Department of Medical Assistance Services – Eligibility and Enrollment Unit MMIS WebEx Training

1. Department of Medical Assistance Services Department of Medical Assistance Services – Eligibility and Enrollment Unit MMIS WebEx Training November 2012 http://dmasva.dmas.virginia.gov 1

2. Department of Medical Assistance Services Agenda • Patient Patient (PP) Adjustments • AC 058 Project Results • New DMAS Desk Tools • Transmittal # 97 http://dmasva.dmas.virginia.gov 2

3. PP ADJUSTMENTS • If a resident requires medical services not covered by Medicaid and the amount of the adjustment is greater than $500, the LDSS office must submit a DMAS-225 form with the necessary documentation attached. Such medical services must not be covered by Medicaid or be subject to third-party payment. • Neither DMAS nor DSS can authorize an adjustment when the member’s patient pay amount is zero.

4. Limitations • A PP adjustment request of this type is completed when no other payer source exists for the medical expense • Supplies, equipment, or services used in the direct care and treatment of residents are covered • Services received must be provided by the nursing home.

5. Adjustment Requests • PP adjustment requests are first submitted by the NF directly to the LDSS • When the item/service cost is less than $500 the LDSS makes the determination to adjust patient pay • Examples include: • Routine dental care, dentures, & denture repair for members over 21 years of age • Routine eye exams, eyeglasses, and repair • Hearing aids, and hearing batteries & repair • Batteries for power wheelchairs • Chiropractor services • Prescription drugs • Transportation costs

6. Adjustment Requests • All requests submitted for any adjustment must include: • The member’s Medicaid ID number • Physician’s order for non-covered services • The service description and cost • If equipment repair or battery replacement; documentation that that the equipment continues to be needed • EOB or denial of payment from any other insurance • All identifying information for any TPL

7. Adjustment Requests • If the request submitted to the LDSS does not include all required information: • The request should be returned to the facility • No authorization will be made until all documentation has been provided • A copy of the letter to the facility will be sent to the LDSS • Do not forward an incomplete request to DMAS.

8. Adjustment Requests to DMAS • Adjustments to PP which exceed $500.00 are submitted by the LDSS to DMAS for authorization • Requests must include: • Documentation of the current or most recent PP amount • Medicaid ID # • Service description • Minimum Data Sheet (MDS) for any devices • Physician’s order & medical justification for non-covered services • All identifying information for any TPL

9. Medical Justification • Medical justification must include: • The physician’s prescription • Diagnosis and medical findings • Identification of functional limitation • Documentation of required quantity, frequency, and projected length of use • Identification of how service will be used

10. Mobility Requests • Mobility requests must include: • Description of mobility and postural impairments • Description of cognitive ability • Description of how needs were previously met • Components must match functional limitations • Requested wheelchair components must be matched to the member’s functional limitations and must include an evaluation by a therapist

11. Communication Devices • Adjustments for communication device requests must include: • Medical documentation describing speech limitation, diagnosis, prognosis, and therapy • Description of how current needs are being met • Documentation of why the device was chosen as well as the member’s motivation & ability to use • Speech language pathologist evaluation • Documentation of planned device training

12. Hearing Aids • Adjustment requests for hearing aids must include: • Medical documentation • The audiologists evaluation and the interpretation

13. Eyeglasses • Adjustments for eyeglasses must include: • Medical documentation • An ophthalmologic or optometric evaluation • Identification of cataracts or any cataract surgery

14. Prescriptions • Adjustment requests for drugs and biologicals must include: • Medical documentation • The National Drug Code (NDC) • The condition being treated by the drug

15. Emergency Services • DMAS provides telephone pre-authorizations for emergency medical services by calling (804) 786-2622 • A written response will be sent to the requestor preauthorizing the adjustment • Normal procedures for the PP adjustment request must still be followed • Attach a copy of DMAS’ written response to the adjustment package

16. Patient Pay Adjustment Responses • All letters of response are sent on last business day of month to LDSS and facility. • If the request is an Emergency the LDSS should follow the Emergency Procedure. • Incomplete packets – denied after 30 days

17. AC 058 Project Purpose • The DMAS AC 058 project which was started in July was intended to assist with: • Finding incorrect open ended enrollments in AC 058 in the MMIS • Assisting local agencies with corrections and training issues. • More projects to come from DMAS…

18. AC 058 Project Results • LDSS responses for the AC 058 project were due to DMAS by 8/31/12. • Replies for 987 members received to date. • Of these replies 31% of the enrollments were correct and 69% of the enrollments were incorrect

19. AC 058 Project Findings • A majority of the incorrect enrollments were due to: • Not end dating spenddown periods • Not verifying applicant met non-financial requirement of applying for Title II benefits • Non-reporting by member at start of Title II benefits • Incorrect evaluation of bills used to meet spenddown

20. DMAS Desk Tool – Title II • A DMAS desk tool has been developed to assist workers with questions regarding the non-financial requirement for individuals to apply for Title II benefits. • The desk tool can be found on the Eligibility and Enrollment webpage (http://dmasva.dmas.virginia.gov/content_pgs/dss-elgb_enrl.aspx) under the “MMIS FAQ’s & Other Training Documents” section. The desk tool is titled “SSA Title II Disability Desk Tool”.

