEALTH PLAN MANDATORY AND EXCLUDED MEMBERS . 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.

002.02 HERITAGE HEALTH PLAN EXCLUDED POPULATIONS. The following clients are excluded from the Nebraska Medicaid managed care program:

(A) Non-Citizens eligible under the Emergency Medical Services Assistance (EMSA) for non-citizens program;

(B) Clients who have excess income or who are required to pay a premium, and are intermittently eligible;

(D) Clients in the Program for All-Inclusive Care for the Elderly;

(E) Clients with Medicare coverage where Medicaid only pays co-insurance and deductibles; and

(F) Inmates of public institutions.

002.03 DENTAL BENEFITS MANAGER MANDATORY MEMBERS. Any member required to participate in a Heritage Health plan must participate as a member in the Dental Benefits Manager, except for:

(A) Unborn members eligible for Children’s Health Insurance Program (599 CHIP); or

(B) Members who are not physically present in the State of Nebraska; or.

002.04 COVERAGE FOR EXCLUDED CLIENTS. Medicaid coverage for clients excluded from participation in managed care or Dental Benefits Manager remains on a fee-for-service basis for services they are eligible for. Excluded clients cannot voluntarily enroll in managed care or the Dental Benefits Manager.

002.05 COVERAGE DURING ENROLLMENT. The Heritage Health plan and Dental Benefits Manager are responsible for providing services covered by Heritage Health plan and Dental Benefits Manager for the member as long as the member is enrolled in the Heritage Health plan and Dental Benefits Manager.

003. ENROLLMENT ACTIVITIES IN A HERITAGE HEALTH PLAN . 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.

003.02 HEALTH PLAN ACCEPTANCE. The Heritage Health plan must accept members in the order in which they are enrolled through the enrollment broker.

003.03 INITIAL ENROLLMENT PLAN CHANGE. A member has ninety (90) days after the effective date of their initial Heritage Health plan enrollment to choose another Heritage Health plan. Family members may select a different primary care provider and Heritage Health plan but are encouraged to choose the same Heritage Health plan.

003.04 DEPARTMENT NOTIFICATION. Enrollment activities must be completed and communicated to the Department by the enrollment broker following the date of the notice sent to the member informing the member of the Heritage Health plan assignment.

003.05 REENROLLMENT. A member will automatically be enrolled with the previous Heritage Health plan effective the first day of the next possible month if the member is identified as mandatory for enrollment into a Heritage Health plan no later than two months of losing Medicaid eligibility.

003.05(A) REENROLLMENT EXCEPTIONS. During reenrollment the member may choose a different Heritage Health plan in the following circumstances only:

(i) If the reenrollment is during the initial ninety (90) day period;

(ii) If the reenrollment is during the open enrollment period; or

(iii) For cause, per Title 482 NAC 2-004.02(C), by contacting the enrollment broker and completing a plan transfer request.

003.06 DEPARTMENTAL WARDS AND FOSTER CARE MEMBERS. The enrollment broker must coordinate enrollment activities for departmental wards or foster children with the Department staff responsible for the case management of the member.

003.07 ENROLLMENT OF AN UNBORN AND NEWBORN CHILD. Unborns will be pre-enrolled into a Heritage Health plan prior to birth if the unborn has either a mother or sibling enrolled. If the Department is notified after a live birth, the newborn will be immediately enrolled in either the mother’s Heritage Health plan or an eligible sibling’s Heritage Health plan. The mother’s Heritage Health plan supersedes the sibling’s plan, in the event that both mother and sibling are enrolled in a Heritage Health plan. Enrollment changes may be made as allowed for any other member participating in a Heritage Health plan per Title 482 NAC 2-004.02.

003.08 MEMBER ENROLLMENT REQUIREMENTS. The member must complete the enrollment process. For purposes of completing the enrollment process, the following rules apply:

(A) Any individual with sufficient knowledge of the member’s health status may complete the informational portion of the enrollment process;

(B) The member must make the choice of the Heritage Health plan and primary care provider; and

(C) The Departmental staff or designee must act on a Department ward’s behalf. The child’s foster parents must be involved in the selection of the Heritage Health plan and primary care provider.

003.09 HEALTH PLAN CONTACT. The Heritage Health plans must not have any direct contact with the member or the member’s legal representative, family, or friends prior to the client becoming enrolled with that Heritage Health plan, unless the contact is initiated by the enrollment broker.

003.10 EFFECTIVE DATE OF HERITAGE HEALTH PLAN AND DENTAL BENEFITS MANAGER COVERAGE. The effective date of coverage is the first calendar day of the month of the Heritage Health plan or Dental Benefits Manager enrollment. The date of enrollment will match the Medicaid eligibility date. This date may occur up to three (3) months prior to the date of enrollment. The Heritage Health plan and Dental Benefits Manager are responsible for benefits and services in the core benefits package and dental benefits package from and including the effective date of an enrolled member’s Medicaid eligibility. The Heritage Health plan and Dental Benefits Manager must reimburse a provider for appropriate covered services and that provider must reimburse a member for any payments made by the member.

003.10(A) SERVICES RECEIVED BEFORE ENROLLMENT. Medicaid-coverable services received before the Heritage Health or Dental Benefits Manager coverage becomes effective will be paid on a fee-for-service basis under the rules and regulations of the Department Title 471 NAC.

003.11 NOTIFICATION OF COVERAGE. Members will be notified of their coverage within the first month of enrollment.

003.11(A) HERITAGE HEALTH PLAN NOTIFICATION. The Heritage Health plan must provide each member a member handbook that includes general information about the member’s integrated health coverage and the Heritage Health plan itself.

003.11(B) DENTAL BENEFITS MANAGER NOTIFICATION. The Dental Benefits Manager must provide each member a member handbook that includes general information about the Dental Benefits Manager.

003.11(C) PROVIDER NOTIFICATION. Providers must verify a member’s coverage through:

(i) Medicaid’s internet access for enrolled providers;

(ii) The Medicaid inquiry line; or

(iii) The standard electronic health care eligibility benefit inquiry and response transaction (ASC X12N 270/271).

003.12 COVERAGE WHEN THERE IS A DISCREPANCY. The Heritage Health plan is responsible for providing the services in the core benefits package to members listed on the enrollment report generated for the month of enrollment. Any discrepancies between the member notification and the enrollment report must be reported to the Department for resolution. The Heritage Health plan must continue to provide and authorize services until the discrepancy is resolved.

003.12(A) DISCREPANCY REVIEW. In case of a discrepancy, the eligibility and enrollment databases used to build the enrollment file serves as the official source of validation. Once the cause for the discrepancy is identified, the Department will work cooperatively with the Heritage Health plan to identify responsibility for the member’s services until the cause for the discrepancy is corrected.

003.13 DENTAL BENEFITS MANAGER NOTIFICATION. The Dental Benefits Manager will notify its members, through written materials and notice, of the member’s enrollment and right to change dental homes.

003.14 CONTINUITY OF CARE. The Heritage Health plan and Dental Benefits Manager must continue all services authorized by Medicaid fee-for-service prior to the member becoming enrolled in the Heritage Health plan or Dental Benefits Manager. These services must be continued until the Heritage Health plan or Dental Benefits Manager determines the service no longer meets the definition of medical necessity.

003.15 HOSPITALIZATION. When a Medicaid client is admitted to an acute care medical or rehabilitation facility prior to the client’s enrollment in a Heritage Health plan, Medicaid fee-for-service remains responsible for the hospitalization until the client is discharged from the facility, transferred to a lower level of care, or sixty (60) days, whatever is earliest.

003.15(A) HOSPITALIZATION IN MONTH OF ASSIGNMENT. In the event that a client is admitted as an inpatient in an acute care medical or rehabilitation facility and is assigned to a Heritage Health plan in the same month, the Heritage Health plan is responsible for that hospitalization.

003.16 AUTOMATIC ASSIGNMENT FOR HERITAGE HEALTH. If a choice of a Heritage Health plan is not made at the time of application, the member will be automatically assigned to a Heritage Health plan based on criteria established by the Department.

004. DISENROLLMENT OR TRANSFERS . 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.

004.01(B) TRANSFER UNDER RESTRICTED SERVICES. Any transfer for a Heritage Health plan member under a restricted services provision must be completed per restricted services procedures (see 482-000-7).

004.02 DISENROLLMENT REQUESTS. A Heritage Health plan member may request a change from one Heritage Health plan to another. The effective date will be the first day of the month following the month of the approval determination.

004.02(A) DISENROLLMENT REASONS. The enrollment broker will allow for a disenrollment as follows:

(i) With cause, at any time;

(ii) During the ninety (90) days following the date of the member’s initial enrollment with the Heritage Health plan, or the date the Department sends the member’s notice of enrollment, whichever is later;

(iii) During the designated open enrollment period;

(iv) Upon automatic reenrollment if the temporary loss of Medicaid eligibility has caused the member to miss the annual disenrollment opportunity; or

(v) If the Department imposes the established intermediate sanctions on the Heritage Health plan.

004.02(B) CAUSE FOR DISENROLLMENT. The following are cause for disenrollment:

(i) The Heritage Health plan does not, because of moral or religious objections, cover the service the member seeks;

(ii) The member needs related services (for example a cesarean section and a tubal ligation) to be performed at the same time; not all related services are available within the network; and the member’s primary care provider or another provider determines that receiving the services separately would subject the member to unnecessary risk;

(iii) Other reasons, including but not limited to, poor quality of care, lack of access to providers experienced in dealing with the member’s health care needs or lack of access to services covered under the contract; or

(iv) The Department and Heritage Health plan contract termination.

