ADAP and Medicaid Denial Clarification

1. ADAP and Medicaid Denial Clarification April 19, 2019

2. Objectives • Review Medicaid-eligible status and issues • Share what VDH is receiving for Medicaid denials • Clarify which denials are appropriate for approval into ADAP • Why denial reasons are important • Medicaid eligibility and application reminders

3. Review of Medicaid-eligible Status • If VDH previously received an enrollment worksheet indicating a client was Medicaid-eligible, VDH is expecting the client to complete the Medicaid application process. • New applicants and clients completing recertificationswill have to complete the Medicaid application process if they appear eligible. • Clients should either be approved for Medicaid or denied based on not meeting Medicaid’s eligibility criteria

4. Review of Medicaid-eligible Status • VDH can be notified once the client receives an approval into Medicaid • VDH does check the Medicaid eligibility portal to confirm Medicaid coverage for clients that have applied • If a client is denied Medicaid coverage, VDH requires a copy of the denial letter to be faxed or mailed to VDH.

5. Review of Medicaid-eligible Status • Insurance premiums can not be paid until an appropriate denial letter is received. • Clients may only receive temporary medication access (30-day fills) until the appropriate denial documentation is provided.

6. Types of Denial Documents Received • Various computer-generated denial letters from DSS or DMAS, specifically stating the denial reason (acceptable) • Personally-composed letters from DSS workers stating the denial reason (acceptable) • Letters from Federal Marketplace indicating a recent Medicaid denial without a specific denial reason (not acceptable)

7. Examples of Denial Reasons Received • Income exceeds allowable limit (acceptable) • Voluntarily withdrew (not acceptable) • Failure to provide information needed to determine eligibility (not acceptable) • Duplication application (not acceptable) • Failure to complete renewal - renewal packet not received (not acceptable)

8. Other Denial Documents • There may be other official denial documents from DSSor DMAS that VDH has not seen yet. • The denial document submitted to VDH must indicate the reason the client/applicant was denied or did not meet Medicaid’s eligibility criteria.

9. Why is the Denial Reason Important? • Per HRSA guidelines, grantees and their sub-grantees must vigorously pursue Medicaid enrollment (or other sources of assistance) for eligible clients. • If another payer source for services is available to the client, that source must be prioritized over using Ryan White services. • It is VDH’s and its sub-recipients responsibility to abide by these HRSA guidelines.

10. Income Eligibility Beginning January 1, 2019 • Applicants may be eligible if they make less than: Information from www.coverva.org

11. How to Apply for Medicaid Expansion • Call the Cover Virginia Call Center at 1-855-242-8282 (TDD: 1-888-221-1590) to apply on the phone Mon - Fri: 8:00 am to 7:00 pm and Sat: 9:00 am to 12:00 pm • Complete an online application at Common Help: www.commonhelp.virginia.gov • Complete an online application at The Health Insurance Marketplace: www.healthcare.gov Information from www.coverva.org

12. How to Apply for Medicaid Expansion • Mail or drop off a paper application to your local Department of Social Services (Mailing may take longer than other methods of applying). Find your nearest local department of social services by visiting: http://www.dss.virginia.gov/localagency/ • Call the Virginia Department of Social Services Enterprise Call Center at 1-855-635-4370 (If you also want to apply for other benefits) Information from www.coverva.org

13. Questions