Presentation Transcript

1. Department of Medical Assistance Services

   MMIS WebEx Training

   Department of Medical Assistance Services – Eligibility and Enrollment Unit February 2014 http://www.dmas.virginia.gov 1
2. Agenda Newsletter Eligibility and Enrollment Unit (EEU) & VaCMS Hospital Presumptive Eligibility (HPE) Spenddown Entry Medicare Savings Plans (MSP’s) & Medicare Part A Commonwealth Coordinated Care (CCC)
3. EEU Newsletter To provide a broad scope of information to local agencies from DMAS First publication made available in January 2014 Posted quarterly to MMIS portal and EEU webpage: http://dmasva.dmas.virginia.gov/content_pgs/dss-elgb_enrl.aspx
4. DMAS & VaCMS The EEU continues to provide support with MMIS enrollment and technical assistance. VaCMS technical issues directed to the VDSS Help Desk. Issues involving the MMIS should be directed to the EEU Inbox at: enrollment@dmas.virginia.gov
5. HPE The Affordable Care Act (ACA) gives qualified hospitals the opportunity to determine presumptive eligibility (PE) for certain Medicaid- eligible populations States are required to set up a HPE presumptive eligibility process; it is optional for hospitals to participate in completing HPE determinations. PE Policy: Medicaid Manual M0120.300 A.5
6. HPE (cont.) HPE provides: Temporary enrollment in Medicaid Access to, and compensation for, hospital based services not limited to hospital services Pathway to longer-term Medicaid coverage HPE was effective January 1, 2014
7. HPE (cont.) HPE impacts the following groups: Low-Income Families with Children – AC 065 ChildUnder Age 19 – AC 064 Pregnant Women – AC 035 Former Virginia Foster Care Children – AC 077 Breast and Cervical Cancer Prevention and Treatment Act group – AC 067 Plan First (not for January 1, 2014) – AC 084
8. HPE (cont.) HPE is a time limited period of Medicaid benefits and eligible individuals are limited in the number of PE periods they can have throughout a calendar year Pregnant women-one per pregnancy All others – one per calendar year
9. HPE (cont.) Provider requirements: must be a Virginia Medicaid provider must sign the Virginia Qualified Entity Agreement for Hospital Presumptive Eligibility must participate in the DMAS HPE training ONLY hospital employees are authorized to perform HPE determinations; cannot be done by third-party contractors and local departments of social services (LDSS).
10. HPE (cont.) Individuals who are enrolled on the basis of HPE will be covered by Medicaid beginning the date the HPE determination was made and the following month.
11. HPE (cont.) If an individual is determined eligible for continued Medicaid coverage, the LDSS eligibility worker is to continue ongoing coverage in the appropriate AC beginning the first day of the month after the effective date of the HPE coverage cancellation.
12. HPE (cont.) Pregnant women are only eligible for limited outpatient benefits in HPE. If determined eligible for full-Medicaid in the retroactive period HPE coverage should be cancelled and reinstated in full-coverage.
13. HPE (cont.) Individuals who subsequently file a Medicaid application and are determined ineligible must be sent a Notice of Action advising them of the application denial. Advance notice of the HPE cancellation is not required.
14. HPE (cont.) The individual’s HPE coverage is valid regardless of whether or not the individual is eligible for ongoing coverage. Do not refer the cases to the DMAS Recipient Audit Unit.
15. Spenddown Enrollment Spenddowns should ALWAYS be entered as a closed period of coverage. Leaving spenddowns open-ended can result in receipt of benefits that the member is not entitled to causing unnecessary Recipient Audit Unit (RAU) referrals.
16. Spenddown Enrollment (cont.) Review of the correct procedures for entering a spenddown in the MMIS. Spenddown training available on EEU Webpage: http://dmasva.dmas.virginia.gov/content_pgs/dss-elgb_enrl.aspx. The training is titled: AGENDA - Spenddown Policy & Processing & MMIS Spenddown Enrollment (08/2012).
17. Spenddown Enrollment (cont.)
18. Spenddown Enrollment (cont.) The entry of closed SD eligibility segments is performed by the DMAS Eligibility and Enrollment Unit (EEU) when there is ongoing coverage in the MMIS. If limited ongoing coverage exists, EEU staff will reenter the coverage.
19. Spenddown Enrollment (cont.) LDSS workers submit a MMIS Coverage Correction form to the DMAS Eligibility and Enrollment Unit (EEU) at enrollment@dmas.virginia.gov. The MMIS Coverage Correction form (Form Number: DMAS-09) can be found in the Form section of the SPARK page.