004.02(C) DETERMINATION OF DISENROLLMENT FOR CAUSE. When the disenrollment request is for cause, the enrollment broker must complete a Plan Disenrollment Member Request Form with the member and forward the request to the Department staff for a decision. The Department will approve or deny the request based on the following:

(i) Reasons cited in the request;

(ii) Information provided by the Heritage Health plan at the Department’s request; and

(iii) Any of the reasons cited in Title 482 NAC 2-004.02A.

004.02(D) COERCEMENT OR ENTICEMENT. The Heritage Health plan may work with the enrollment broker to resolve any issues raised by the member at the time of request for disenrollment but may not coerce or entice the member to remain with them as a member.

004.02(E) DISENROLLMENT UNDER RESTRICTED SERVICES. Any disenrollment for a Heritage Health plan member under a restricted services provision must be completed per restricted services procedures (see 482-000-7).

004.03 PRIMARY CARE PROVIDER TRANSFER REQUESTS. The primary care provider may request that the Heritage Health plan member be transferred to another primary care provider. The primary care provider must provide the services in the core benefits package to the Heritage Health plan member until a transfer is completed.

004.03(A) TRANSFER REASONS. Transfers will be allowed based on the following situations:

(i) The primary care provider has sufficient documentation to establish that the member’s condition or illness would be better treated by another primary care provider;

(ii) The primary care provider has sufficient documentation to establish that the member or provider relationship is not mutually acceptable. This may include when the member is uncooperative, disruptive, does not follow medical treatment, or does not keep appointments;

(iii) The individual provider retired, left the practice, died, or is no longer available to provide services; or

(iv) Travel distance substantially limits the member’s ability to follow through the primary care provider services and referrals.

004.03(B) REASONABLE ACCOMMODATIONS. The Heritage Health plan must assist the primary care providers and specialists in their efforts to provide reasonable accommodations. This may include additional funding and support to obtain the services of consultative physicians for Heritage Health plan members with special needs.

004.03(C) PROCEDURE FOR PRIMARY CARE PROVIDER TRANSFER REQUESTS. The following procedure applies when a primary care provider requests a transfer:

(i) The primary care provider must contact the Heritage Health plan for which the member is enrolled and provide documentation of the reason(s) for the transfer. The Heritage Health plan must investigate and document the reason for the request. Where possible, the Heritage Health plan must provide the primary care provider with assistance to try to maintain the medical home;

(ii) The Heritage Health plan must review the documentation and conduct any additional inquiry to clearly establish the reason(s) for transfer;

(iii) The Heritage Health plan must submit the request to the Department for approval within ten (10) business days of the request;

(iv) If a primary care provider transfer is approved, the Heritage Health plan will contact and assist the member in choosing a new primary care provider;

(v) If the member does not select a primary care provider within fifteen (15) calendar days after the decision, the Heritage Health plan will automatically assign a primary care provider; and

(vi) The Heritage Health plan must enter the approved transfer of primary care provider on the primary care provider file for the information to be reflected in the managed care system.

004.03(D) TRANSFER CRITERIA. The criteria for terminating a member from a practice must not be more restrictive than the primary care provider's general office policy regarding terminations for non-Medicaid members. The Heritage Health plan must provide documentation to the Department prior to submitting the primary care provider transfer request that attempts were made to resolve the primary care provider member issues (see 482-000-3).

004.03(E) INTERIM PRIMARY CARE PROVIDER ASSIGNMENT. The Heritage Health plan will be responsible for assigning an interim primary care provider in the following situations:

(i) The primary care provider has terminated the member’s participation with the Heritage Health plan;

(ii) The primary care provider is still participating with the Heritage Health plan but is not participating at a specific location and the member requests a new primary care provider; or

(iii) A primary care provider or Heritage Health plan initiated transfer has been approved (see Title 482 NAC 2-004.03C) but the member does not select a new primary care provider.

004.03(F) MEMBER NOTIFICATION. The Heritage Health plan must immediately notify the member, by mail or by telephone, that the member is being temporarily assigned to another primary care provider within the same health plan and that the new primary care provider must meet the member’s health care needs until a transfer can be completed.

004.04 HERITAGE HEALTH DISENROLLMENT REQUESTS. The Heritage Health plan may request that the member be disenrolled from the plan and re-enrolled in another plan.

004.04(A) DOCUMENTATION. The Heritage Health plan must provide documentation showing attempts were made to resolve the reason for the disenrollment request through contact with the member, the primary care provider, or other appropriate sources.

004.04(B) COVERAGE OF SERVICES. The Heritage Health plan must provide the services in the core benefits package to the member until a disenrollment is completed. The Heritage Health plan is prohibited from requesting disenrollment because of a change in the member’s health status or because of the member’s utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from the member’s special needs.

004.04(C) DISENROLLMENT REASONS. Disenrollment will be allowed based on the following situations:

(i) The Heritage Health plan has sufficient documentation to establish that the member’s condition or illness would be better treated by another Heritage Health plan; or

(ii) The Heritage Health plan has sufficient documentation to establish fraud, forgery, or evidence of unauthorized use or abuse of services by the member.

004.04(D) PROCEDURE FOR HERITAGE HEALTH PLAN DISENROLLMENT REQUESTS. The following procedure applies when the Heritage Health plan requests a member disenrollment:

(i) The Heritage Health plan for which the member is enrolled must provide documentation to the Department which clearly establishes the reason(s) for the disenrollment request;

(ii) The Heritage Health plan must submit the request to the Department;

(iii) The health plan must send notification of the disenrollment request to the member at the same time the request is made to the Department. The member notification must include the member’s grievance and appeal rights;

(iv) The member, primary care provider and health plan are notified of the approval or denial of the disenrollment request and information will be made available electronically; and

(v) If approved, the disenrollment will become effective the first day of the following month, given system cut-off.

004.05 HOSPITALIZATION DURING TRANSFER. When a Heritage Health plan member is admitted to an inpatient for acute or rehabilitation services on the first day of the month a transfer to another Heritage Health plan is effective, the Heritage Health plan that admitted the member to the hospital is responsible for the member (hospitalization and the related services in the core benefits package) until an appropriate discharge from the hospital, transfer to a lower level of care, or for sixty days, whatever is earliest.

(A) The Heritage Health plan the member is transferring to is responsible for the member (hospitalization and the related services in the core benefits package) beginning the day of discharge, the day of transfer to a lower level of care, or on the sixty-first (61st) day of hospitalization following the Heritage Health plan transfer, whatever is earliest.

(B) The Heritage Health plans must work cooperatively with the enrollment broker and the Department to coordinate the member’s transfer between the Heritage Health plans.

005. WAIVER OF ENROLLMENT . 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.

005.02 HOSPITALIZATION 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.

005.03 ADMISSION 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.

History

Effective 2021-09-27

Chapter 3 Enrollment Broker

Neb. Admin. Code tit. 482, ch. 3 Enrollment Broker {#sec-482-nac-3 omnilex-key=us-ne-regs-official--title-482--482 NAC 3}

001. SCOPE AND AUTHORITY . 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.

002. DEFINITIONS . 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.

003. ENROLLMENT MATERIALS . 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;

(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.

004. MEMBER WEBSITE . 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;

(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.

005. ENROLLMENT ACTIVITIES AND CHOICE COUNSELING . 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.

(B) Provide information specific to each health plan available in the State, including:

(i) Covered benefits;

(ii) Cost sharing, if any;

(iii) Names, locations telephone numbers of, and non-English languages spoken by current contracted providers;

(iv) Identification of providers not accepting new patients; and

(v) For Medicaid benefits not covered under Heritage Health, the enrollment broker must provide information about how and where to obtain services, any cost sharing, and how transportation is provided;

(C) Provide an explanation of those services which do not require primary care provider or health plan approval or prior authorization;

(D) Provide an explanation of the availability of interpreter services and alternative formats for written materials;

(E) Provide an explanation of passive enrollment;

(F) Provide an explanation of disenrollment and waiver of enrollment;

(G) Provide the member with enrollment materials that are easily understood by the member, and developed in ways appropriate to meet the needs of the member; and

(H) Enter the health plan and primary care provider (PCP) selection in the Heritage Health file.

History

Effective 2020-01-27

Chapter 4 The Heritage Health Managed Care Core Benefits Package

Neb. Admin. Code tit. 482, ch. 4 The Heritage Health Managed Care Core Benefits Package {#sec-482-nac-4 omnilex-key=us-ne-regs-official--title-482--482 NAC 4}

001. SCOPE AND AUTHORITY . 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.

002. MANAGED CARE ORGANIZATION REQUIREMENTS . Heritage health administers the core benefits package to Medicaid members through one (1) or more health plans. The following provisions describe the health plan responsibilities.

