Medicaid Managed Long Term Care Enrollment & Disenrollment Information for MCOs

1. MedicaidManaged Long Term CareEnrollment & Disenrollment Information for MCOs

2. Objectives • Understand the basics for monitoring enrollment in the Family Care, Partnership, and PACE programs • Understand the main players involved in Wisconsin’s managed long-term care (MLTC) programs • The Aging and Disability Resource Center (ADRC) • The County Income Maintenance (IM) unit • The Managed Care Organization (MCO) June, 2011

3. Initial Enrollment Roles IM ADRC Determine and certify Medicaid eligibility Enter MCO enrollments and disenrollments in CARES Worker Web (CWW) • Provide information & assistance • Provide counseling about LTC Options • Conduct functional eligibility determination • Gather Financial/MRE Information for IM MCO • Complete a comprehensive assessment and develop a plan of care • Provide and/or coordinate LTC services June, 2011

4. Systems Involved in Enrollment There are many systems involved in the eligibility and enrollment process for Wisconsin’s MLTC programs. There are different information management systems involved that affect the business of the ADRCs, IM and MCOs. The following graphics detail the complexity and interplay of the different systems involved. June, 2011

5. June, 2011

6. iC Enrollment Update Timeline June, 2011

7. Managed Long Term Care (MLTC) Medicaid Programs • Family Care • Partnership • PACE • IRIS Program (Not Managed Care) Participation in MLTC Programs is voluntary. Members are allowed to choose from these programs and switch to other available programs as they wish. June, 2011

8. Enrollment Basics • Individuals must be Medicaid eligible to be enrolled in MLTC programs. • Medicaid Eligibility from CWW is sent each month to update FowardHealth interChange (iC). • Enrollment cannot be updated on ForwardHealth iC if there is no eligibility. Check in ForwardHealth iC for Medicaid eligibility. June, 2011

9. Criteria for Enrollment in MLTC programs Individuals who meet the following criteria can be enrolled in MLTC programs: June, 2011

10. Full Benefit Medicaid Benefit Plans The following Benefit Plans are considered to be full benefit Medicaid. Therefore, members who want to enroll into Family Care, PACE or Partnership would have to be eligible for one of the Benefit Plans below on or before the member’s managed care enrollment date. Benefit Plan Description MCDW Medicaid Waiver SSIMA Medicaid for SSI MCD Medicaid FSTMA FosterCare Medicaid MAPW Medicaid Purchase Plan Waiver MAP Medicaid Purchase Plan WWMA Well Woman Medicaid BCSP BadgerCare Standard Plan June, 2011

11. Determining Level of Care • ADRC staff use the Long Term Care Functional Screen (LTCFS) to assess an applicant’s level of care (LOC). • The LOC information is provided to the IM Worker, along with the med/remedial and MA card coverable expenses to determine eligibility for a long term care program. • Initial screening results are communicated to IM by the ADRC • Once the member is enrolled in a MLTC program, the MCO is responsible for the subsequent screenings. These are auto-populated to CWW through the Community Waiver page. • If the auto-update fails, the screener must send the LTC FS eligibility results page to the IM worker for a manual update in CWW June, 2011

12. LOC matters There are specific managed care capitation rates associated with the levels of care so it is important that level of care and level of care effective date information is accurate. June, 2011

13. MLTC Levels of Care Nursing Home • Individuals who are found functionally eligible for Nursing Home LOC may have their eligibility determined using Waiver logic. They may also have Medicaid eligibility through another source such as SSI (Group A). Non-Nursing Home • Individuals who are found functionally eligible for Non-Nursing Home LOC can only enroll in FC but must be Group A. (See the list of full benefit Medicaid plans on slide 10) June, 2011

14. Family Care Enrollment Date • The ADRC provides the enrollment date to the IM worker, after the LTC FS is complete. This is the date the MCO will begin providing services to the member. • The enrollment date is entered on the Family Care Page in CWW. • The enrollment date determines the date the capitation payments to the MCO begin. June, 2011

15. Family Care Cost Share • When the Medicaid eligibility is determined using Waiver logic, the Waiver cost share is the FC cost share. • When the Medicaid eligibility is Institutional Medicaid, the patient liability is the FC cost share. • Both of these types of cost shares are identified as “Waiver Cost Share” amounts in ForwardHealth iC. • These “Waiver Cost Share” amounts are used to offset the member’s Family Care capitation payments to the MCO. June, 2011

16. Community Waiver Budget

17. Family Care Budget

18. MCO Duties • Once a member is enrolled, the MCO must monitor ForwardHealth iC enrollment reports for discrepancies in persons the MCO considers enrolled. • Monitoring for discrepancies and reconciling the discrepancies ensures that the members are correctly enrolled and the MCO is appropriately paid June, 2011

