198.530. Managed care services provided in long-term care facilities, when, conditions--reimbursement rate--services included.
Managed care services provided in long-term care facilities, when,conditions--reimbursement rate--services included.
198.530. 1. If an enrollee in a managed care organization is also aresident in a long-term care facility licensed pursuant to chapter 198, or acontinuing care retirement community, as defined in section 197.305, RSMo,such enrollee's managed care organization shall provide the enrollee with theoption of receiving the covered service in the long-term care facility whichserves as the enrollee's primary residence. For purposes of this section,"managed care organization" means any organization that offers any health plancertified by the department of health and senior services designed to provideincentives to medical care providers to manage the cost and use of careassociated with claims, including, but not limited to, a health maintenanceorganization and preferred provider organization. The resident enrollee'smanaged care organization shall reimburse the resident facility for thoseservices which would otherwise be covered by the managed care organization ifthe following conditions apply:
(1) The facility is willing and able to provide the services to theresident; and
(2) The facility and those health care professionals delivering servicesto residents pursuant to this section meet the licensing and trainingstandards as prescribed by law; and
(3) The facility is certified through Medicare; and
(4) The facility and those health care professionals delivering servicesto residents pursuant to this section agree to abide by the terms andconditions of the health carrier's contracts with similar providers, abide bypatient protection standards and requirements imposed by state or federal lawfor plan enrollees and meet the quality standards established by the healthcarrier for similar providers.
2. The managed care organization shall reimburse the resident facilityat a rate of reimbursement not less than the Medicare allowable rate pursuantto Medicare rules and regulations.
3. The services in subsection 1 of this section shall include, but arenot limited to, skilled nursing care, rehabilitative and other therapyservices, and postacute care, as needed. Nothing in this section shall limitthe managed care organization from utilizing contracted providers to deliverthe services in the enrollee's resident facility.
4. A resident facility shall not prohibit a health carrier'sparticipating providers from providing covered benefits to an enrollee in theresident facility. A resident facility or health care professional shall notimpose any charges on an enrollee for any service that is ancillary to, acomponent of, or in support of the services provided under this section whenthe services are provided by a health carrier's participating provider, orotherwise create a disincentive for the use of the health carrier'sparticipating providers. Any violation of the requirements of this subsectionby the resident facility shall be considered abuse or neglect of the residentenrollee.
(L. 1999 H.B. 316, et al. § 3)