002.01 GENERAL REQUIREMENTS. The health plan is required to comply with, but is not limited to, the following general requirements and as specified in the contract between the Department and the health plan:

(A) Provide the services in the core benefits package according to all provisions in Title 482 NAC 4 and Title 471 NAC and ensure the services in the core benefits package are provided in the same amount, duration, and scope as defined under Title 471 NAC, but can place appropriate limits on a service based on medical necessity or utilization control;

(B) Maintain an adequate network of primary care providers to ensure adequate access for members enrolled in Heritage Health, notify the Department via the provider network file prior to the effective date of any primary care provider change whenever possible and if required, notify the member of an interim primary care provider (see 482 NAC 3-004.03(E));

(D) Provide an appropriate range of services and access to preventive and primary care services statewide, and maintain a sufficient number, mix, and geographic distribution of providers that are skilled in areas such a cultural diversity and sensitivity, languages, and accessibility to members with mental, physical and communication disabilities;

(E) Accept the member choice of primary care provider and health plan;

(F) Provide care management (see 482-000-8, Care Management Requirements);

(G) Provide a member handbook to the members enrolled with the health plan, and other informational materials about Heritage Health benefits that are easy-to-read and understand. The health plan must also provide the information in the guidebook in the most prevalent non-English speaking languages and alternative formats in a manner that takes into consideration the special needs of those who, for example, are visually limited or have limited reading proficiency;

(H) Provide a comprehensive provider network directory;

(I) Medicaid prohibits the health plan from performing any direct solicitation to individual Medicaid members. The Department must approve any general marketing to Medicaid members prior to implementation. The health plan must comply with the following marketing materials:

(i) Obtain Departmental approval for all marketing materials;

(ii) Ensure marketing materials do not contain any false or potentially misleading information in a manner that does not confuse or defraud the Department;

(iii) Ensure marketing materials are available for members being served within the State;

(iv) Avoid offering other insurance products as an inducement to enroll;

(v) Comply with federal requirements for provision of information including accurate oral and written information sufficient for the member to make an informed decision about treatment options; and

(vi) Avoid any direct or indirect door-to-door, telephonic or other "cold-call" marketing.

(J) Meet all requirements of the Americans with Disabilities Act and provide appropriate accommodations for members with special needs. Ensure primary care providers and specialists are equipped in appropriate technologies, including teletype and telecommunications device for the deaf, and language services, or are skilled in various languages and areas of cultural diversity and sensitivity, and the network is appropriately staffed to ensure an adequate selection for those members who have special cultural, religious or other special requests;

(K) Coordinate activities with the Department, other Heritage Health contractors, and other providers for services outside the core benefits package, as appropriate, to meet the needs of the member, and ensure systems are in place to promote well managed patient care, including, but not limited to:

(i) Management and integration of health care through the primary care provider, and coordination of care issues with other providers outside the health plan, for services not included in the core benefits package, including behavioral health services, pharmacy, and dental services, or for services requiring additional Departmental authorization, which may include abortions and transplants (except corneal);

(ii) Provision of or arrangement for emergency medical services, twenty-four (24) hours per day, seven (7) days per week, including an education process to help assure members know where and how to obtain medically necessary care in emergency situations;

(iii) Unrestricted access to protected services such as emergency room services, family planning services, and tribal clinics in accordance with Title 471 NAC;

(iv) Retention of plan-maintained records and other documentation during the period of contracting, and for ten (10) years after the final payment is made and all pending matters are closed, plus additional time if an audit, litigation, or other legal action involving the records is started before or during the original ten (10) year period ends; and

(v) Adequate policy regarding the distribution of the member’s medical records if a member changes from one primary care physician to another.

(L) Comply with regulations for advance directives;

(M) The health plan is prohibited from refusing enrollment of a member, disenrolling a member or otherwise discriminating against a member solely on the basis of age, sex, race, physical or mental handicap, national origin, or type of illness or condition;

(N) Require that all subcontractors meet the same requirements as are in effect for the health plan that are appropriate to the service or activity delegated under the subcontract;

(O) Provide member services;

(P) Maintain, at all times, an appropriate certificate of authority to operate issued by the Nebraska Department of Insurance;

(Q) Comply with all applicable state and federal regulations, such as the prohibition against assisted suicide; inappropriate use of funds/profits, lack of mental health parity, and the noncompliance with the provisions of the Hyde Amendment;

(R) Prohibit discrimination against providers based upon licensing;

(S) Prohibit hiring, employing, contracting with or otherwise conducting business with individuals or entities barred from participation in Medicaid or Medicare;

(T) Ensure adequate numbers of providers in its network to meet the needs of its members;

(U) Provide written notice to the member of any adverse action regarding the provision of services that complies with all federal and state requirements. Allow member to appeal decisions to deny, limit or terminate authorization, coverage, or payment of services. Plans must allow members to file complaints, grievances and appeals, according to Title 482 NAC 7;

(V) Comply with the Maternity and Mental Health Requirements in the Health Insurance Portability and Accountability Act of 1996 the maternity length of stay and mental health parity requirements specifically requiring coverage for a hospital stay following a normal vaginal delivery not be limited to less than forty-eight (48) hours for both the mother and newborn child, and the health coverage for a hospital stay in connection with childbirth following a cesarean section not be limited to less than ninety-six (96) hours for both the mother and newborn child;

(W) Report all fraud and abuse information to the Department;

(X) Comply with the provisions of Title 482 NAC 4-004 for provider payments;

(Y) Sign a contract with the Department and comply with all contract requirements and any other responsibilities specified by the Department in the overall operation of Heritage Health, and any other activities deemed appropriate by the Department and supported in regulations and contractual amendments;

(Z) Comply with all applicable requirements of the Health Insurance Portability and Accountability Act of 1996 and Balanced Budget Act of 1997; and

(AA)Provide access to behavioral health services necessary referrals twenty-four (24) hours per day, seven (7) days per week.

003. HEALTH CHECK EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT . 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).

003.02 THIRD PARTY LIABILITY REQUIREMENTS. The health plan must utilize a cost avoidance methodology whenever there is a verified third party resource. Under Federal Law, the Department is required to identify legally liable third parties and treat verified third party liability as a resource of the member. The health plan, or its subcontractors or providers, must not pursue collection from the member, but directly from the liable third party payers, except as allowed in Title 477 NAC. The health plan must assume responsibility for all third party liability requirements.

003.02(A) ASSIGNMENT OF RIGHTS. The health plan shall exercise full assignment rights as applicable and shall be responsible for making every reasonable effort to determine third parties to pay for services rendered to members and cost avoid and/or recover any such liability for the third party.

003.02(B) COORDINATION OF BENEFITS. The health plan shall coordinate benefits in accordance with 42 CFR 133.135 et seq and Title 471 NAC 3-004, so that costs for services otherwise payable by the health plan are cost avoided or recovered from a liable party. The two methods used are cost avoidance and post-payment recovery.

004. PROVIDER PAYMENTS . The following provisions apply regarding payments to providers by the health plans.

004.01 TIMELINESS OF PROVIDER PAYMENTS. The health plan must provide payment to a provider of services on a timely basis, consistent with Medicaid claims payment procedures and the minimum standards provided below, unless the health care provider and health plan agree to a capitated payment schedule or other arrangement.

004.01(A) ELECTRONIC CLAIMS SYSTEM. The health plan must maintain a health information system that includes the capability to electronically accept claims for adjudication and make payments in accordance with the standards set forth in the Health Insurance Portability and Accountability Act of 1996. Such electronic system must have the ability to transmit data to a central data repository that complies with the requirements for confidentiality of information under the Medicare program.

004.01(B) MINIMUM TIMEFRAMES. The health plan must comply with the following minimum timeframes for the submission and processing of clean claims. Timeframes are calculated from the day the clean claim is received by the health plan until the date of the postmark that returns the claim either to the provider or until posted on an electronic system;

(i) The health plan must pay ninety (90%) percent of all clean claims from practitioners, who are in individual or group practice or who practice in shared health facilities, within fifteen (15) business days of the date of receipt. The date of receipt is the date the health plan receives the claim; and

(ii) The health plan must also pay ninety-nine (99%) percent of all clean claims from practitioners, who are in individual or group practice or who practice in shared health facilities, within sixty (60) days of the date of receipt. The health plan must fully adjudicate (pay or deny) all other claims within six (6) months of the date of receipt.

004.01(C) PROMPT INVESTIGATION AND SETTLEMENT OF CLAIMS. The health plan must comply with the requirements related to claim forms as set forth in Title 471 NAC. For providers of outpatient services, this must include the use of CMS-1500 form, the Health Insurance Claim form, and the standard electronic Health Care Claim: Professional Transaction form (ASC X12N 837). For hospitals providing inpatient or outpatient services, this must include the CMS-1450 form (UB-92) and the standard electronic Health Care Claim: Institutional Transaction form (ASC X12N 837).

004.01(D) SYSTEM REQUIREMENT. The health plan must maintain an editable system for recording all claims, clearly indicating the date on which a claim is received and the date(s) any action(s) on the claim occur.

004.01(E) PAYMENT STANDARD. The health plan must pay clean claims promptly as provided above after the date of receipt of or electronic notice of the claim. If, for whatever reason, the claim is submitted electronically and in written form, the date of the earlier submission of the claim will be the date of notice from which the health plan must calculate the maximum thirty day period.

004.01(F) NOTICE OF CONTESTED CLAIM. The health plan must provide written or electronic notice to the provider of a determination by the health plan that the claim is a contested claim with the returned claim. The written or electronic notice must comply with the provisions in Title 482 NAC 4-004.