19. Identify Discrepancies • DHS generates enrollment and capitation payment reports. The reports are stored in a portal on ForwardHealth iC. • The MCOs can download the enrollment and capitation payment reports that identify enrollment dates, level of care effective dates, disenrollment dates and capitation payment amounts for all of their enrollees. • MCOs should compare the information in each ForwardHealth iC report (following slides) to the information in the MCO system. June, 2011

20. MLTC Reports interChange Reports • Enrollment – Paper and 834 HIPAA Transaction • The INITIAL CMO Enrollment Reportis produced 12-13 days before the upcoming capitation month. This report containing a listing of all members and their enrollment status for the next month in iC. This report also includes members who 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 Reportis 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. June, 2011

21. MLTC Reports (cont’d.) • Capitation Payments – Text file and 820 HIPAA Transaction • This report provides a detailed listing of the members for which managed care programs are receiving capitation payments. Regular capitation payments are created once a month while capitation adjustments are created weekly. • 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 newly enrolled members. • Cost Share Report • interChange- This is a monthly report that contains 3 months of member cost share information. * This is not a comprehensive listing of MCO reports. It is a subset of reports related to member eligibility and MCO enrollment. June, 2011

22. Family Care Disenrollments Disenrollment from the MCO may occur for a variety of reasons. Some of the more common reasons for disenrollment include: • The loss of Medicaid eligibility (disenroll with timely CARES notice) • A change in functional eligibility (disenroll with timely CARES notice) In both of these situations CARES will automatically populate the disenrollment date. June, 2011

23. Family Care Disenrollments Other common disenrollment reasons include: • A voluntary move out of the MCO’s service area • Member requests disenrollment (may include requests to transfer to IRIS) • Disenrollment date= the date member requested but not prior to the last date of accepted services. In these situations, the IM worker must enter the disenrollment date on the Family Care Page. CARES will send the entered disenrollment date to ForwardHealth iC once the FC fail has been confirmed. June, 2011

24. Family Care Disenrollments in CARES FC disenrollments are entered in CWW on the Family Care page. A disenrollment date more than three months in the past cannot be entered in CWW. If disenrollment is due to loss of functional eligibility or loss of Medicaid eligibility, CARES will populate the correct disenrollment date using Adverse Action logic. June, 2011

25. MLTC Loss of Eligibility Disenrollments When IM is informed via CWW or in writing by the MCO: • Loss of non-financial (including functional) • Loss of financial eligibility • Failure to met the cost share obligation, the member may be disenrolled. Disenrollment will occur according to adverse action logic. June, 2011

26. MLTC Loss of Eligibility Disenrollments • Death/date of death • Incarceration/date of incarceration • Admission to an IMD/date of IMD admittanceIMD admissions for individuals <21 or <65 • Move out of state or service area/date of Move June, 2011

27. Re-enrollment in Family Care Family Care enrollees who lose Medicaid eligibility, reapply and again are found eligible for Medicaid may be re- enrolled in Family Care for up to three calendar months prior to the Medicaid application month, only if all of the following conditions are met: • The person (or his/her representative) requests backdated Medicaid. • The person is determined to have met Medicaid financial and non-financial requirements in the month(s) being considered for re-enrollment in Family Care. • The person is determined to have been functionally eligible for Family Care in the month(s) being considered for re-enrollment in Family Care. • The person is determined to have received services, in addition to care management, under the Family Care (MCO) plan of care during the month(s) being considered for re-enrollment in Family Care. June, 2011

28. Re-enrollment in Family Care The local IM agency is not able to re-enroll anyone in Family Care earlier than the first of the month, three months prior to the application month.     June, 2011

29. Enrollment/Disenrollment Processing Basics • Members must be disenrolled from one MLTC program before s/he can be enrolled in a different MLTC program. • Members must be disenrolled from one MCO before s/he can be enrolled in another MCO. • The disenrollment must be completed and confirmed in one day and the new enrollment completed and confirmed the next day. June, 2011

30. When to contact OFCE? • The MCO should follow the process outline in the Technical Assistance document for notifying the state of discrepancies. • If the proper enrollment date is more than 3 months in the past and is incorrect in ForwardHealth iC. • If LOC is incorrect in ForwardHealth iC and is more than 3 months in the past. • If the disenrollment date is more than 3 months in the past and IM can no longer update CARES, *Incorrect cost share information can only be corrected by IM. Do not contact OFCE about incorrect cost share. June, 2011

31. In Summary • MCOs are responsible to monitor ForwardHealth iC enrollment reports for discrepancies in persons the MCO considers enrolled. • Monitoring for discrepancies and reconciling the discrepancies ensures that the members are correctly enrolled and the MCO is appropriately paid. • There are multiple systems and agencies involved in the process. June, 2011