| (30) Resource Utilization Group (RUG)--A categorization
method, consisting of multiple categories based on the minimum data
set core elements in a resident assessment instrument, that is used
to determine a recipient's service and care requirements for a nursing
facility. A RUG determination is necessary for MDCP and the STAR+PLUS
HCBS Program eligibility because these programs require a nursing
facility level of care.
(31) Service coordination--A specialized care management
service that is performed or arranged by the MCO to identify needs,
including physical health, mental health services and long term support
services, facilitate development of a service plan or individualized
service plan to address those identified needs, and coordination of
services among the member's primary care provider, specialty providers,
and non-medical providers to ensure timely access to covered services,
non-capitated services, and community services.
(32) Service coordinator--The person with primary responsibility
for providing service coordination to Medicaid managed care members.
(33) Service management--A clinical service performed
by the STAR Health MCO for members with special health care needs
and other members in the STAR Health program when appropriate to facilitate
development of a healthcare service plan and coordination of clinical
services among a member's primary care provider and specialty providers
to ensure members have access to, and appropriately utilize, medically
necessary covered services.
(34) Service manager--The person with primary responsibility
for providing service management to STAR Health members.
(35) Service plan (SP)--An individualized and person-centered
plan in which a member, with assistance as needed, identifies and
documents his or her preferences, strengths, and needs in order to
develop short-term objectives and action steps to ensure personal
outcomes are achieved within the most integrated setting by using
identified supports and services. The service plan is supported by
the results of the member's program-specific assessment. In STAR+PLUS,
a service plan applies to members who are not enrolled in the STAR+PLUS
HCBS Program.
(36) STAR+PLUS Home and Community-Based Services (HCBS)
Program--The program that provides person-centered care services that
are delivered in the home or in a community setting, as authorized
through a federal waiver under §1115 of the Social Security Act,
to qualified Medicaid-eligible clients who are age 21 or older, as
cost-effective alternatives to institutional care in nursing facilities.
(37) Telecommunications--An exchange of information
by electronic and electrical means.
(38) Telephonic--Audio-only communication using a telephone.
Telephonic communication does not include audio-visual communication.
(39) Verbal consent--The spoken agreement of a member,
a member's legally authorized representative, or a member's medical
consenter.
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