1 / 46

How do I fix this case?? Long-Term Managed Care Enrollment in iC and CARES

How do I fix this case?? Long-Term Managed Care Enrollment in iC and CARES. WSSA Conference 5/28/2009 Heidi Herziger & Linda Auchue. Topics Covered. iC Supplement for Partner Portal eligibility verification**

catriona
Download Presentation

How do I fix this case?? Long-Term Managed Care Enrollment in iC and CARES

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. How do I fix this case??Long-Term Managed Care Enrollment in iC and CARES WSSA Conference 5/28/2009 Heidi Herziger & Linda Auchue

  2. Topics Covered • iC Supplement for Partner Portal eligibility verification** • How quickly does managed care enrollment and disenrollment entered in CARES update in iC? • CARES processing basics • When does a paper form need to be faxed to the State? • How to remove enrollment using CARES • What to do in CARES when a member is switching to another managed care program or IRIS? • Waiver Cost Share and NH Liability Update Examples and Issues • For a new member • For a member moving from a NH to waivers and vice versa • Reference documents – managed care systems, reports and cycle schedules for iC NOTES: **This supplemental documentation can be used in conjunction with the Resource Center PowerPoint presentation that was provided for the Centralized Enrollment Conference Calls

  3. iC Partner Portal Eligibility Verification via the iC Functionality • County staff and Resource Center staff that do not have access to the Partner portal need to request access using the link in the Quick Links box in the bottom right of the Partner Portal public page. • Once a user has received an email with a temporary password, the user can log in and will see a new menu item called “iC Functionality” at the top of the Partner Portal secure landing page. • Clicking on the “iC Functionality” tab will bring up the following page:

  4. Partner Portal Eligibility Verification Using iC Functionality Tab • Member Search • Once the role has been assigned to the user, the user can log in and will see a new menu item called “iC Functionality” at the top of their screen. • Clicking on the “iC Functionality” menu will bring up the following options:

  5. iC Functionality Member Search Clicking on “Member Search” will bring up the screen below. As you can see, this screen allows greater range of options for searching on member information – including a name search and a “sounds-like” search. Partners are encouraged to narrow their searches by as many fields as possible since search requests that produce too many results will return an error.

  6. Member Search cont. • The screen below shows an example of the results returned when searching on the last name of “TESTUSER”. As you can see at the bottom, there were at least 3 pages of results returned for this search request. Partners must select the row (by clicking on it) to bring up member information for the member they are looking for.

  7. iC Member Information

  8. Member Information cont. The Member Information screen includes the demographic information for the member, in the first two columns, as well as high level eligibility, enrollment, Medicare, TPL, and Patient Liability information. The following fields, all on the right hand side of the screen, should be noted for the LTC MCOs: • Active – this indicates whether the Member ID that was entered is the active ID for this member. When a Member ID is linked to another Member ID, usually due to permanent demographic changes that assign a new MCI ID for the member, the old Member ID will display as Inactive. • Linked ID – if the Member ID entered was inactivated, and linked to a new Member ID, then the new Member ID will display in this field (and the Active field will be “Inactive”). • Benefit Plan – this is the high level member Medicaid, SSI MA, SSI payment or limited benefit plan eligibility information. This is the same Benefit Plan information provided via the Enrollment Tab. • Managed Care – this is the Managed Care program enrollment information for a member. Valid values are: FAMCR (Family Care), PACPB (PACE and Partnership), HMOM_ (HMO enrollment), SSIM_ (SSI HMO enrollment), WAMMM (Wraparound Milwaukee) and CCFMM (Children Come First). • MC Special Cond – this is either the level of care for members enrolled in LTC MCOs or an exemption from HMO or SSI HMO enrollment. Exemptions are E01-E99 and they do not prevent LTC MCO enrollment. Family Care levels of care are: L04 – Non Nursing Home and L06 – Nursing Home PACE and Partnership levels of care are: ICF/IC1, SNF/SN1 and ISN/IS1 • Patient Liability – this field includes a member’s Liability and/or Waiver Cost Share amounts. The “Waiv Cost Share” is the Family Care cost share amount(s) for members with Waiver MA and/or Nursing Home MA and this is the amount used for the Family Care capitation payment offset. For nonFamily Care members, the “Waiv Cost Share” is the waiver cost share amount from CARES and the MCD Cost Share is the member NH Liability from CARES.