004.01(G) NOTICE REQUIREMENT FOR PARTIALLY CONTESTED CLAIM. If the health plan determines that part of a claim is a contested claim and returns the claim, the health plan must provide written or electronic notice of that determination to the entity submitting the claim and must proceed to pay the portion of the claim determined by the health plan to be a clean claim timely.

004.01(H) PROHIBITED ACTION. In no instance will the health plan contest or return a claim or a portion of a claim because the claim fails to provide certain information if the missing information does not prevent the plan from adjudicating the claim.

004.01(I) NOTICE OF INSUFFICIENT INFORMATION. If the health plan determines a claim provides insufficient information for the payment of the claim, the health plan must provide written or electronic notice of this determination to the entity submitting the claim timely including the following information:

(i) All of the reasons for the denial of the claim;

(ii) The date the service was rendered, the type of service rendered, the name of the provider who rendered the service and the name of the person to whom the service was rendered; and

(iii) The address of the office responsible for handling the claim, and means by which the office may be contacted without toll charges exceeding the charges that otherwise apply for the provider or member to place a call in their area code.

004.01(J) EFFECTIVE NOTICES AND PAYMENTS. Written notice of a claim will be effective upon the date that the claim is received. Electronic transmission of the claim will be the date the claim is posted to the electronic transfer system. Payment and notices from the health plan will be effective as of the date that:

(i) A draft or other valid instrument equivalent to payment is placed in the United States mail in a properly addressed, postage-paid envelope;

(ii) The date of posting of the item to an electronic transfer system; or

(iii) The date of delivery of the draft or other valid instrument equivalent to payment if (i) or (ii) do not otherwise apply.

004.01(K) CONTENTS OF A NOTICE OF A CONTESTED CLAIM. The health plan must specify in its notice of a returned claim at least the following information:

(i) The name, address, telephone number and facsimile number of the office handling the claim or other designated claims representative knowledgeable about the claim with which the person submitted the claim, or provider should communicate to resolve problems with the claim;

(ii) The date of the service, the type of service, the provider of the service, and the name of the person to whom the service was rendered to the extent that this information is known to the health plan;

(iii) The specific information needed by the health plan to make a determination that the claim is a clean claim;

(iv) The date the claim was received; and

(v) In addition, the health plan must include in a notice regarding a claim determination in part a contested claim, a statement specifying those portions of the claim that are considered to be clean claim, and the amounts payable with respect to the clean claim portion. Requests for information made by the health plan on a contested claim must be reasonable and relevant to the determination of whether the claim is a clean claim or claim that must be denied.

004.01(L) USE OF INTERMEDIARIES. A health plan’s use of subcontractors to perform one or more of the health plan’s claims handling functions must not mitigate, in any way, the health plan’s responsibility to comply with all of the terms of Title 482 NAC.

004.01(M) ELECTRONIC REMITTANCE ADVICE. Electronic remittance advice must be provided in accordance with the standards set forth in the Health Insurance Portability and Accountability Act of 1996.

004.01(N) CLAIM STATUS INQUIRY AND RESPONSE. Electronic claim status inquiry and response must be provided in accordance with the standards set forth in the Health Insurance Portability and Accountability Act of 1996.

004.01(O) ENCOUNTER DATA. The health plan must maintain an information system that includes the capability to collect data on member and provider characteristics, and claims information through an encounter data system. The health plan must submit encounter data to the Medicaid Management Information System monthly per Departmental specifications.

005. CORE BENEFITS PACKAGE GENERAL PROVISIONS . 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.

005.02 SERVICES IN THE CORE BENEFITS PACKAGE. Services provided in the core benefits package are as follows and represent covered services under Heritage Health. The health plan is responsible for working with the Department to ensure the member has access to all services.

005.02(A) PHYSICAL HEALTH SERVICES. The physical health services include those listed below as covered by Title 471 NAC:

(i) Inpatient hospital services, including transitional hospital services and transplant services (see 471 NAC 10-000);

(ii) Outpatient hospital services (see 471 NAC 10-000);

(iii) Ambulatory surgical center (ASC) services (see 471 NAC 10-000 and 471 NAC 26-000);

(iv) Physician services, including services provided by nurse practitioners, certified nurse midwives, and physician assistants, and clinic-administered injections or medications, and anesthesia services including those provided by a certified registered nurse anesthetist (see 471 NAC 18-000);

(v) Services provided in federally-qualified health centers and rural health clinics (see 471 NAC 29-000 and 471 NAC 34-000);

(vi) Services provided in Indian Health Service facilities (see 471 NAC 11-000);

(vii) Clinical and anatomical laboratory services, including the administration of blood draws completed in the physician’s office or an outpatient clinic for a behavioral health diagnosis (see 471 NAC 10-000, 471 NAC 18-000, 471 NAC 20-000, 471 NAC 26-000, 471 NAC 32-000);

(viii) Radiology services (see 471 NAC 10-000);

(ix) Health Check services (see 471 NAC 33-000);

(x) Home health services (see 471 NAC 9-000);

(xi) Private duty nursing services (471 NAC 13-000);

(xii) Therapy services (physical therapy, occupational therapy, and speech pathology and audiology) (see 471 NAC 14-000, and 471 NAC 23-000);

(xiii) Durable medical equipment and medical supplies, including hearing aids, orthotics, prosthetics, and nutritional supplements (471 NAC 7-000, 471 NAC 8-000, 471 NAC 19-000, 471 NAC 15-000);

(xiv) Podiatry services (471 NAC 19-000);

(xv) Chiropractic services (471 NAC 5-000);

(xvi) Vision services (471 NAC 24-000);

(xvii) Free standing birth center services (471 NAC 42);

(xviii) Hospice services, except when provided in a nursing facility (471 NAC 36-000 and 471 NAC 12-000);

(xix) Skilled or rehabilitative and transitional nursing facility services (471 NAC 21-000, 471 NAC 12-000, and 471 NAC 13-000);

(xx) Ambulance services (471 NAC 4-000);

(xxi) Non-emergency transportation services (471 NAC 27-000);

(xxii) Transplant services; and

(xxiii) Pharmacy services (471 NAC 16-000).

005.02(B) BEHAVIORAL HEALTH SERVICES. The behavioral health services include those listed below as covered by Title 471 NAC:

(i) Services for individuals age twenty (20) and under, see Title 471 NAC 32:

(1) Crisis stabilization services (includes treatment crisis intervention);

(2) Inpatient psychiatric hospital (acute and sub-acute); and

(3) Psychiatric residential treatment facility (age 19 and under).

(4) Outpatient assessment and treatment:

(a) Partial hospitalization;

(b) Day treatment;

(d) Medication management;

(e) Outpatient therapy (individual, family, or group);

(f) Injectable psychotropic medications;

(g) Substance use disorder treatment;

(h) Psychological evaluation and testing;

(i) Initial diagnostic interviews;

(j) Sex offender risk assessment;

(k) Community treatment aide services;

(l) Comprehensive child and adolescent assessment addendum;

(m) Hospital observation room services (up to 23 hours and 59 minutes in duration);

(n) Parent child interaction therapy;

(o) Child-parent psychotherapy;

(p) Applied behavioral analysis;

(q) Multi-systemic therapy; and

(r) Functional family therapy.

(5) Rehabilitation services:

(a) Day treatment and intensive outpatient;

(b) Community treatment aid services;

(d) Therapeutic group home.

(ii) Services for individuals age twenty-one (21) and over, see Title 471 NAC 20:

(1) Crisis stabilization services (includes treatment crisis intervention);

(2) Inpatient psychiatric hospital services (acute and sub-acute);

(3) Outpatient assessment and treatment:

(a) Partial hospitalization;

(b) Social detoxification;

(d) Intensive outpatient;

(e) Medication management;

(f) Outpatient therapy (individual, family, or group);

(g) Injectable psychotropic medications;

(h) Substance use disorder treatment;

(i) Psychological evaluation and testing;

(j) Electroconvulsive therapy;

(k) Initial diagnostic interviews;

(l) Ambulatory detoxification; and

(m) In-home psychiatric nursing.

(4) Rehabilitation services:

(a) Dual-disorder residential;

(b) Intermediate residential for substance use disorder;

(d) Halfway house;

(e) Therapeutic community for substance use disorder only;

(f) Community support;

(g) Psychiatric residential rehabilitation;

(h) Secure residential rehabilitation;

(i) Assertive community treatment and alternative community support; and

(j) Day rehabilitation.

005.02(C) AMOUNT, DURATION, AND SCOPE. The health plan must provide the above services in amount, duration and scope defined by the Department in Title 471 NAC. The health plan must provide care and services when medically necessary to ensure the member receives necessary services. The health plan must also ensure the services provided to the member are as accessible (in terms of timeliness, amount, duration and scope) as those services provided to the non-enrolled Medicaid client.

005.02(D) VALUE-ADDED SERVICES. The Department allows the health plan to provide medically necessary services to the member that are in addition to those covered under Medicaid. The Department allows the health plan to provide value-added services that are more cost effective than the covered service and the health status of the member is expected to improve or at least stay the same. If the plan provides additional or value-added services, the total payment to the health plan will not be adjusted but will remain within the certified rates agreed upon in any resulting contract and approved by the Centers for Medicare and Medicaid Services.

