Nursing Home: Complex Care
This is a draft cheat sheet. It is a work in progress and is not finished yet.
South Carolina Medicaid Complex Care is a program that targets Medicaid-eligible hospital patients who no longer require hospitalization, but meet the nursing facility level of care. The program is intended to provide financial incentives to enrolled nursing facilities who admit Medicaid beneficiaries with complex care needs
Be a Medicaid recipient.
All Complex care individuals must meet level of care criteria for long-term care.
Have 2 or more of the following requirements
Wound/Decubitus Ulcer Stage 4 or greater
Trach/cannula needing aseptic care and suctioning
Extended duration of parental (IV) fluids for 2 weeks or more
Disruptive behavior 60% of the time 24/7. May be r/t mental health illness, head/brain trauma, other neurological deficits
Medicaid only participant in need of goal directed (Physical/Occupation/Speech) therapies.
Total Care with all ADLs
Initial CCP approval is for 180 days or 6 months.
Recertification approval is for 90 days or 3 months.
CCP participants must be recertified by SNF prior to expiration of initial approval.
SNF completes 185s or CCP assessment forms with all pertinent information. Send to program area via fax or email. Please allow at least 5 days for response.
SNF must recertify every 90 days for the duration of participation time at CCP level of care.
If participant is in HMO, prior authorization is necessary before accepting CCP patient. This is a negotiated rate done between HMO and provider.
CCP can transfer. The certification time transfers as well. New SNF is responsible for maintaining recertification.
Reduce difficulty of placing Medicaid beneficiaries
Facilitate access to SNF services and to provide most appropriate level of care in the most appropriate settings
Provide cost savings
Provide financial incentives to SNF for admission of Medicaid beneficiaries with complex care needs