  9. iC Member Maintenance Menu

  10. Member Maintenance cont The “Member Maintenance” Menu is shown at the bottom of the Member Information screen. This allows the user access to more specific information for the member. By clicking the categories on the left (Member, Managed Care, Medicare, etc…) the user will be given sub-menu options to choose from. In the above example, the category “Member” is selected, which reveals submenu items of “Benefit Plan”, “Member ID Cards”, and “Member Review”. County IM will have access to the following “Member Maintenance” Categories: • Member • SSI – not reviewed today • Case Search • TPL – not reviewed today • Managed Care • Provider – not reviewed today • Medicare – not reviewed today • Claims Search – not reviewed today

  11. iC Member Benefit Plan Information

  12. Member Benefit Plan Information cont. • The sub-menu “Benefit Plan” will allow the user to view more detailed member eligibility information. All of the benefit plans that a member is or was eligible for will display. The user can select any of the rows of Benefit Plan information to view more detailed information for that specific Benefit Plan. • Members can have multiple Benefit Plans for the same timeframe. Each Benefit Plan will have at least one medical status code. While members can have multiple overlapping Benefit Plans, the medical status codes within each Benefit Plan will not overlap. • In the example on the last page, the member’s Medicaid Waiver (MCDW) Benefit Plan was selected and now the user can determine that the member’s Medical Status code associated with the MCDW Benefit Plan was W5 from 4/1/09 – 4/30/10. **Note: The Family Care Non-MA Benefit Plan does NOT mean that the member is a Family Care Non-MA member from 4/1/09 - 4/30/10. The Family Care Non-MA is not used for capitation payment purposes or claims editing purposes, it is just stored because of the Family Care information sent from CARES.

  13. iC Member Managed Care Information

  14. iC Managed Care Information • To get to Member Managed Care information, click on “Managed Care” in the Member Maintenance box and then select “Member MCO Enrollment History.” The member’s managed care enrollment history will display. • The member MCO Enrollment History will show you all MCO Enrollment segments, both active and inactive for the member, as well as the Effective and End Date for each enrollment segment and the MCO name and MCO ID, which is not available on the Member Information screen. • If you select one row of enrollment history, the details for that row will display, including the update source for the enrollment. If the source is “Automated RT 35 process,” the update was made directly from the CARES system. If the source is “Health Care Authority,” then the information was updated manually by State or EDS staff. • Enrollment segments with a status of “Inactive” on the right hand side of the screen are not valid and will not generate a capitation payment, nor will it be used for Medicaid claims editing purposes. Also, MC Enrollment segments that are inactivated after a capitation payment was issued will cause the capitation payments to be recouped. The 11/1/08 – 12/31/2299 enrollment segment on the last slide was “Inactive.” • Enrollment segments are inactivated if a member decides not to enroll in a MCO. They are also inactivated if the member’s enrollment date is changed from an earlier date to a later date because once the MCO enrollment segment is saved in iC, the enrollment begin date cannot be changed.

  15. Where is Member Cost Share and Spenddown Information?Detailed Member cost share and spenddown information is not available at this time using the iC functionality tab. County staff can however use the Enrollment Tab (below) to verify this information.

  16. Member Spenddown Information • Once at the Enrollment Verification tab enter the member ID and click “search” • Note that you will get a tracking number

  17. Member Spenddown Information

  18. Member Spenddown information • Towards the bottom of the eligibility results page is the Spenddown information. • Members that are eligible for Group C Waivers have their Waiver Spenddown amount and the effective and end date in this section of the eligibility results page. • The member Cost Share amounts, in the NH Liability field will match the Cost Share amounts that can be viewed using the iC Functionality but the eligibility results using this function will include the distinction between the member “Waiver Cost Share” and the “MCD Cost Share.”