005.03 EXCLUDED SERVICES. The following Medicaid coverable services are excluded from the Heritage Health core benefits package and are not the responsibility of the health plan. Members must access these services through Medicaid. For all Medicaid covered services, the health plan is required to coordinate the members care to promote the continuity of care. The health plan and enrollment broker must inform the member of the availability of these services and how to access them. Excluded services:

(A) Dental services (see Title 471 NAC 6 and 482 NAC 5);

(B) Services in Intermediate Care Facilities for Persons with Developmental Disabilities (see Title 471 NAC 31);

(C) Any institutional long-term care nursing facility services at a custodial level of care (see Title 471 NAC 12 and 471 NAC 13);

(D) School-based services (see Title 471 NAC 25);

(E) All home and community-based waiver services (see Title 404 and 480 NAC);

(F) Targeted case management (see Title 480 NAC); and

(G) Medicaid state plan personal assistance services (see Title 471 NAC 15).

005.04 FAMILY PLANNING SERVICES. Approval by the member’s primary care provider and health plan is not required for family planning services. The health plan and enrollment broker must inform Heritage Health members of their freedom of choice for family planning services and that they are not restricted to a provider participating in Heritage Health but they must use a Medicaid enrolled provider.

005.04(A) SERVICES COVERED UNDER FAMILY PLANNING. Family planning services are services to prevent or delay pregnancy, including counseling services and patient education, examination and treatment by medical professionals, laboratory examinations and tests, medically approved methods, procedures, pharmaceutical supplies and devices to prevent conception. This includes tubal ligations and vasectomy. The health plan must reimburse treatment for sexually transmitted infections in the same manner as family planning services, without referral or authorizations.

(i) Family planning services do not include hysterectomies, other procedures performed for a medical reason (such as removal of an intrauterine device due to infection) or abortions.

(ii) Family planning services are to be paid by the health plan even if the provider is not part of the health plan’s network.

005.05 EMERGENCY SERVICES. Approval by the member’s primary care provider and health plan is not required for receipt of emergency services. The health plan and enrollment broker must inform Heritage Health members that approval of emergency services is not required and must educate members regarding the definition of an "emergency medical condition," and how to appropriately access emergency services.

005.05(A) EMERGENCY SERVICES PROVIDED TO MANAGED CARE MEMBERS. The health plan must cover and pay for emergency services regardless of whether the provider that furnishes the services has contracted with the health plan.

(i) An emergency medical condition is a medical condition, which manifests itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in:

(1) Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;

(2) Serious impairment to bodily functions; or

(3) Serious dysfunction of any bodily organ or part.

005.06 FEDERALLY QUALIFIED HEALTH CENTERS. The health plan must contract with any federally qualified health center located within the designated coverage area or otherwise arrange for the provision of federally qualified health center services:

(A) If a health plan reimburses a federally qualified health center on a fee-for-service basis, it cannot pay less for those services than it pays other providers;

(B) Federally qualified health center’s electing to be reimbursed on a negotiated risk basis are not entitled to reasonable cost reimbursement. If the federally qualified health center requests reasonable cost reimbursement, the health plan must reimburse the federally qualified health center at the same rate it reimburses its other subcontractors of this provider type;

(D) Federally qualified health center payments include direct payments to a medical provider who is employed by the federally qualified health center; and

(E) The same reasonable efforts that are applied to the federally qualified health center, apply to rural health clinics and tribal clinics.

006. PAYMENT FOR SERVICES . The Department pays a monthly capitation fee health plan for each enrolled member for each month of Heritage Health coverage (per member per month). The monthly capitation fee includes payment for all services in the core benefits package.

006.01 TIMELY PAYMENT FOR SERVICES. The health plan must provide payment to providers for services rendered on a timely basis consistent with Medicaid claims payment procedures, unless the health care provider and organization agree to an alternative payment schedule.

006.02 PAYMENT IN FULL. Payment to the health plan is payment in full for all services included in the core benefits package. The health plan shall not request additional payment from the Department or the member.

006.03 CAPITATION RATES. The capitation rates are actuarially determined and are based on geographic location, eligibility category, gender, age and type of services. The Department will adjust rates, and complete all necessary contract amendments, when it is determined appropriate, based on any changes in Medicaid fee-for-service rates, or in instances where an error or omission in the calculation of the rates has been identified.

006.04 INCORRECT PAYMENTS. Medicaid shall not normally recoup payments from health plans. However, in situations where payments are made incorrectly, Medicaid shall work with the health plan to identify the discrepancy and shall recoup/reconcile such payments.

006.05 ENROLLMENT REPORT. On or before the first day of each month, the Department or the enrollment broker will provide to each health plan a monthly enrollment report that lists all enrolled and disenrolled members for that month. This report will be used as the basis for the monthly capitation payments to the health plan. The health plan is responsible for payment of all services in the core benefits package provided to members listed on the enrollment report generated for the month of coverage. If an enrollment report does not list an eligible member, the Department will be responsible for all medical expenses.

006.06 COVERAGE FOR PREGNANT WOMEN, NEWBORNS, AND 599 CHIP. Coverage for pregnant women, newborns, and 599 CHIP is provided within the following parameters:

(A) Pregnant Woman and Newborn are Medicaid Eligible: Coverage is provided for the pregnant woman from the month of enrollment until disenrollment occurs; and for the newborn from the month of birth until disenrollment occurs. Payment to the health plan is made for the month(s) of enrollment for the pregnant woman and the newborn until disenrollment occurs;

(B) Only the Newborn is Medicaid Eligible: Coverage is provided for the pregnant woman from the month of enrollment until disenrollment occurs. Coverage for the birth and post-partum care for the mother is provided for the month of birth through the month in which the sixtieth 60th day following the month of birth occurs. Coverage for only the newborn continues past the sixty (60)-day postpartum period as long as the newborn remains eligible and enrolled. Payment to the health plan is made for the month(s) of enrollment for the pregnant woman and the newborn until disenrollment occurs; and

(C) 599 CHIP: Coverage is provided for the unborn child of the pregnant woman that is otherwise ineligible for Medicaid under 599 CHIP. Coverage is limited to prenatal care and pregnancy-related services solely for the unborn child. This coverage does not include postpartum care and medical issues separate to the mother and unrelated to the pregnancy.

006.07 BILLING THE MEMBER. The health plan may not bill a member for a Medicaid coverable service, regardless of the circumstances. The provider may only bill the member pursuant to Title 471 NAC.

006.07(A) OUT-OF-NETWORK. The health plan may or may not be responsible for an out-of-network service if the service is a Medicaid-coverable service. The agreement the health plan has with the provider will determine whether the health plan is responsible to pay the provider. In some cases, the plan may not pay the provider. The health plan is not required to pay a non-Medicaid enrolled provider for a Medicaid-covered service.

006.08 REINVESTMENT AND FORFEITED FUNDS. The health plan must provide for the reinvestment of profits in excess of the contracted amount, performance contingencies imposed by the department, and any unearned (forfeited) hold back funds, pursuant to Neb. Rev. Stat. § 71-831, and any successor statutes. The health plan must establish and manage two accounts: a hold back account and a reinvestment account. Both accounts must be separate from other accounts. Neither accounts can have risk-bearing investments. Both accounts must be created and operated in full compliance with the Nebraska Uniform Trust Code (Neb. Rev. Stat. § 30-3801 to 30-38,110).

006.09 QUALITY PERFORMANCE PROGRAM AND HOLD BACKS. The health plan must participate in the Department’s quality performance program. The quality performance program must be in accordance with Neb. Rev. Stat. § 71-831 and any successor statutes. Pursuant to Neb. Rev. Stat. § 71-831, and any successor statutes, the health plans must hold back a pre-determined amount in a separate account. The hold back is the aggregate of all income and revenue earned by the health plans and related parties under the contract and constitutes the maximum amount available to the health plan to earn via the quality performance program. The health plans must report its performance measures that affect its eligibility to earn the hold back funds, as the Department requires:

(A) Each year of the contract constitutes a performance year, beginning on the contract start date. The Department will assess the health plan performance based on the measures annually and notify the health plan of the amount of the earned hold back and unearned (forfeited) hold back. The Department will make this determination within six (6) months after the end of each contract year;

(B) All earned hold back funds become the property of the health plan;

(C) The health plan must deposit unearned (forfeited) hold back funds into the reinvestment account. The Department will reimburse the Federal share of the forfeited funds to the Centers for Medicare and Medicaid Services. The remaining State share of the forfeited hold back funds will become the property of the Department;

(D) No interest will be due to either party on hold back funds retained by the health plan or returned to the Department; and

(E) Any earned hold back will not be included in the health plan’s income for the year nor considered part of the medical loss ratio calculation.

006.10 HOLD BACKS, PENALTIES, AND LIQUIDATED DAMAGES. A percentage of the aggregate of all income and revenue the health plan and related parties under the contract earn must be at risk as a penalty if the health plan fails to meet minimum performance metrics, pursuant to Neb. Rev. Stat. §71-831 and any successor statutes. The Department will provide the minimum performance metrics to the health plans prior to year two (2) of the contract. The health plans must report its performance on the minimum performance metrics, as the Department requires:

(A) The Department reserves the right to modify annually the measures and criteria for earning the hold back funds and assessing liquidated damages; and

(B) In the event the Department modifies the measures or criteria, the Department will provide the health plans sixty (60) calendar days advance written notice. These measures will include operational or administrative measures that reflect the health plans’ business processes and may lead to improved access to and quality of care, Centers for Medicare and Medicaid Services Medicaid Adult and Child Core Measure sets, healthcare effectiveness data and information set measures, and Departmental-identified measures that represent opportunities for improvement as indicated by Heritage Health historical performance.

