Uninsured Eligible Consumers

Transcription

1 C h a p t e r 3 Uninsured Eligible Cnsumers 3.1. Intrductin 3.2. Uninsured Eligible 3.3. Registering a New Member in PrviderCnnect 3.4. Applying fr Uninsured Eligibility 3.5. Uninsured Eligibility fr Substance Use Disrder Services 3.6. Uninsured Eligibility fr Mental Health Services 3.7. Crdinatin f Care 3.8. Curtesy Review Prcess fr Grant Funded Services Only 3.9. Uninsured Certificatin Perids Beacn Health Optins Maryland Prvider Manual 1

2 3.1. Intrductin Befre the details f the uninsured eligibility prcess are discussed, it is imprtant t nte that the Administrative Services Organizatin (ASO) was riginally planned t be the entity t receive and manage all Medicaid, state nly, and grant funds fr the Public Behaviral Health System (PBHS) when the new system went live in January Hwever, after careful cnsideratin, a phased-in apprach was adpted. The first phase f the mental health/substance use disrder integratin is t have all data fr thse served using grant funds and Medicaid entered int ne data system. This allws fr a central repsitry f data related t mental health and substance use disrder services. This secnd phase f integratin will prvide fr reimbursement fr ambulatry services thrugh the ASO, Beacn Health Optins, Inc. (Beacn), regardless f whether the persn has Medicaid r is uninsured. This will increase access and prvide fr cntinuity f care fr thse individuals wh are uninsured r wh lse Medicaid cverage during the curse f their treatment. Under the third and final phase f integratin, substance use disrder-related residential grant funds will be mved under the ASO. Please nte: Effective July 1, 2016 (FY17), the Maryland Department f Health and Mental Hygiene (DHMH) will begin the secnd phase f integratin, which includes remving grant funds fr ambulatry substance use disrder-related services frm annual jurisdictinal awards and mving them t Beacn. Ambulatry services are: Assessment Level 1 utpatient grup and individual services Level 2.1 intensive utpatient Level 1 and Level 2.1 withdrawal management Medicatin assisted treatment Txiclgy specimens Fr thse individuals wh need ambulatry substance use disrder-related services wh d nt have Medicaid eligibility, prviders registered with Beacn will submit all necessary registratin, discharge, and transfer infrmatin t the ASO, btain authrizatin, and submit claims t Beacn. Beacn will, when apprpriate, determine eligibility and medical necessity, issue authrizatins, and will prcess and pay claims. Reimbursement fr services prvided t the uninsured will be at the same rate as the Medicaid reimbursement rate Uninsured Eligible Uninsured eligible cnsumers are individuals fr whm the cst f medically necessary and apprpriate cmmunity-based behaviral health services will be subsidized by the Behaviral Health Administratin (BHA) because f the severity f illness and financial need. Depending n the availability f state funding, services may be prvided t cnsumers wh meet specific eligibility guidelines. Prviders can verify a cnsumer s eligibility r initiate a request fr uninsured eligibility thrugh PrviderCnnect r by calling Beacn s Maryland custmer service team at Beacn Health Optins Maryland Prvider Manual 2