  19. Member Cost Share/NH Liability Just below the Spenddown Information is the Cost Share information in the Nursing Home Liability section of the eligibility results page. • There are 2 types of cost share amounts identified in this field: • Medicaid Cost Share • NH liability cost share amount for a member not enrolled in Family Care. • Waiver Cost Share • For waiver members not enrolled in Family Care, this is only the waiver cost share amount from CARES. • For members enrolled in Family Care, this is the member cost share amount that includes waiver cost share amounts and NH liability amounts. The Waiver Cost Share amount is used for the Family Care capitation payment offset.

  20. iC Enrollment Update Timeline

  21. CARES Processing Basics • CARES sends up to 1 enrollment transaction a day. If there are multiple confirmations with managed care information the last information confirmed is what is sent to iC. • The enrollment information that is sent from CARES is the current enrollment information on the Family Care or Waiver page. • Historical enrollment or level of care change information is never sent to iC. • Running with dates does not fix managed care enrollment, because only the most current enrollment information is sent and it is only sent 1 time per day. • Running with dates should be done to fix/correct member cost share information, as discussed later. • If a member was enrolled in the wrong MCO and ESS leaves the enrollment date as is and simply changes the 5 digit SMCP on the Managed Care page in CARES, the enrollment information will error off when it gets to iC and it will not update. • Enrollment information from CARES that overlaps with existing member enrollment and contains enrollment information for a MCO that the member is not currently enrolled in iC will error off. Members have to be disenrolled from one MCO before s/he can be enrolled in another MCO. • A manual 3070 or the Partner portal certification process will not fix managed care enrollment.

  22. When does a paper form need to be faxed to the State? • When a member’s enrollment date was entered and confirmed and sent to iC and was earlier than the correct date of enrollment and the ESS cannot enter a disenrollment date that is 1 day less than the date of enrollment. • Example: 4/25/09 confirmed in CARES on Tuesday, then on Wednesday the ESS learns that the correct date is 5/1/09 but a Long Term Care Functional screen has updated with an effective date greater than 4/25/09. • If the 4/25/09 was confirmed on Tuesday and later in the day the ESS is told that the correct date is 5/1/09, the ESS can correct the date in CARES, run and confirm and a paper form is not needed. • When CARES edits prevent the correct enrollment or disenrollment date from being entered into the CARES system on the Family Care or Community Waivers page. • When a member’s disenrollment date was entered and confirmed in CARES and it is not the correct date. WHY? CARES send iC 1 managed care enrollment transaction a day which includes an enrollment date a disenrollment date and a level of care. So if Family Care is confirmed multiple times in 1 day as a Pass, only the last information confirmed is sent to iC.

  23. How to remove managed care enrollment using CARES? • ESS need to remove managed care enrollment when: • The member changed his/her mind and chooses not to enroll in managed care Or • The enrollment date that was confirmed on a different date is not correct and it is earlier than the correct or new enrollment date. • In these situations ESS can and should remove the managed care enrollment segment in iC by entering a disenrollment date in CARES that is 1 day less than the enrollment date on the Family Care or Waiver page and running and confirming eligibility. • If the enrollment date needs to be corrected, ESS can enter the correct enrollment date in CARES on a different date** and then run and confirm Family Care eligibility. ** Remember that only 1 enrollment transaction is sent from CARES to iC each day, so if the disenrollment date and new, corrected enrollment date are both confirmed on the same date, iC will not get the disenrollment information from CARES.