006.11 DEPARTMENTAL RESPONSIBILITIES. The Department will ensure the following:

(A) The annual financial reporting package, including the medical loss ratio rebate calculation, risk corridor calculation, and earned/unearned hold back calculation is reviewed, and written approval is provided, within forty-five (45) calendar days after receipt from the health plan;

(B) The health plan will transfer all funds deposited into the reinvestment holding account to the State by the health plan for reconciliation and reimbursement of the Federal share via reporting on Centers for Medicare and Medicaid Services Form 64;

(D) The remaining State share will return to the health plan for deposit into the reinvestment distribution account, which the health plan manages, subject to contractual requirements; and

(E) The Department will hold the health plan responsible and accountable for the necessary fiduciary duties and functions required to administer the reinvestment holding and reinvestment distribution accounts. Oversight of the financial accounting will be in accordance with the financial management reporting requirements.

History

Effective 2021-09-27

Chapter 5 The Dental Benefits Package

Neb. Admin. Code tit. 482, ch. 5 The Dental Benefits Package {#sec-482-nac-5 omnilex-key=us-ne-regs-official--title-482--482 NAC 5}

001. SCOPE AND AUTHORITY . 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.

002. DENTAL BENEFITS PLAN . 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;

(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 guidelines;

(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.

003. DENTAL BENEFITS PACKAGE GENERAL PROVISION . 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.

004. SERVICES IN THE DENTAL BENEFITS PACKAGE . 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.

005. SERVICES FOR EMERGENCY MEDICAL CONDITIONS . 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.

006. COORDINATION OF SERVICES . 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.

007. FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS . 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.

008. INDIAN HEALTH PROTECTIONS . 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.

009. PAYMENT FOR SERVICES . 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.

009.03 RECOUPMENTS AND RECONCILIATION. When the Department incorrectly makes a payment to the Dental Benefits Manager, the Department must recoup those payments from the Dental Benefits Manager. The Dental Benefits Manager must work with the Department to identify the discrepancy and must allow the Department to recoup and reconcile such payments.

History

Effective 2021-09-27

Chapter 6 Quality

Neb. Admin. Code tit. 482, ch. 6 Quality {#sec-482-nac-6 omnilex-key=us-ne-regs-official--title-482--482 NAC 6}

001. SCOPE AND AUTHORITY . 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.

002. CONTINUOUS QUALITY ASSURANCE AND QUALITY IMPROVEMENT . 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.

003. SYSTEMS FOR ASSESSMENT . The Department has implemented systems for the ongoing assessment of the quality and appropriateness of care and services furnished to all Medicaid enrollees under the health plan contracts. These systems enable the Department’s monitoring of data related to the access of Medicaid clients to comprehensive, cost-effective health services, including evidence-based care options that emphasize early intervention and community-based treatment and reduced rates of costly and avoidable emergency and inpatient hospital levels of care. Through the implementation of these assessment systems, the Department can monitor trends, demonstrate success and identify challenges in achieving the objectives of the Heritage Health program.

003.01 ASSESMENT. The Department assesses the quality and appropriateness of care through multiple processes that comprise a comprehensive system of oversight:

(A) Quarterly reporting of provider accessibility analyses, timely access standards monitoring, grievances and appeals process compliance, utilization management monitoring, results of service verification monitoring, out of network referrals monitoring and case management results.

(B) Annual reporting of Medicaid selected performance measure results and trends related to quality of care, service utilization and member and provider satisfaction.

(D) Annual, external independent reviews of the quality outcomes, timeliness of and access to, the services covered by the plan through its external quality review organization.

(E) Annual state-staff–conducted onsite operational reviews that include validation of reports and data previously submitted by the plan and in-depth review of areas that have been identified as potentially problematic.

(F) Medicaid requires the plan to attend annual Quality Management Committee meetings, during which data and information designed to analyze the objectives of the Quality Strategy are reviewed. The Quality Management Committee recommends actions to improve quality of care, access, utilization, and client satisfaction, and to review the results of the performance improvement projects and recommend future performance improvement projects topics. The Quality Management Committee also reviews the state’s overall Quality Strategy and makes recommendations for improvement.

003.02 OPERATIONAL ON-SITE REVIEW. Operational reviews are conducted for each health plan annually by the Department. Additionally, random reviews of each health plan notification of adverse actions will be completed. The Department and other agencies may use the operational review to validate a plan’s accreditation.

003.02(A) COMPONENTS OF THE OPERATIONAL REVIEWS. Operational reviews include, but are not limited to, an in-depth review of each health plan’s quality management work plan, review of cultural competency, general administration, and delivery system.

003.03 EXTERNAL QUALITY REVIEW. The Department is required to contract with a qualified External Quality Review Organization to perform an annual external quality review for each contracting health plan. The External Quality Review Organization is independent from the Department and from the health plans.

003.03(A) EXTERNAL QUALITY REVIEW ORGANIZATION DUTIES. The External Quality Review Organization will annually:

(i) Validate performance improvement projects required by the Department that were underway during the preceding 12 months;

(ii) Validate the health plans performance measures reported to the Department during the preceding 12 months; and

(iii) Conduct a review to determine the health plans compliance with standards.

003.03(B) EXTERNAL QUALITY REVIEW ORGANIZATION RESULTS. The Department will use the results of the reviews in assessing and monitoring the quality and appropriateness of care provided to members as part of the Department’s quality strategy.

003.04 DETERMINATION OF CONTRACT COMPLIANCE. The Department will monitor the health plans contract for compliance. A plan is noncompliant if it falls below the established standards for quality of care, access, client satisfaction, utilization, and encounter submission.

003.04(A) VIOLATIONS SUBJECT TO INTERMEDIATE SANCTIONS. The following violations are grounds for intermediate sanctions that may be imposed when a health plan acts or fails to act as follows:

(i) The health plan fails substantially to provide medically necessary services that the health plan is required to provide, under law or under its contract with the State, to an enrollee covered under the contract;

(ii) The health plan imposes on enrollees premiums or charges that are in excess of the premiums or charges permitted under the Medicaid program;

(iii) The health plan acts to discriminate among enrollees on the basis of their health status or need for health care services;

(iv) The health plan misrepresents or falsifies information that it furnishes to the Centers for Medicare and Medicaid Services or to the State;

(v) The health plan misrepresents or falsifies information that it furnishes to an enrollee, potential enrollee, or health care provider;

(vi) The health plan fails to comply with the requirements for physician incentive plans, if applicable;

(vii) The health plan has distributed directly, or indirectly through any agent or independent contractor, marketing materials that have not been approved by the State or that contain false or materially misleading information; or

(viii) The health plan has violated any of the other applicable requirements of sections 1903(m) or 1932 of the Social Security Act and any implementing regulations.

003.04(B) ENFORCEMENT. The health plans that are determined to be performing below quality standards through periodic reporting, performance measures, member satisfaction surveys, encounter data submission, on-site operational review, and/or review and analysis of the quality management work plan will be required to submit a plan of correction which addresses each deficiency specifically and provides a timeline by which corrective action will be completed. Medicaid requires follow-up reporting by the health plan to assess progress in implementing the plan of correction.

003.04(B)(i) ADDITIONAL ACTIONS. If the health plan has not come into compliance upon completion of the plan of correction, the Department will take additional actions against the health plan. These additional actions include:

(1) Instituting a restriction on the types of enrollees;

(2) Changing the auto assignment algorithm to limit the number of enrollees into the plan, when applicable; or

(3) Ban new auto-assignments to the plan, when applicable.

003.04(C) INTERMEDIATE SANCTIONS. The Department will impose the following sanctions for violations subject to intermediate sanctions listed in 482 NAC 6-003.04(A):

(i) Civil monetary penalties in the following specified amounts:

(1) A maximum of $25,000 for each determination of failure to provide services; misrepresentation or false statements to members, potential members, or health care providers; failure to comply with physician incentive plan requirements; or marketing violations;

(2) A maximum of $100,000 for each determination of discrimination; or misrepresentation or false statement to the Centers for Medicare and Medicaid Services or the Department;

(3) A maximum of $15,000 for each recipient the Department determines was not enrolled because of a discriminatory practice, subject to the $100,000 overall limit;

(4) A maximum of $25,000 or double the amount of the excess charges, whichever is greater, for charging premiums or charges in excess of the amounts permitted under the Medicaid program. The Department must deduct from the penalty the amount of overcharge and return it to the affected client member.

(ii) Appointment of temporary management as described in Section III.Y Early Termination of the health plan’s contract;

(iii) Granting members the right to terminate enrollment without cause and notifying the affected members of their right to disenroll;

(iv) Suspension of all new enrollment, including default enrollment, after the date of the effective date of the sanction; and

(v) Suspension of payment for members enrolled after the effective date of the sanction and until the Centers for Medicare and Medicaid Services or the Department is satisfied that the reason for imposition of the sanction no longer exists and is not likely to occur.

