Virginia s Medicaid MCO Program

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2. 2 Presentation Outline Why Medicaid Managed Care Eligibility Enrollment Services What If. . .

3. 3 Richmond Foster Care Pilot The Richmond Foster Care Medicaid Pilot Program was developed in response to a request from the City to provide more coordinated care for children in foster care The Department of Medical Assistance Services (DMAS) received permission from the Governor and the federal government to move foster care children in the City into managed care health plans DMAS, Richmond City DSS and the four MCOs in Richmond have been working together since January to make the transition as smooth as possible

4. 4 MCO Program Medallion II - Virginia�s Mandatory Medicaid Managed Care Program Began in 1996 in Tidewater and has expanded to 114 cities and counties across the state Medicaid clients are enrolled into contracted Managed Care Organizations (MCOs) There are approximately 531,000 clients enrolled in managed care with approximately 400,000 of them children The Focus: to provide access to preventive and coordinated care

5. 5 MCO Program An MCO is a managed care organization. It is a managed care health plan in which a group of doctors and other health care providers work together to give the members health care services Each person in an MCO has a primary care provider (PCP) The PCP is a doctor or other health provider who will manage your child�s health care and refer (send) the child to other providers when necessary Children under your care do not need to be enrolled in the same MCO or PCP

6. 6 Comparison of Member Services(See MCO Benefits Handout) Medicaid Fee-For-Service (FFS) Medicaid ID Card Recipient helpline (not toll-free) Managed Care Organization (MCO) MCO member ID card, handbook, and provider directory Toll-free member helplines Access to free translation services /language telephone line 24-hour nurse advice line Access to assistance with medical issues (case management) Member outreach and health education materials Access to credentialed providers No co-payments

7. 7 Presentation Outline Why Medicaid Managed Care Eligibility Enrollment Services What If. . .

8. 8 Eligibility Mandatory enrollment of Medicaid clients into a MCO The majority of Medicaid clients are eligible for MCO enrollment Medicaid clients who are excluded from MCO enrollment receive services through fee-for-service (regular) Medicaid. Those excluded from MCO enrollment include: Other Primary Insurance, including Medicare Foster care (not in the custody of the City of Richmond) /subsidized adoptions Hospitalized at the time of enrollment Individuals in nursing facilities Individuals participating in the Technology Assisted Waiver Individuals institutionalized in a state facility

9. 9 Eligibility The Richmond Foster Care Program includes Foster care children under the custody of the City of Richmond Department of Social Services and who are not in residential care Non-custodial children who are not in residential care Minor children of eligible foster care children

10. 10 Eligibility The Richmond Foster Care Program does not include Children in Adoption Assistance Children not under the custody of the City of Richmond Department of Social Services but live in a foster care home in the City Example: foster care child living in City but under the custody of Henrico DSS Children placed in Residential Treatment Centers Undocumented minors

11. 11 Presentation Outline Why Medicaid Managed Care Eligibility Enrollment Services What If. . .

12. 12 Enrollment in Managed Care Determined to be eligible for Medicaid DSS enters enrollment into the Medicaid system 15-45 days after eligibility entered into system, the system assigns the child to one of four MCOs (this process is called pre-assignment) DSS notified by letter of which MCO child will be pre-assigned to DSS calls by the deadline to make alternative selection of MCO No call = enrollment into pre-assigned MCO indicated in letter Child obtains services through fee-for-service (regular Medicaid) until MCO is effective

13. 13 Enrollment Timeline 10/18/2011 � MCO Preassignment Processing Occurs Foster Care children randomly pre-assigned to an MCO 10/20-31/2011 � Pre-assignment letters mailed to RDSS Social Worker (SW) SW reviews placement address to ensure MCO participates where child is currently residing SW shares information with FC parent/placement provider SW may request MCO change during preassignment - must be done prior to 11/18/2011 to be effective 12/01/2011 11/18/2011 � MCO Assignment Processing Occurs MCOs receive file of members assigned for 12/01/2011 MCOs mail ID card, handbook and provider directory to foster care parent/placement provider 12/01/2011 � Managed care enrollment begins � child must go to doctor that is part of MCO network

14. 14 ID Cards(See Sample ID Cards Handout) You will receive two ID Cards Medicaid plastic ID card RDSS will give you this card if you do not already have it MCO ID card You will receive in the mail from the MCO after 11/18/2011 Take both cards with you every time you take the child for an appointment

15. 15 Changing MCOs DSS Foster Care Social Workers (not foster parents) responsible for requesting MCO changes Parents/providers may contact the Foster Care Social Worker (SW) to request change If change is requested, effective date to change MCOs: Before 18th of month, effective 1st of following month (ex � call January 16th, change effective February 1st) After 18th of month, enrollment delayed another month (ex � call January 20th, change effective March 1st)

16. 16 Placement Change Child moves to your home: SW will provide you with the MCO and Medicaid ID cards SW will advise you of foster care child�s MCO enrollment MCO may change if new residence is a different locality Child leaves your home: Return MCO and Medicaid ID cards to SW Advise SW of any appointments scheduled with current MCO

17. 17 Loss of Coverage If Medicaid eligibility is cancelled the child�s MCO enrollment ends Examples: Returned mail will cause a temporary cancellation Child is incarcerated (Medicaid enrollment will also be discontinued until released) If Medicaid eligibility is regained within 60 days, child is automatically re-enrolled in same MCO Notified by letter from DMAS of re-enrollment Child may be disenrolled from MCO but remain eligible for Medicaid if placed in a residential treatment facility or if placed in a foster care home in a locality where there is no MCO participation

18. 18 Presentation Outline Why Medicaid Managed Care Eligibility Enrollment Services What If. . .