  24. How to remove enrollment in CARES?

  25. How to switch a member from one Long-Term Care MCO to another MCO? Day 1 • Enter the disenrollment date on the Family Care or Waiver page. • Run and confirm eligibility Day 2 – enrollment into another managed care program • Create new Family Care and/or Waiver pages as needed. • Enter the new enrollment date (it should not be equal to or less than the member’s disenrollment date) for managed care. • Enter the new level of care • Enter the new SMCP Organization Choice • Run and confirm eligibility with dates if necessary to ensure that the correct cost share information is sent from CARES and updates in iC. Day 2 – enrollment into the IRIS program • Enter the new IRIS waiver program type • Enter the new IRIS waiver start date • Remove the SMCP and member level of care information • Run and confirm eligibility with dates if necessary to establish the correct waiver med stat for the IRIS program.

  26. Day 1 Disenrollment date entered and confirmed in CARES

  27. Day 2 New enrollment information entered and confirmed

  28. Cost Share Updates from CARES PACE and Partnership • PACE and Partnership are very straightforward, CARES sends either the Waiver cost share amount or a NH Liability amount depending on the member’s living arrangement. • A Waiver Cost Share amount updates as a Waiver Cost Share amount in the NH Liability field. • A NH Liability amount updates as a Medicaid Cost Share amount in the NH Liability field. • There is no MCO capitation payment offset for PACE and Partnership members. Family Care • Both the Waiver Cost Share and the NH Liability amounts from CARES are updated in iC as a Waiver Cost Share. • The capitation payment and adjustment cycles use the Waiver Cost Share amount in iC to offset the member’s capitation payment. • When enrolling a member into Family Care it is necessary to run eligibility (with dates if necessary) for both Medicaid and Family Care for all of the initial months of enrollment to ensure that the Family Care member’s cost share amount is accurate for initial and ongoing months of enrollment. • If this is not done with dates for initial months the cost share for those months will not be sent to iC. An example of how it looks when dates are not run follows on the next several slides.

  29. Cost Share – CARES information Enrollment date is 2/2/09

  30. Cost Share – CARES cont. Medicaid/NH MA budget for 01/01/09 - 02/28/09 is $1819.13

  31. Cost Share – CARES cont. Family Care Budget in CARES The earliest Family Care budget is effective 3/1/09 (there was another 03/09 budget that was no longer valid for this member).

  32. Cost Share - CARES cont. Family Care – CARES confirmation dates Family Care eligibility was never confirmed for 02/09, so the 02/09 Family Care Cost Share amount was never sent to iC.

  33. Cost Share - iC Below is the iC Cost Share information for this member, note that there is no Waiver Cost Share, which is used for the Family Care capitation offset, for 02/09.

  34. Cost Share contChanging Waivers to NH and Vice Versa • When a waiver eligible member moves to a NH there can still be a waiver cost share amount for the month of the move to a NH. • When a NH eligible member becomes eligible for Waiver MA, CARES will automatically zero out the NH liability amount for the month of the move and any subsequent months that were open for NH MA. This does not display in the NH MA budget in CARES but is sent to the iC system via the interface. • CARES does not zero out the Family Care cost share amount for the same timeframe. So, this can create a residual NH liability cost share amount for Family Care that is not correct. • ESS can run eligibility with dates to ensure that the correct Family Care cost share information is calculated in CARES and sent to iC.

  35. Cost Share – Systems issues Systems issues specific to Family Care members: • A systems issue caused by the incorrect interface and update of member eligibility information. The issue occurs because a one MA type is closing and another MA type is opening while Family Care remains open. Running eligibility with dates will resolve this issue that is specific to members transitioning between Waiver MA and NH MA and vice versa. • A related system issue specific to members moving mid month from NH to Waiver MA with Family Care enrollment. In these situations, $0 is not sent to iC for the Family Care Waiver Cost Share amount while $0 is sent to iC for the NH Liability amount for the member. Running with dates for Waiver MA and Family Care for the month of the move out of the NH and subsequent months should correct the Family Care cost share in CARES and interChange. ****The exception to the solution to #2 is the 1st month of Waiver eligibility when the waiver begin date is not the 1st of the month. For the first month, the old Waiver Cost Share amount (the NH liability that was not zeroed out) will remain from the 1st of the month through the day before the Waiver MA Program Start Date. The waiver cost share amount will update with an effective date equal to the Waiver Program Start Date in CARES. A manual 3070 needs to be sent to EDS to change the Waiver Cost Share amount to the correct amount for that month. See slide 37.