004. IMPROVEMENT . Based on the results of assessment and monitoring of quality and appropriateness of care and contract compliance, the Department will target improvement efforts.

004.01. INTERVENTIONS FOR IMPROVEMENT. The Department will utilize, but is not limited to the following interventions to improve the quality and appropriateness of care:

(A) Quality Committee: The Department has established a Quality Committee;

(B) Performance Improvement Projects: The health plans are required to conduct at least two clinical and one non-clinical projects annually. For each project, the Department with the Quality Management Committee will choose the topic, develop the study methodology and determine interventions to reach improvement goals. Each plan will conduct the same project, at least one will be a joint project with another plan (See 482-000-11);

(C) Quality Performance Dashboard: In an effort to monitor a health plans performance on quality measures, a quality performance dashboard was developed. The dashboard approach provides a framework for benchmarking performance and assists health plans to prioritize quality improvement planning. The dashboard gives a multi-dimensional view of a health plans performance by comparing quality measures to national standard measures, if appropriate, to baseline measures for the program, and over two years. The dashboard results will display on the Department’s website; and

(D) Health plans sanctions-See 482 NAC 6-003.04(A).

005. QUALITY MANAGEMENT COMMITTEE . The Department has established a Quality Committee for Managed Care consisting of Department staff, Medicaid staff, Public Health staff, the health plans, providers, and other stakeholders.

006. ACCREDITATION . The Heritage Health plans must have National Committee for Quality Assurance Accreditation or another national accreditation for the Medicaid Managed Care plan. The dental plan must have National Committee for Quality Assurance Accreditation or URAC accreditation. The health plans must submit a copy of the accrediting body’s letter indicating the most recent accreditation status at the time of initial contracting. The plans must submit any changes or updates to the Department within thirty (30) days of receipt.

006.01 SURVEY RESULTS. Upon survey by the accrediting body, the health plan must submit a copy of the survey results to the department within thirty (30) days of receipt. The health plan must submit a copy of any work plan that addresses improvements needed or follow-up necessary because of the survey. The plan must submit any changes or updates to the survey results or work plan to the Department within 30 days of receipt.

006.02 NON-ACCREDITATION. In the event that a health plan is not accredited at the time of contracting, the health plan is required to submit to the Department, for approval, a plan to be fully accredited within the five year contracting period. The health plan must submit a work plan including the timeline to accomplish plan accreditation to the Department. The health plan must provide a status update to Departmental staff at the time of the annual on-site operational review.

History

Effective 2020-01-27

Chapter 7 Rights and Responsibilities

Neb. Admin. Code tit. 482, ch. 7 Rights and Responsibilities {#sec-482-nac-7 omnilex-key=us-ne-regs-official--title-482--482 NAC 7}

001. SCOPE AND AUTHORITY . This chapter sets forth responsibilities of the health plans, Dental Benefits Manager, and providers of services to ensure the member is fully informed, in writing and verbally, of their rights and responsibilities as well as avenues for pursuing complaints and grievances. Similarly, providers participating in the health plan networks are entitled to the same processes as any Medicaid-enrolled provider according to Title 471 Nebraska Administrative Code (NAC).

002. RIGHTS AND RESPONSIBILITIES . The following rights and responsibilities apply to a member participating in Heritage Health. The health plans haves the requirement to inform the member, in writing and verbally, regarding their rights and responsibilities. No person may be subjected to discrimination in any Departmental program or activity based on their race, color, sex, age, national origin, religious creed, political beliefs, or disability.

002.01 MEMBER RIGHTS. The member has the right to:

(A) Be treated with respect, dignity, and without discrimination or retaliation;

(B) Be given information about their illness, or medical condition; understand the treatment options, risks and benefits; and make an informed decision about whether they will receive treatment;

(D) Talk with their doctor and health plan and know their medical information will be kept confidential;

(E) Choose their health plan and primary care physician provider;

(F) Have access to their health plan and primary care provider;

(G) Receive medical care in a timely manner;

(H) Request a copy of their medical record and request changes to their medical record;

(I) Make a complaint about the provider or health plan, and receive a timely response;

(J) Receive information on the medical services provided by their health plan;

(K) Change their primary care provider at any time;

(L) Change their health plan within 90 days of initial enrollment or every 12 months without cause thereafter;

(M) Have Heritage Health and health plan materials explained or interpreted;

(N) Have interpreters at no cost, if necessary, during medical appointments and in all discussions with their primary care provider or health plan;

(O) Request an appeal if services are denied, terminated, or reduced;

(P) Make advance directives, if desired, and receive assistance if needed; and

(Q) Receive proper medical care twenty-four (24) hours a day, seven (7) days a week.

002.02 MEMBER RESPONSIBILITIES. The member has the responsibility to:

(A) Understand, to the best of his or her ability, how Heritage Health is used to receive health care;

(B) Choose a primary care provider within the health plan's network;

(C) Take their Medicaid ID card and health plan ID card to all medical appointments and to the pharmacy for prescriptions;

(D) Keep their scheduled appointments;

(E) Call their doctor’s provider’s office at least 24 hours in advance if their appointment must be rescheduled;

(F) Tell their doctor about any medical problems;

(G) Ask questions about things they do not understand;

(H) Follow the provider’s orders and advice;

(I) Assist with the transfer of their medical records;

(J) Receive services from their primary care provider unless referred elsewhere by their primary care provider; and

(K) Cooperate with all Heritage Health inquiries and surveys.

002.03 PROVIDER RIGHTS AND RESPONSIBILITIES. Providers participating in Heritage Health or Dental Benefits Manager have the same rights and responsibilities as any Medicaid enrolled provider pursuant to Title 471 NAC.

003. GRIEVANCE PROCESS . The health plan or dental benefits manager must inform the member, in writing, of the grievance process for issuing a complaint involving access to care, quality of care, or communication issues with the plan or primary care provider. The member, or legal representative, must file the grievance with the health plan or dental benefits manager, according to the same plans’ internal grievance procedure, pursuant to 1931(b)(4) of the Social Security Act.

(A) A member may file a grievance either orally or in writing;

(B) A provider may file a grievance when acting as the client’s authorized representative;

(C) The health plan must resolve each grievance and provide notice, as expeditiously as the member’s health condition requires, not to exceed 90 days from the day the plan receives the grievance;

(D) The plan must provide notice of the grievance resolution in writing in a language and format which is easily understood by the member. The plan must make reasonable effort to notify the member orally of the grievance resolution; and

(E) All contacts with the health plan regarding grievances must be documented and submitted to the Department.

004. APPEALS PROCESS . The Heritage Health plan or Dental Benefits Manager must notify the member in writing of the appeals process for challenging any adverse benefit determinations. The member, or the provider on behalf of the member, may request an appeal with the Heritage Health plan or Dental Benefits Manager, request a State fair hearing, or both.

004.01. AVENUES FOR REQUESTING AN APPEAL. The member, or the provider with the member’s written consent on behalf of the member, has the following avenues for requesting an appeal:

(A) File a Heritage Health plan or Dental Benefits Manager Level Appeal: The member may contact verbally or in writing the Heritage Health plan or Dental Benefits Manager to request a hearing and following that Heritage Health plan’s or Dental Benefits Manager’s internal appeal process. The request for appeal must be within sixty (60) days from the date on the notice of adverse benefit determination. An appeal filed orally must be followed by a written, signed appeal; or

(B) Request a State Fair Hearing: A member may request a State fair hearing only after the member has exhausted the Heritage Health plans or Dental Benefits Manager’s internal appeal process. The member must submit in writing to the DHHS Legal and Regulatory Services within one hundred twenty (120) days from the date of the Heritage Health plan’s or Dental Benefits Manager’s notice of resolution. Hearings are scheduled and conducted according to the procedures outlined in 465 NAC.

004.02 NOTICE OF ADVERSE BENEFIT DETERMINATION. The Heritage Health plan or Dental Benefits Manager must notify the requesting provider, and give the member written notice of any adverse benefit determination. The notice must be in writing and be a language and format that is easily understandable to the member. The notice to the provider need not be in writing.

004.02(A) TIMEFRAMES FOR NOTICE OF ADVERSE BENEFIT DETERMINATION. The following are timeframes for notice of adverse benefit determination:

(i) Denial of Payment: The Heritage Health plan or Dental Benefits Manager must give notice on the date of adverse benefit determination when the adverse benefit determination is a denial of payment.

(ii) Standard Service Authorization Denial: Notice must be given as expeditiously as the member’s health condition requires not to exceed fourteen (14) calendar days following the receipt of the request for service. The timeframe may be extended up to fourteen (14) additional calendar days if the member or provider requests the extension or if the Heritage Health plan or Dental Benefits Manager shows that there is need for additional information and demonstrates that the delay is in the member’s interest. If the timeframe is extended, the member must be provided written notice of the reason for the decision to extend the timeframe and right to file a grievance if he or she disagrees with that decision. The determination must be issued and carried out as expeditiously as the member health condition requires and no later than the date the extension expires.