3 3.3. Registering a New Member in PrviderCnnect After lgging int Beacn s PrviderCnnect system, a prvider will d a search fr a cnsumer t learn whether the cnsumer is already in the PBHS. When the cnsumer is nt in the PBHS, the cnsumer needs t be added t the system s that Beacn can assign the cnsumer a Beacn medical recrd number (cmmnly referred t as an M number ). The cnsumer needs t be assigned an M number befre services can be requested r any data can be entered in PrviderCnnect. Adding a new cnsumer t the PBHS 3.4. Applying fr Uninsured Eligibility Any prvider applying fr uninsured eligibility in PrviderCnnect will be ntified, immediately, f the cnsumer s uninsured eligibility status. Fr every request fr uninsured eligibility, the prvider is required t verify and dcument the cnsumer meets all six uninsured eligibility criteria. These criteria are: 1. The cnsumer requires treatment fr a behaviral health diagnsis(es) cvered by the PBHS. 2. The cnsumer meets the financial criteria (under 250% f federal pverty level) and is nt cvered by Medicaid r anther insurance. The service prvider is respnsible fr cllecting and maintaining dcumentatin frm the cnsumer that validates the cnsumer s financial need. This may include dcumentatin f applicatin and utcme fr benefits, pay stubs, ther incme, etc. t dcument that the cnsumer meets the financial criteria. 3. The cnsumer has a verifiable scial security number. 4. The cnsumer is a Maryland resident. 5. The cnsumer has applied fr Medicaid, the Health Care Exchange, Scial Security Incme (SSI), r Scial Security Disability Insurance (SSDI), if they have an illness/disability fr a perid f 12 mnths r mre (r are expected t have an illness/disability fr 12 mnths r mre). If the cnsumer is nt eligible fr Medicaid, SSI, r SSDI, dcumentatin frm Medicaid r Scial Security stating the reasn fr ineligibility must be prvided and maintained in the cnsumer s medical recrd. 6. The individual meets US citizenship requirement. BHA is requiring prviders t maintain dcumentatin in the medical recrd t validate the individual's uninsured eligibility. Beacn and BHA will be mnitring requests fr uninsured eligibility spans and prviders withut dcumentatin may be audited. Failure t maintain all supprting dcumentatin may result in a retractin f funds. Beacn Health Optins Maryland Prvider Manual 3

4 Exceptins t the dcumentatin requirement may be made by BHA under extenuating circumstances. The exceptins are related t the type f crisis and type f service. If a cnsumer is in immediate need fr services (such as acutely suicidal) r the cnsumer's symptms prevent that persn frm being able t prvide infrmatin and they are being seen by an assertive cmmunity treatment team, mbile crisis team, residential crisis prgram, r ther utpatient setting, dcumentatin criteria may be waived. If an individual is in immediate need f services, the cnsumer will be given an uninsured span f ne mnth. If at the end f the first mnth, the cnsumer still is in crisis and dcumentatin is still nt available, the prvider may request anther mnth by cmpleting the registratin fr the uninsured span again. If at the end f the secnd mnth, the prvider again requests an uninsured eligibility span withut the dcumentatin, the request will be denied and the prvider must submit a written request t the Cre Service Agency (CSA) t demnstrate the need fr cntinued services in spite f the missing dcumentatin. If Beacn denies the request fr an uninsured eligibility span due t the individual nt meeting the minimum criteria, the prvider may request a review by the CSA fr an exceptin t the criteria due t an urgent care r special exceptin need. The prvider may call r fax a request fr urgent care using the designated frms t the CSA f the cnsumer s cunty f residence. The CSA will review the request t determine if an urgent care need is met and an exceptin will be granted. Ratinale fr the exceptins is t include discharge/release r diversin frm a state hspital r ther inpatient setting r detentin center. If the CSA denies the request, the CSA ntifies the prvider. If CSA apprves the exceptin, the CSA frwards the State f Maryland - Request fr Reimbursement fr Nn-Medicaid Outpatient Services frm (if member number, Medicaid ID is available) t Beacn. The Maryland: Prvider Request t CSA fr Urgent Care fr Uninsured frm will nt be sent t Beacn but retained by the CSA. Upn receipt, Beacn will enter the cnsumer infrmatin int ur system (expectatin is within 24 hurs) n later than tw business days. Beacn will update the frm with the cnsumer ID and it back t the CSA with a cpy t the prvider. The frm requires the prvider s address be included. If the CSA apprves, then an uninsured eligibility span is established. If at any pint during this prcess, the prvider updates the uninsured cnsumer's eligibility recrd with the missing dcumentatin, the uninsured eligibility span is established fr three mnths frm the initial begin date f the uninsured span. Additinally, there are ther exceptins t dcumentatin if the cnsumer meets these criteria: 1. If the individual meets all f the abve dcumentatin criteria except item 2 and ne f the fllwing: a. Is under age 19 b. Has been released frm prisn, jail r Department f Crrectins facility within the last three mnths c. Is pregnant d. Is an injectin drug user e. Has HIV/AIDS f. Was discharged frm a Maryland-based psychiatric hspital within the last three mnths Beacn Health Optins Maryland Prvider Manual 4