  36. Cost Share – Systems issues This is an example of what iC looks like when a Family Care member moves from a NH to Waiver MA and the Waiver MA starts mid month, leaving a residual NH Liability Waiver Cost Share amount. Below is the NH page with the 1/13/09 NH discharge date.

  37. Cost Share – NH to Waiver MA Below is the first waiver page created for the member after the NH discharge date of 1/13/09 was entered and confirmed in CARES.

  38. Cost Share – NH to Waiver MA NH Closure in CARES – this closure also sends a $0 NH Liability (Medicaid Cost Share in interChange) to iC for 1/1/09 – 3/31/09.

  39. iC Cost Share information Medicaid Cost Share = $0 which is the $0 NH Liability from CARES based on the NH discharge date of 1/31/09 and the NH AG closure date of 3/31/09

  40. Cost Share - Waiver MA open On 4/22/09 the ESS ran with dates for 03/09. The confirmation of this AG sent iC a Waiver cost share information for 3/6/09-3/31/09.

  41. CARES cost share – waiver Family Care and Waiver budget in CARES for 3/6 – 3/31/09 match because ESS ran with dates for 03/09.

  42. iC Waiver Cost Share information • Note that there is still a residual Waiver Cost Share amount for 3/1-3/5/09 of $1043.57 (the NH Liability) with the 3/6-3/31/09 Waiver Cost Share confirmed in CARES. This case would require a manual 3070 to EDS to remove this amount and make the Waiver Cost Share amount of $604.95 effective from 3/1-3/31/09.

  43. Long Term Managed Care and the CARES and iC Systems Questions?

  44. Long Term Managed Care Reports* interChange Reports • Enrollment – Paper and 834 HIPPA Transaction • The INITIAL CMO Enrollment Report is produced 12-13 days before the upcoming capitation month. This report containing a listing of all recipients and their enrollment status for the next month in iC. This report also includes recipients would are “pending” or do not have Medicaid eligibility on file for the next month and therefore will not be enrolled unless Medicaid is updated for that month before the Final. • The FINAL CMO Enrollment Report is produced on the last business day before the 1st of the enrollment month. This report includes the final status of either enrolled or disenrolled for members identified as “PENDING” on the initial enrollment report as well as any other changes that have occurred since the initial report was created. • Capitation Payments – Paper and 820 HIPPA Transaction • This report provides a detailed listing of the recipients for which managed care programs are receiving capitation payments. Regular capitation payments are created once a month while capitation adjustments are done created weekly. MCOs have the option of receiving both the Capitation Payment Listing paper report and HIPAA 820 transactions or just the 820 transactions. • Coordination of Benefits Report • A monthly report that provides managed care programs with 1 year of private insurance and Medicare (Part A, Part B, both and Medicare Part D) information for all of their enrolled recipients. CARES and interChange Report - Temporary • Cost Share Report • CARES - This is a monthly report that contains cost share information for Family Care, PACE and Partnership recipients. It contains 3 months (next month, current month, last month) of cost share information for each recipient. The report is sent from CARES staff to MEDS staff for distribution to the managed care programs. • interChange- This is still a monthly report with the same basic information for each member including 3 months of cost share information. There are currently issues with the interChange PACE and Partnership Cost Share report and until that issue is resolved the report will be generated out of both CARES and iC. * This is not a comprehensive listing of MCO reports. It is a subset of reports related to member eligibility and MCO enrollment.

  45. iC 2009 Enrollment and Capitation Payment Cycle Schedule • Capitation adjustment cycles run every Friday. • Note that the June capitation payments are being held until July as requested by fiscal. • Dates are subject to change based on holiday schedules.

More Related