21. DMAS Desk Tool – Evaluating Bills • A DMAS desk tool has been developed to assist workers with questions regarding the application of bills to an individual’s spenddown. • The desk tool can be found on the Eligibility and Enrollment webpage (http://dmasva.dmas.virginia.gov/content_pgs/dss-elgb_enrl.aspx) under the “MMIS FAQ’s & Other Training Documents” section. The desk tool is titled “Bill Evaluation Desk Tool”.

22. Transmittal # 97 • Broadcast 7600 announced the release of Transmittal # 97 which was effective 9/1/12 • Revised Policy – Medicaid covered groups now fall under one of two categories – CN and MN • See Medicaid Manual subchapter M0320 for all ABD CN and MN covered groups • See Medicaid Manual subchapter M0330 for all F&C CN and MN covered groups

23. Transmittal # 97 • VA Residence for Foster Care Children • Foster care children who receive SSI meet the Virginia residency requirement regardless of whether another state’s child placing agency maintains custody. • CNNMP & MI Classifications • Have been absorbed into the Categorically Needy classification. Any references to CNNMP and MI that remain in the manual will be deleted in future transmittals.

24. Transmittal # 97 • Additional clarifications in Transmittal # 97 include: • Medicaid eligibility for individuals who refuse to cooperate with DCSE • Evaluation of government benefits on government sponsored debit cards • Verification of value of bank accounts • Determining value of countable annuity • Resource assessment and evaluation in M1480 • Time frame for acting on reported changes and renewals • Procedure for Recipient Audit Unit referrals

25. Medicaid Covered Groups

26. ABD Covered Groups

27. ABD – Sequential Evaluation • Determine an individual’s eligibility first in a CN covered group. If the individual is not eligible in a full-benefit CN covered group, determine the individual’s eligibility as MN (on a spenddown).

28. ABD Individual – Sequential Evaluation • Current SSI/AG recipient • Former SSI or AG recipient • ABD with income < 80% FPL • Medicaid Works (if disabled, income < 80% FPL, & going to work) • Meets definition of institutionalized individual, evaluate in the 300% of SSI covered groups • Medicare beneficiary, evaluate in the Medicare Savings Programs (MSP) groups (QMB, SLMB, QI, QDWI). • If the individual meets all the requirements, other than income, for coverage in a full benefit Medicaid group, evaluate as MN • If the individual is not eligible for Medicaid coverage in an MSP group AND he is at least age 19 years but under age 65 years or he requests a Plan First evaluation, evaluate in the Plan First covered group.

29. F&C Covered Group Hierarchy

30. F&C Covered Groups

31. F&C Sequential Evaluation • First, determine an individual’s eligibility first in a CN covered group. If the individual is not eligible as CN, go to the MN groups.

32. F&C Child Sequential Evaluation • FC child, AA child, special medical needs AA child or an individual under age 21 • Newborn child group • Under the age of 19; evaluate in the FAMIS Plus group (no resource test) • Child meets definition of institutionalized individual (including hospice); F&C 300% groups. • Child does NOT meet the definition of an institutionalized individual, evaluate for FAMIS eligibility (M21) • Child is a • Child under age 1, • Child under age 18, • Individual under age 21 or • Special medical needs adoption assistance child, but has income in excess of the appropriate F&C income limit, evaluate as MN.

33. F&C Adult – Sequential Evaluation • Parent/caretaker relative; LIFC covered group • Not LIFC, but meets definition of pregnant woman; pregnant woman/newborn child group • Income exceeds LIFC limits, but meets definition of institutionalized individual (including hospice), evaluate in the F&C 300% SSI groups • Pregnant woman whose income exceeds 133% FPL, evaluate as FAMIS MOMS (M22) • Screened & diagnosed with breast or cervical cancer or pre-cancerous conditions by Every Woman’s Life program & does not meet the definition of coverage as SSI, LIFC, Pregnant Woman or Child Under 19 individual; evaluate in the BCCPTA covered group • Excess income for full coverage in a Medicaid covered group & between the ages of 19 and 64, evaluate for Plan First coverage • Pregnant woman but has excess income for coverage in a CN group or FAMIS MOMS, evaluate as MN

34. Medicaid Fraud Referrals

35. Remember… • Send all questions and proposed topics to mmiswebex@dmas.virginia.gov • If you have viewed this part of the presentation through the Knowledge Center, don’t forget to join the DMAS Enrollment Unit for our live WebEx sessions. Thank You!