Nursing Facilities and FIDA FAQ

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1. Are nursing facility services covered under FIDA?

A. Yes, skilled nursing facility services are covered under FIDA, as are traditional Medicaid custodial care services provided in a nursing facility. For a full list of FIDA services, see Appendix A contained within the Three-way Contract, which can be found at:

2. For FIDA Participants, is a three-day hospital stay required prior to a skilled nursing facility stay?

A. No, under FIDA, the three-day hospital stay is not required prior to any nursing facility stay. The FIDA Plan is required to assure that the hospitals and nursing facilities are not imposing a requirement for a three-day hospital stay prior to covering a skilled or other nursing facility stay.

3. Can Participants stay in their current nursing facility for the duration of the FIDA Demonstration?

A. Yes. All FIDA Plans must have contracts with the nursing facility or payment arrangements, so that FIDA Participants who are already in a nursing facility can stay at that same facility for the duration of the FIDA Demonstration. In addition, the continuity of care provisions in Section of the FIDA Three-way Contract provide that the FIDA Plan must allow "Participants who reside in a Nursing Facility to maintain current Nursing Facility Provider for the duration of the Demonstration."

4. What is the role of the FIDA Care Manager and the nursing facility IDT?

A. The FIDA Plan IDT will authorize service plans for the Participants who are residing in a nursing facility. These services must be developed by the FIDA IDT but can be based on the service plan recommended from of the facility´s IDT process. The FIDA service planning process must be coordinated with the existing service planning processes within the nursing facility. The FIDA IDT and Person-Centered Services Plan (PCSP) processes do not supplant the facility´s pre-existing responsibilities around service planning and care management; however, the pre-existing responsibilities do not negate the requirement for the PCSP process to occur for all FIDA Participants. The FIDA Care Manager leads the FIDA IDT and is responsible for ensuring that the FIDA Participants to whom he/she is assigned receive all of the items and services that they require. The FIDA Care Manager shall work with the facility to ensure that this occurs.

5. Nursing facilities have a care coordinator that schedules respiratory therapists, specialty transportation to appointments and getting back to the nursing facility. How does that fit with the FIDA IDT?

A. The nursing facility and the FIDA IDT must work together. The plan of care (also known as the PCSP) will need to outline which activities the nursing facility´s care coordinator will undertake. Again, the FIDA Plan Care Manager is ultimately responsible for ensuring that all necessary items and services are received.

6. In FIDA, who does the nursing facility send the pharmacy bill to?

Most nursing facilities contract with a single LTC pharmacy. All plans offering Part D are required to provide "convenient access" to LTC pharmacies for beneficiaries residing in the facility. The Facility´s contracted pharmacy submits the claims for Part D drugs to the plan (or Pharmacy Benefit Manager if the plan has one).

7. If a FIDA Participant is a resident at a nursing facility and receiving short-term, skilled care, how are the medications paid for? Does the FIDA Plan pay the pharmacy through the Part D plan?

A. FIDA Plans cover Part D. No Participant enrolled in a FIDA Plan has a separate Part D Plan. Under FIDA, all medications that are covered by Part D would be paid for by the FIDA Plan since FIDA includes Part D coverage.

8. What are the requirements for the sharing of care plan information between the FIDA Plan and the Nursing Facility for an enrollee?

A. The FIDA IDT will develop the plan of care (i.e., PCSP) for a Participant. The care plan will go into the Comprehensive Medical Record for the Participant. Information about services provided in the nursing facility should be included in the Comprehensive Medical Record as well. The FIDA Plan is responsible for effective and efficient information sharing among a Participant´s providers. How information is shared is at the discretion of the plans.

9. In FIDA, who makes the determination on when the skilled nursing need ends?

A. The facility would make the recommendation to the IDT, and the IDT or FIDA Plan would determine when the skilled nursing would end.

10. In FIDA, who extends/continues the skilled nursing need?

A. The FIDA IDT makes a determination for long term placement based on the plan´s written medical necessity criteria, informed by the clinician´s recommendation, the assessment and person centered care plan. If the determination is outside the scope of practice of the individuals participating in the IDT meeting, the FIDA Plan´s UM Department may make the decision.

11. Since skilled nursing is covered under FIDA, is the rate for skilled nursing the same rate for custodial?

A. The skilled nursing rate is negotiated between the Plan and the facility.

12. In FIDA, who pays for the bed hold, the FIDA Plan? Who provides prior authorization?

A. Yes, the FIDA Plan pays for the bed hold per existing regulations. It is not the intent of the Department to require prior authorization for bed hold.

13. Does the FIDA IDT care manager document in a SNF´s chart? DOH performs surveys, so who would get the deficiency?

A. No, the FIDA Plan´s Care Manager would not enter information into the SNF´s chart. The facility is still required to perform its care management functions; however, should be coordinating with the FIDA Plan Care Manager.

14. What happens during a rehab stay in a SNF when the SNF wants the Participant to stay two weeks but the FIDA IDT/Plan says the Participant can only stay 2 days?

A. The FIDA Plan and facility would engage in the dispute resolution process. Additionally, the FIDA Participant would be provided with appeal rights.

15. What process are Plans supposed to follow when a FIDA member enters a nursing facility for long term care but does not qualify for institutional Medicaid? On the MLTC side, Plans are supposed to disenroll the member, but this is not specifically listed as a reason for involuntary disenrollment from FIDA.

A. Upon community-based enrollment into an MLTC product (including FIDA), Medicaid eligibility is established for coverage of community-based long term care services. The 60 month look back and institutional eligibility is not completed until someone is in a Nursing Home (NH), beyond a 29 day stay. Like MLTC, a FIDA Plan must disenroll a member who is in a NH and is not eligible for the appropriate Medicaid eligibility. The FIDA member could be ineligible for institutional Medicaid, but would still be eligible for community-based long term services and can return to the community and receive services covered by the FIDA Plan.

16. If a FIDA Participant is in a SNF and then needs hospice, would hospice be carved out of the FIDA capitation and reimbursed through FFS?

A. Yes.

For additional questions and answers regarding the transition of the Nursing Home Populations and Benefits to Managed Care, please visit the MRT #1458 website: