Welcome to the Montana Medicaid Provider Training Spring 2007

1. Welcome to the Montana MedicaidProvider TrainingSpring 2007

2. Today’s Schedule Introduction Eligibility Determination and Verification PASSPORT/Team Care Web Portal Walk Thru Claim Denials TPL/Medicare and COBA

3. Introductionand Housekeeping

4. Medicaid Eligibility A Brief Overview

5. Application Process • Applicant or representative submits a completed and signed application to Office of Public Assistance • An interview is scheduled to assist the applicant through the process –but is not required • The applicant provides information necessary to determine eligibility • Eligibility determination is within 45 days or less

6. Eligibility Determination • Applicant must meet an eligible coverage group • ABD–Related programs • Aged (65 or older) • Blind • Disabled (using Social Security Criteria) • Family-Related programs • Minor child (under 19) • Pregnant woman • Parent/caretaker relative with minor child in home • Women diagnosed with breast and/or cervical cancer or precancer

7. Eligibility Requirements • U.S. Citizen or Qualified Alien • Identity • Social Security Number • Montana Resident • Cooperate with Third Party Liability and Program Compliance • Resources within limits • Income within program limits • Other requirements vary by group

8. Citizenship/Identity • The Deficit Reduction Act of 2005 (DRA) requires evidence of Citizenship and Identity prior to receipt of Medicaid benefits • Primary documentation that provides verification of both is a U.S. Passport • Other documentations vary by group

9. Qualified Alien • Many categories of Qualified Aliens • Most are subject to 5 year ban if not in the U.S. prior to August 22, 1996 • Most required to have 40 quarters of work if not in the U.S. prior to August 22, 1996 • Some eligible for only 7 years from date of entry into the U.S.

10. Residency • Montana has no durational requirement • Residency is intent to make ones home in Montana, and not be here for a temporary purpose or • Living in Montana, not receiving benefits in another state

11. Third Party Liability • Cooperation with Third Party Liability encompasses • Providing health insurance information • Providing information on other legally liable third party for Medicaid payable services • Responding to questionnaires regarding injuries

12. Resource Eligibility • Resources are evaluated for each member of the household • Resource limits are based on the category of coverage

13. Resource Limits • ABD-Related: • $2000 single • $3000 couple • Family-Related: • $3000 • Two Children’s Programs: • $15,000

14. Resource Eligibility Factors • Resources are evaluated to determine countable and excluded assets • Excluded resource examples: • Home and surrounding property if it is the principal place of residence • One vehicle per household-depending on the program

15. Income Eligibility • Varies by group • Adults covered with children are at approximately 35% FPL • 100% or 133% FPL to cover children • 200% FPL for breast and/or cervical cancer/precancer • Aged, blind and disabled – related to SSI standards (currently $623 – 1/$934 – 2)

16. FPL (Federal Poverty Level) • Federal Poverty Level @ 100% Family Size Monthly Standard 1 $851 2 $1141 • If income exceeds standards, Medically Needy Medicaid may exist, but will not cover adults who are not aged/blind/disabled or pregnant

17. Income – Medically Needy • Countable income is over the Medically Needy Limit • Household pays for their medical expenses that comprise the difference between their income and the limit—called an incurment • Is called the “spend down” • Met by obligated medical expenses • Paying cash payment to Medicaid-called Cash Option • Or, combination of medical expense obligation and cash

18. Medicaid –Other Programs • Nursing Home residents • Home and Community Based Services • Medicare Beneficiary Programs

19. Spouses of nursing home residents can retain more assets & an income allowance Medical need exists Resident’s income and other benefits are less than cost of care Asset/Resource transfers prior to or after Medicaid application may result in penalties Nursing Home Coverage

20. Home & Community Based Services • Referred to as waiver services • May cover assisted living • More items/services Medicaid payable for waiver patients • Asset/resource transfers can result in ineligibility • Spouses can retain more assets • Spouses could receive income maintenance allowance

21. QMB, SLMB, QI-1 Qualified Medicare Beneficiary Special Low-Income Medicare Beneficiary Qualifying Individual-1 Asset limits twice those of regular Medicaid Income levels based on percentages of poverty up to 135% FPL Easy to complete four-page application Medicare Savings Programs

22. QMB pays for: • Medicare premiums • Co-insurance • Deductibles • Not restricted to Medicaid-approved services • No retroactive coverage

23. SLMB and QI-1 pay for: • Medicare premiums only • Retroactive coverage could be determined • QI-1 applicants must not be eligible for other Medicaid –such as Medically Needy