(iii) Termination, Suspension, or Reduction of Services: Notice must be given at least ten (10) days before the date of adverse benefit determination when the adverse benefit determination is a termination, suspension, or reduction of a previously authorized Medicaid-covered service. The period of advance notice is shortened to five (5) days if probable fraud has been verified. Notice by the date of the adverse benefit determination must be given by the date of the adverse benefit determination for the following circumstances:

(1) Death of the member;

(2) A signed written member statement requesting service termination or giving information requiring termination or reduction of services (where the member understands that this adverse benefit determination must be the result of supplying that information);

(3) The member’s admission to an institution where the member is ineligible for further services;

(4) The member’s address is unknown and mail directed to him or her has no forwarding address;

(5) The member has been accepted for Medicaid services by another jurisdiction;

(6) The member’s physician or dentist prescribes the change in the level of medical care; or

(7) The safety or health of individuals in the facility would be endangered, the resident’s health improves sufficiently to allow a more immediate transfer or discharge, an immediate transfer or discharge is required by the resident’s urgent medical needs.

(iv) Expedited Service Authorization Denial: For cases in which a provider indicates or the Heritage Health plan or Dental Benefits Manager determines that following the standard timeframe could seriously jeopardize the member’s life, or health, or ability to attain, maintain, or regain maximum function, an expedited authorization decision must be made and notice provided as expeditiously as the member’s health condition requires and no later than seventy-two (72) hours after receipt of the request for service. This timeframe may be extended up to fourteen (14) additional calendar days if the member requests the extension or if the Heritage Health plan or Dental Benefits Manager shows that there is need for additional information and demonstrates that the delay is in the member’s interest. If the timeframe is extended, the member must be provided written notice of the reason for the decision to extend the timeframe and right to file a grievance if they disagree with that decision. The determination must be issued and carried out as expeditiously as the member’s health condition requires and no later than the date the extension expires.

(v) Untimely Service Authorization Decision: Notice must be provided on the date that the timeframes expire when service authorization decisions are not reached within the timeframes for either standard or expedited service authorizations. Untimely service authorizations constitute a denial and are thus adverse benefit determinations.

004.03 RESOLUTION AND NOTIFICATION. The Heritage Health plan or Dental Benefits Manager must resolve each appeal, and provide notice, as expeditiously as the member’s health condition requires, not to exceed thirty (30) days from the day the appeal is received. This timeframe may be extended up to fourteen (14) calendar days if the member requests an extension or the Heritage Health plan or Dental Benefits Manager shows that there is need for additional information and how the delay is in the member’s interest. For any extension not requested by the member, notice of the reason for delay must be provided to the member.

004.03(A) WRITTEN NOTICE OF RESOLUTION. Written notice of resolution of the appeal must be provided to the member. The written resolution must include:

(i) Results and date of the appeal resolution; and

(ii) For decisions not wholly in the member’s favor:

(1) The right to request a state fair hearing for decisions not wholly in the member’s favor;

(2) How to request a State fair hearing;

(3) The right to receive benefits pending a hearing;

(4) How to request the continuation of benefits; and

(5) If the appeal decision is upheld, that the member may be liable for the cost of continued benefits received while the appeal was pending.

004.04 CONTINUATION OF BENEFITS. The member may have his or her benefits continue while an appeal is pending.

004.04(A) REQUIREMENTS FOR CONTINUATION OF BENEFITS. The Heritage Health plan or Dental Benefits Manager must continue member benefits if all of the following apply:

(i) The appeal is filed timely, meaning on or before the later of the following:

(1) Ten (10) calendar days of the Heritage Health plan or Dental Benefits Manager mailing of the notice of adverse benefit determination; or

(2) The intended effective date of the proposed adverse benefit determination;

(ii) The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;

(iii) The services were ordered by an authorized provider;

(iv) The authorization period has not expired; and

(v) The member requests a continuation of benefits.

004.04(B) REQUIREMENTS FOR ENDING CONTINUED BENEFITS. If the member’s benefits are continued or reinstated while the appeal is pending, the benefits must be continued until one of the following occurs:

(i) The member withdraws the appeal;

(ii) The member does not request a fair hearing and continuation of benefits within ten (10) calendar days from when the Heritage Health plan or Dental Benefits Manager mails the notice of adverse resolution to the member’s appeal;

(iii) A state fair hearing decision adverse to the member is made; or

(iv) The authorization expires or authorization service limits are met.

004.04(C) RECOVERY OF COSTS DURING CONTINUATION OF BENEFITS. The Heritage Health plan or Dental Benefits Manager may recover the cost of the continuation of benefits furnished to the member while the appeal was pending if the final resolution of the appeal upholds the Heritage Health plan’s or Dental Benefits Manager’s adverse benefit determination.

004.04(D) PAYMENT OF COSTS DURING CONTINUATION OF BENEFITS. The Heritage Health plan or Dental Benefits Manager must pay for disputed services if the Heritage Health plan or Dental Benefits Manager or State fair hearing decision reverses a decision to deny authorization of services and the member received the disputed services while the appeal was pending.

004.05 EXPEDITED APPEALS PROCESS. The Heritage Health plan or Dental Benefits Manager must conduct an expedited review process when the Heritage Health plan or Dental Benefits Manager determines, for a request from the member, or the provider indicates that taking the time for a standard resolution could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function. Expedited appeals must follow all standard appeal regulations. The Heritage Health plan or Dental Benefits Manager must not take punitive action against a provider who either requests an expedited appeal or supports a member’s appeal.

004.05(A) REQUESTING AN EXPEDITED APPEAL. The member or provider may file an expedited appeal either orally or in writing. No additional member follow-up is required.

004.05(B) TIMEFRAMES FOR EXPEDITED APPEALS. The Heritage Health plan or Dental Benefits Manager must resolve each expedited appeal and provide notice as expeditiously as the member’s health condition requires and in no event longer than seventy-two (72) hours after the Heritage Health plan or Dental Benefits Manager received the appeal. This timeframe may be extended by up to fourteen (14) calendar days if the member requests the extension or if the Heritage Health plan or Dental Benefits Manager shows that there is need for additional information and demonstrates that the delay is in the member’s interest. For any extension not requested by the member, written notice of the reason for delay must be provided to the member.

004.05(C) TIMEFRAMES FOR PROVIDING EVIDENCE AND ALLEGATIONS. The Heritage Health plan or Dental Benefits Manager must inform the member of the limited time available for the member to present evidence and allegations of fact or law, in person and in writing.

004.05(D) DENIAL OF AN EXPEDITED APPEAL. If the Heritage Health plan or Dental Benefits Manager denies a request for an expedited resolution of an appeal, the Heritage Health plan or Dental Benefits Manager must:

(i) Transfer the appeal to the standard timeframe of no longer than thirty (30) days from the day the Heritage Health plan or Dental Benefits Manager receives the appeal; and

(ii) Make reasonable effort to give the member prompt oral notice of the denial and a written notice within two (2) calendar days.

004.05(E) NOTIFICATION OF APPEAL RESOLUTION. The Heritage Health plan or Dental Benefits Manager must provide written notice of the appeal resolution. In addition to written notice, reasonable effort must be made to provide oral notice of resolution.

005. CULTURAL SENSITIVITY AND DIVERSITY . The Department is a culturally diverse environment that exercises zero tolerance of any acts of discrimination, racism, or prejudice. Understanding, valuing, and promoting cultural sensitivity and diversity is part of the ongoing philosophy of the Department and any of its programs. Heritage Health and the Dental Benefits Manager is required to promote this philosophy with the member, providers, and within the workplace.

005.01 USE OF MEMBER INFORMATION. The Heritage Health plan and Dental Benefits Manager will receive information on the member’s race, ethnicity, and primary language from the eligibility file transmitted to the plans by the Department or the enrollment broker. The Heritage Health plans and Dental Benefits Manager is expected to use this information to promote the delivery of services in a culturally competent manner to all members, including those with limited English proficiency and diverse cultural and ethnic backgrounds.

History

Effective 2020-01-27

Neb. Admin. Code tit. 482 — Nebraska Medicaid Managed Care

Chapter 1 Introduction and Definitions

Neb. Admin. Code tit. 482, ch. 1 Introduction and Definitions {#sec-482-nac-1 omnilex-key=us-ne-regs-official--title-482--482 NAC 1}

Chapter 2 Member Participation and Enrollment

Neb. Admin. Code tit. 482, ch. 2 Member Participation and Enrollment {#sec-482-nac-2 omnilex-key=us-ne-regs-official--title-482--482 NAC 2}

Chapter 3 Enrollment Broker

Neb. Admin. Code tit. 482, ch. 3 Enrollment Broker {#sec-482-nac-3 omnilex-key=us-ne-regs-official--title-482--482 NAC 3}

Chapter 4 The Heritage Health Managed Care Core Benefits Package

Neb. Admin. Code tit. 482, ch. 4 The Heritage Health Managed Care Core Benefits Package {#sec-482-nac-4 omnilex-key=us-ne-regs-official--title-482--482 NAC 4}

Chapter 5 The Dental Benefits Package

Neb. Admin. Code tit. 482, ch. 5 The Dental Benefits Package {#sec-482-nac-5 omnilex-key=us-ne-regs-official--title-482--482 NAC 5}

Chapter 6 Quality

Neb. Admin. Code tit. 482, ch. 6 Quality {#sec-482-nac-6 omnilex-key=us-ne-regs-official--title-482--482 NAC 6}

Chapter 7 Rights and Responsibilities

Neb. Admin. Code tit. 482, ch. 7 Rights and Responsibilities {#sec-482-nac-7 omnilex-key=us-ne-regs-official--title-482--482 NAC 7}

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