19. 19 Dental(Smiles For Children) Dental services are provided through the Smiles For Children program If you need help finding a dentist or making a dental appointment, call 1-888-912-3456 to speak with a Smiles For Children representative There are no costs for dental care services in the Smiles for Children program There is no special Smiles For Children dental card. You may use either your child�s Commonwealth of Virginia plastic ID card or MCO member ID card More information available at http://dmasva.dmas.virginia.gov/Content_pgs/dnt-enrollees.aspx

20. 20 Transportation MCOs provide pre-approved transportation if you need to take your child to a physician or a health care facility and you do not have any other means of transportation Call your MCO at least 5 business days before the scheduled routine medical appointment to arrange for transportation Trips must be for a Medicaid covered service and must be medically necessary Examples: doctor appointments, counseling, dialysis, dental appointments, etc. MCO transportation cannot make stops for shopping except if you need to go to a pharmacy to pick up a prescription that is being filled

21. 21 Transportation Anthem HealthKeepers Plus 1-877-892-3988 CareNet �Southern Health Services, Inc 1-800-734-0430 Optima Family Care 877-892-3986 VA Premier Health Plan, Inc. 800-727-7536

22. 22 MCO Assistance Member Services Responsibilities Assist with choosing or changing a PCP Address and telephone number change Explanation of benefits Assist with replacing a lost member card Member orientation to MCO Assist members with hearing loss, impaired vision and limited reading ability obtain materials in Braille, large print or TDD/TTY Medical Management Responsibilities 24 Hour Nurse Advice Line Case Management (assistance with medical issues) Coordination of health services Disease management services: (Asthma, Behavioral Health, COPD, Heart Disease, Child Weight Management) Children with special health care needs Pre-authorization of health services Health education programs (Prenatal classes, exercise, smoking cessation, women�s health, nutrition and weight management classes, etc), Home health and durable medical equipment needs Assist with translator services

23. 23 MCO Carved Out Services Community Mental Health Rehabilitative Services: Intensive In-Home Services for Children and Adolescents Therapeutic Day Treatment for Children and Adolescents Day Treatment/Partial Hospitalization Psychosocial Rehabilitation Crisis Intervention Intensive Community Treatment Crisis Stabilization Services Mental Health Support Services Case Management Mental Retardation Community Services: Case Management Services Private Duty Nursing for HCBS waiver enrollees Substance Abuse Treatment Services: Substance Abuse Crisis Intervention Substance Abuse Intensive Outpatient Substance Abuse Day Treatment Opioid Treatment Substance Abuse Case Management Dental (Smiles For Children) School Health Services Specialized Infant Formula for Children Under Age 21 Health Department Lead Investigations Early Intervention Services Personal Care services

24. 24 Presentation Outline Why Medicaid Managed Care Eligibility Enrollment Services What If. . .

25. 25 What If. . . I have an emergency I need to change the doctor on the card My doctor is not in the MCO network I need transportation to an appointment I want to know if a service is covered I need a referral to another doctor What if I change my contact information Call the PCP if you have time, or call 911, or go to the nearest hospital emergency room Call MCO member services number on the back of the card Call MCO member services to select an in-network doctor Call MCO Transportation services in advance to schedule Refer to member guide or call MCO member services number on the back of the card Contact the doctor to obtain referrals MUST Contact SW and MCO

26. 26 What If. . . I need to change MCOs I have more than one child and they are in different MCOs My foster care child has a baby I lost the Medicaid Card I lost the MCO card Call your child�s Social Worker at Richmond DSS Call your child�s Social Worker at Richmond DSS and ask if the children can be enrolled with the same MCO. The child�s doctor will need to be in the MCOs network Call your child�s Social Worker at Richmond DSS Call your child�s Social Worker at Richmond DSS Call MCO Member Services

27. 27 MCO Member Services Anthem HealthKeepers Plus 1-800-901-0020 CareNet � Southern Health 1-800-279-1878 Optima Family Care 1-800-881-2166 Virginia Premier Health Plan 1-800-727-7536

28. 28 MCO Nurse Advice Line Anthem HealthKeepers Plus 1-800-382-9625 CareNet � Southern Health 1-877-878-8940 Optima Family Care 1-800-394-2237 Virginia Premier Health Plan 1-800-256-1982

29. 29 Visit Us On The Web http://dmasva.dmas.virginia.gov/Content_pgs/mc-home.aspx http://www.virginiamanagedcare.com

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