24. Medicaid Coverage • Medicaid is processed for month of application and future months • Medicaid coverage may be provided retroactively based on the coverage request date and group • Retroactive Coverage request at application • Could include the 3 months prior to application date • Retroactive coverage request after Medicaid has been opened • Could include the 3 months prior to the date of request

25. Medicare D and Prescription Drug Plans Medicaid only covers limited group of drugs for Medicare eligible's Two Children’s programs resource limit-- $15,000 Citizenship & Identity requirements Medicaid Application form-specific to Medicaid programs ABD Medicaid Specific Nursing Home and Waiver residents asset transfer look back is 60 months if transfer occurred after 2/8/06 Some assets more restrictive Annuities Home Equity Recent Changes

27. Verifying Eligibility

28. Montana Access to Health Hard Card Jane R. Client Member No: 1234567 DOB: 08/29/1963

29. Montana Access to Health Hard Card

30. Automated Voice Response (AVR) Faxback Medifax Montana Access to Health Provider Relations Methods of Verifying Eligibility

31. Automated Voice Response (AVR) Facts • 1-800-714-0060 • Verbal verification • Available 24/7 • Access one client at a time • multiple clients within phone call • Free to providers

32. AVR Eligibility • Information that can be found with AVR • Client Eligibility • Third Party Liability(TPL) • Managed Care and other restrictions • Amount of last check sent to provider

33. FAXBACK Facts • 1-800-714-0075 • Response within minutes • Paper verification • Available 24/7

34. Medifax Service • Swipe technology – magnetic stripe reader to verify eligibility • Available 24/7 • Paper documentation of eligibility and associated information • Batch capability useful for providers with large Medicaid caseloads • Charges associated with use include transaction fees and monthly fees

35. Medifax Service Facts • Information that can be found with Medifax • Client Eligibility • Third Party Liability (TPL) • Managed Care and other restrictions • Client Demographics

36. www.mtmedicaid.org Created by ACS in conjunction with DPHHS Medicaid related information Montana Access to Health (MATH)

37. Montana Access to Health (MATH) • Active providers • Appropriate forms available from the website: www.mtmedicaid.org • Secure website

38. Montana Access to Health Facts • Information that can be found with MATH • Client Eligibility • Third Party Liability(TPL) • Managed Care and other restrictions • Client Demographics

39. Provider Relations • Contacting Provider Relations • 1-800-624-3958 or 406-442-1837 • Hours 8 a.m. until 5 p.m. Mountain Time • Monday thru Friday

40. Provider Relations Facts • Information available from Provider Relations • Client Eligibility • Prior Authorization Status • Claim Status • Amount of last check sent • Enrollment status • Service limits

41. MHSP Eligibility Verification • Eligibility verified by: • AVR • Faxback • Medifax • Montana Access to Health • Provider Relations • Call Provider Relations to determine how many sessions have been billed

42. Presumptive Eligibility for Pregnant Women • Eligible from date of presumptive • Presumptive eligibility may be for only a partial month and does not cover inpatient hospital services • include all other applicable Medicaid services listed on the Covered Services table in Appendix A.

43. Important Eligibility Tips For all Medicaid Clients • Client Control Number on hard card • Client Medicaid ID number confidential • Verify prior to each visit

44. If a client does not have eligibility: Private pay arrangements prior to service If client believes they have eligibility for the date of service: Contact local Office of Public Assistance prior to service Important Eligibility Tips For all Medicaid Clients

45. Important Eligibility Tips For all Medicaid Clients • If you believe a client may meet Medicaid qualifications: • Have client contact local Office of Public Assistance • If a client is retroactively eligible: • Claims past timely filing must include a FA-455 • Provider’s choice to accept

46. Questions

48. Passport to Health What is it? • Mission Statement: Manage the delivery of health care to Montana Medicaid clients in order to improve or maintain access and quality while minimizing health care resources • Managed Care - Primary Care Case Management model • Clients choose a primary care provider (PCP) • Many services require PCP authorization • 70% of Montana Medicaid clients are on Passport • Operational in 54 counties (not in McCone or Sanders)

49. Establishing a Medical Home • The Passport to Health program aims to assist providers in establishing a "medical home" for their clients • A medical home is established when one provider serves as the central coordinator of care for the client's medical and emotional service and support needs

50. Tools for the Passport Provider • Monthly client lists • Referral Form • Passport to Health (1-800-362-8312) • Passport Provider handbook • General and specific provider manuals • Montana Medicaid Webpage (www.mtmedicaid.org) • ACS Provider Relations (1-800-624-3958)