You May be Wondering…
Our LIFE Story
LIFE stands for Living Independence For the Elderly. LIFE programs in the State of Pennsylvania are a part of the Program of All-Inclusive Care for the Elderly (PACE). The idea of the LIFE model of care is to help individuals live independently, while focusing on helping them stay in their own homes and communities for as long as possible by providing them with all-inclusive care. This all-inclusive care is provided under one umbrella by LIFE, including primary care services & specialist services. To see what services LIFE may provide to you if you qualify, click here.
The LIFE program is centered on the belief that it is better for the well-being of individuals with chronic care needs and their families to be served in their homes and communities whenever possible. This type of all-inclusive care is delivered by a team of medical professionals with a preventive focus to help ensure that individuals can safely live in their own homes and be an active part of their communities. Individuals, who may otherwise be residing a skilled nursing facility, could be cared for in the comfort of their own homes with the support of the LIFE-NWPA team.
How is LIFE paid for?
You probably have a lot of questions about how LIFE services are paid for and what service delivery may look like for you, so we have some answers for you! What you pay for LIFE depends on your eligibility under Medicare and Medicaid. If you are eligible for Medicaid or dually eligible for both Medicare and Medicaid, you don’t pay a monthly premium for LIFE. If you don’t qualify for Medicaid, but you do have Medicare, you’ll be charged a monthly premium for LIFE.
Here’s the great news…..There are no deductibles or copayments for any drug, service, or care approved by your LIFE team! Also, if you don’t have Medicare or Medicaid, you can pay for LIFE privately. It is also very important to know that individuals enrolled in LIFE may be fully responsible and personally liable for the costs of unauthorized or out of LIFE program agreement services. A LIFE intake staff can help you figure all of this out! Don’t worry if you don’t qualify for Medicaid now or if you think you don’t qualify for Medicaid because we are here to help you figure all of that out! Let our friendly LIFE intake staff call you and answer your questions!
Who provides the services I may receive from LIFE?
All services that you may receive from LIFE are provided by the LIFE Primary Care Providers (Physician and Nurse Practitioner), the LIFE Interdisciplinary Team (IDT) and the LIFE-NWPA network of providers (including all medical specialties). This team becomes the sole provider of all care for participants enrolled in the LIFE program. An exception to this would be if you need emergency services. In an emergency, it is okay to go outside of the LIFE network of providers for emergent care.
The good news is that LIFE-NWPA has a large network of providers that spans all service areas of LIFE-NWPA! However, LIFE-NWPA is not able to guarantee access to a certain provider. If you have questions whether the doctors and specialists that you currently see are in the LIFE-NWPA network of providers, we would love to have you talk to our intake staff that can work through this with you to find out!
In addition to having our Intake staff walk you through every question and step of the process of looking into the option of LIFE for you, you may also appoint a representative to support you! According to Medicare guidelines, an “Appointed Representative” is a person who can act on your behalf to request and exception, appeal or grievance. A representative can be a friend, relative, or caregiver that you trust to help you make decisions and to help you figure things out with regards to your healthcare. Click here to find the form that will help you appoint this special person for you!
Learn more about…
In order to qualify for LIFE, an individual must be:
- 55 years of age or older;
- Certified by the Commonwealth of Pennsylvania as eligible for nursing home level of care;
- Residents of Erie, Crawford, Mercer, Warren, Clarion, Venango, Forest, Jefferson, Elk, Cameron, McKean, and Clearfield Counties in which LIFE-NWPA is operating with the approval of Centers for Medicare & Medicaid Services (CMS) and the Pennsylvania State Administering Agency (SAA);
- And, at the point of enrollment, can be, and is willing to be, safely cared for in a community setting with the support of LIFE-NWPA and its network of providers.
Prior to enrollment, a prospective participant will accept their care plan as presented by the LIFE-NWPA care team. This care plan will summarize the services that the individual will receive if they choose and are qualified for the LIFE program. The LIFE-NWPA Intake Staff is with individuals every step of the way as they explore the LIFE program as an option for themselves. The LIFE-NWPA intake staff will be sure to answer any and all questions prior to the individual accepting the LIFE program as their health care provider as the intake staff are readily available!
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Grievance / Appeals
LIFE-NWPA encourages open communication with all participants and their support systems. If, at any time, a participant is not satisfied with the care or services that they receive, LIFE encourages the communication of that concern to their LIFE team. LIFE-NWPA has a process that evaluates and resolves any grievances, whether medical or non-medical in nature, by its participants, their family members or representatives. LIFE-NWPA will assure that every grievance is handled efficiently while maintaining open communication with the griever with the goal of resolving the grievance to the satisfaction of the concerned participant. If the LIFE team is not able to resolve the grievance to the satisfaction of the participant, further assessment of the grievance will be conducted by the Executive Director or Medical Director and/or by the Plan Advisory Committee with the continued goal of resolution to the satisfaction of the participant.
An appeal is defined as the participant’s and/or representative’s action with respect to LIFE-NWPA non-coverage of, or non-payment for, a service including denials, reductions, or termination of services. A participant/family member/representative may file an appeal by communicating with any LIFE staff or by calling toll free 844-456-5433 (711 TTY). LIFE-NWPA’s request for an involuntary disenrollment may also be appealed. All requests for appeals will be treated in a confidential manner. Contracted providers will be held accountable to all Appeal Procedures established by LIFE-NWPA, as outlined in the Contracted Provider’s Manual.
The appeals process will be reviewed with participants/ family members/ representatives upon enrollment, in writing to the participants and/or responsible parties annually, and whenever the Interdisciplinary Team denies a request for service or payment. Upon Enrollment, at least annually thereafter, and whenever the Interdisciplinary Team denies a request for services or payment, LIFE-NWPA will provide the participant oral and written information on the appeals process. Beneficiary notification will include the availability of assistance with completing an appeal.
LIFE-NWPA will observe timely preparation and notice of a written denial of coverage or payment. Notice must include specific reasons for denial or non-payment, instruct Participant how to file an appeal if they do not agree with the action, and advise them of their right to request an expedited appeal process if they believe their life, health or ability to regain or maintain maximum function would be seriously jeopardized absent provision of the service in dispute.
If, during non-center operation hours, the participant/family member/representative wishes to file an appeal, the administrator on-call will be responsible for receiving and then communicating the appeal to the Center Manager the next business day. The Medicaid participant may request a State Fair Hearing after all attempts have been exhausted to resolve issues through the LIFE-NWPA program.
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The LIFE program is voluntary for the individuals that choose to enroll in LIFE-NWPA. Because of this, a participant may voluntarily dis-enroll from LIFE by communicating this to the LIFE-NWPA team in writing with as much advance notice as possible. Even if shorter notice is provided, all efforts will be made to dis-enroll as soon as possible. Until a participant is dis-enrolled from LIFE, all services provided for the participant must continue to be authorized by LIFE-NWPA as LIFE remains liable for payment. The LIFE team will coordinate all care planning activities to primary care and other community resources that the participant may be discharging to.
If you live in a qualifying service area, LIFE-NWPA creates a unique community and support system for you or your loved one that allows staying in your own home and community for as long as possible.