Medicaid Nursing Facilities

Nebraska Medicaid covers ICF/DD for individuals with intellectual disabilities or a related condition.

ICF/DD services are designed to serve individuals who cannot be served in the community through developmental disability (DD) services and to assist individuals in achieving their independence potential.

Services provided in an ICF/DD include formal training to increase one's skills in areas such as daily living skills, personal care skills, behavioral and social skills, and pre-vocational/vocational skills.  Individuals may also receive nursing and medical care per their assessed needs.

Placement in an ICF/DD is never considered permanent as individual needs and alternatives can change over time; other services may be more appropriate.

Eligibility information for ICF/DDs:

The following criteria must be met to be eligible for ICF/DD services:

• Prior authorization
• Physician's certification for the need of ICF/DD level of care
• Individual must also meet ICF/DD level of care criteria

Can residents disenroll from Heritage Health and remain in only fee for service?

No, the physical, behavioral and pharmacy services will all continue to be administered through Heritage Health while the long-term care services will remain in the fee-for-service system.

How active are the health plans in managing care for residents who are dual eligible for Medicare and Medicaid?

With dual-eligible members, Medicare is the primary payer. The plans offer case management services if a referral is made for the member, but they do not have much involvement in managing the utilization as the secondary payer.

Is a managed care plan obligated to pay the Medicare co-insurance amount to a provider who is not in their network?

The Heritage Health plans are required to pay cross-over claims regardless of network participation of the provider. All of the health plans have signed agreements with Medicare to receive cross-over claims directly from Medicare.

When a Medicaid-covered nursing facility resident switches to hospice services, will those services be covered by the Heritage Health plan?

No. The hospice payment for both the service and the room and board for nursing facility residents is carved out of managed care and reimbursed as fee-for-service.