20. Spenddown Enrollment (cont.) A member of the EEU staff will notify the LDSS by email when the SD entry has been completed. Local agencies should NOT attempt to enter past SD eligibility using Retro Cancel Reinstate as this function does not allow for the entry of an end date.
21. Spenddown Enrollment (cont.) EEU staff will cancel the limited coverage with cancel reason code 097 the day before the SD was met. The SD period will be entered and the limited coverage will be reinstated where appropriate. A reply email will be sent to the LDSS worker advising the request is complete.
22. Spenddown Enrollment (cont.) Remember: If the begin date of ongoing limited coverage is 2 months from the month in which action is being taken, the LDSS worker will need to set a personal reminder to enter the limited coverage segment.
23. MSP’s and Medicare Part A To be eligible for QMB, SLMB or QI an individual must be entitled to Medicare Part A. (Medicaid Manual M0320.601, 602, and 603) If not enrolled, refer to the Social Security Administration (SSA) to apply and enroll. If verification of enrollment is not provided the individual is not eligible for a MSP.
24. Department of Medical Assistance Services MSP’s and Medicare Part (cont.) http://www.dmas.virginia.gov 24
25. MSP’s and Medicare Part A (cont.) Individuals who receive Medicare Part A and who are enrolled in an aid category that is eligible for state buy-in must be enrolled in Medicare Part B. If individual is not enrolled in Part B contact the DMAS Buy-in Unit at: MedicareBuyIn@dmas.virginia.gov or Rhonda Bowers (804) 371-8888 Sherrill Taylor (804) 786-7414
26. Department of Medical Assistance Services MSP’s and Medicare Part A (cont.) http://www.dmas.virginia.gov 26
27. Department of Medical Assistance Services CCC Effective March 1, 2014, Virginia launched the CCC Program, a new initiative offered to dually eligible individuals which coordinates their Medicare and Medicaid services under one entity. http://www.dmas.virginia.gov 27
28. CCC (cont.) CCC is implemented under a three-way contract between CMS, DMAS, and selected health plans which DMAS refers to as MMPs (Medicaid-Medicare Plans). The three plans for CCC are: Healthkeepers Humana Virginia Premier
29. CCC (cont.) CCC offers: Individual’s choice Person-centered service coordination and case management One system of coordinated care to include one ID card for all care, a unified appeals process, and a toll free number for assistance 24 hours a day/7 days a week Use of same fiscal agent for consumer-directed services to ensure continuity of care Extended transition period for previously authorized services For individuals with Serious Mental Illness (SMI), behavioral health homes to be created in partnerships with CSB’s
30. CCC (cont.) Medicare-Medicaid enrollees include: Older Active Adults referred to in the CCC Program as “Community Well” Older Adults who are receiving long term care services and supports (to include Elderly or Disabled with Consumer Direction Waiver Services (EDCD) and nursing facility care) Individuals with physical, intellectual, and developmental disabilities, including those receiving long term care and supports, not enrolled in a waiver (except for EDCD)
31. CCC (cont.) Who is Eligible for CCC? Full benefit Medicare-Medicaid Members Participants in the EDCD Residents of nursing facilities Members over the age of Age 21 Live in designated regions (Northern VA, Tidewater, Richmond/Central, Charlottesville, and Roanoke)
32. CCC (cont.) Who is NOT eligible for CCC? ID, DD, Day Support, Alzheimer's, Technology Assisted HCBS Waivers MH/ID facilities ICF/IDs PACE (although they can opt in) Long Stay Hospitals Money Follows the Person (MFP) program Hospice ESRD Other Comprehensive Coverage (TPL)
33. CCC (cont.) Individuals will be passively enrolled, similar to the Medallion II pre-assignment process; enrollment in CCC is voluntary. Individuals can elect to opt into the program, can change MMPs at any time, and can opt-out of program enrollment at any time. (changes will be made on either the first or last of the month)
34. CCC (cont.) Questions about CCC that are received by local agencies should be referred to: Phone: 1-855-889-5243 Monday-Friday 8:30-6:00 or Email: www.virginiaccc.com
35. CCC (cont.) Providers and local agencies should send questions regarding the CCC to: CCC.@dmas.virginia.gov
36. Thank you… Thank you for viewing this presentation. Continue to send questions and comments about this training or ideas for future trainings to: mmiswebex@dmas.virginia.gov. Eligibility and Enrollment issues should be sent to the Enrollment Inbox at enrollment@dmas.virginia.gov Patient Pay enrollment questions or issues should be sent to the Patient Pay Inbox at patientpay@dmas.virginia.gov