5 g. Was discharged frm a Maryland-based medically-mnitred residential; treatment facility within the last 30 days (American Sciety f Addictin Medicine Level 3.7) h. Is requesting services required by HG rder r referred by drug r prbate curt i. Is receiving services as required by an rder f cnditinal release 2. If an individual meets all criteria except items 2 and 5 and is currently receiving SSDI fr mental health reasns 3. If an individual meets all criteria except items 2 and 4 and is hmeless within the state f Maryland 4. If an individual meets all criteria except items 2, 3 and 5 and is a veteran 5. If a nn-us citizen, the exceptin prcess will be used which requires apprval frm the CSAs 3.5. Uninsured Eligibility fr Substance Use Disrder Services An pen and active uninsured eligibility span will nly generate the M number that is necessary fr grant funded service data entry and/r t alert Beacn t set up a curtesy review fr Medicaid cvered services. N state-nly funds will be paid by Beacn t prviders f substance use disrder services when an uninsured eligible cnsumer has n ther cverage t pay fr the service. Substance use disrder prviders treating uninsured eligible cnsumers will be required t fllw the authrizatin prcess in PrviderCnnect, but nly fr data cllectin purpses. There are n state general funds, and limited grant funds, fr uninsured cnsumers managed by Beacn. As has histrically been the case, the nn-medicaid (grant funded) dllars assciated with many f the substance use disrder treatment services will cntinue t be managed by the Lcal Addictins Authrities (LAAs) Uninsured Eligibility fr Mental Health Services An pen and active uninsured eligibility span will allw Beacn t pay fr sme medically necessary, mental health services. Beacn may make payment fr mental health services t an uninsured eligible cnsumer if all f the fllwing are met: The cnsumer meets all the requirements fr uninsured eligibility The prvider has maintained dcumentatin that the uninsured eligibility criteria have been met The mental health services have been authrized as medically necessary, prir t services beginning (except fr urgent services) The mental health services requested are ne f the fllwing: Outpatient mental health clinic services (OMHCs) Excluding OMHCs in HSCRC regulated space Excluding intensive utpatient services Outpatient mental health ffice services (nn-omhcs) Beacn Health Optins Maryland Prvider Manual 5

6 Respite services Enhanced supprt services Psychiatric rehabilitatin prgram (PRP) services, n and ff-site* Crisis services** Mbile treatment services** Residential supprted emplyment services*** Residential rehabilitatin prgram (RRP) services**** The state nly funds remain available fr the requested mental health services Uninsured requests in which the cnsumer des nt have a primary mental health diagnsis r is nt a Maryland resident will be denied withut pprtunity fr exceptin Crdinatin f Care Fr cnsumers with simultaneus Medicare and/r cmmercial cverage, a crdinatin f benefits (COB) is required f Beacn. Beacn will crdinate benefits with the primary insurer befre mental health benefits can be paid against the uninsured eligibility span. Beacn may pay fr services t a dually insured cnsumer, under an uninsured eligibility span, if the cnsumer is: A Medicare beneficiary, and Medicare des nt cver this service, and the individual des nt have ther insurance t cver the service Cvered by a cmmercial insurance and the benefit fr this service is exhausted, there is n benefit fr this service, r the service was deemed nt medically necessary by the insurer and the prvider has exhausted all appeal ptins. COB fr bth Medicare and cmmercial insurance is nt required fr the fllwing services: Supprted emplyment services Residential rehabilitatin prgram (RRP) services Respite services Enhanced supprt services Psychiatric rehabilitatin prgram (PRP) services Occupatinal therapy services* Fr individuals wh are uninsured, emplyed, and requesting authrizatin fr PRP services, Beacn Health will direct the prvider t refer the individual t Maryland Department f Disabilities Emplyed Individuals with Disabilities (EID) Outreach prgram in rder fr the prgram t apply fr EID n behalf f the individual. Befre an uninsured request is determined, BHA is requiring an EID applicatin be submitted. Exceptins will be granted nly fr an urgent care and referrals frm state hspitals. * Cnsumers must meet additinal criteria t qualify fr these services. ** N cpays apply t these services. *** The individual s incme frm supprted emplyment will nt be included in the incme verificatin. **** Cnsumers are required t cntribute t the cst f care fr RRP. Beacn Health Optins Maryland Prvider Manual 6

7 Fr veterans in Maryland, BHA will prvide gap services, utpatient treatment, and crisis interventin services until their US Veterans Administratin benefits are activated and available. Financial data must be reviewed annually, dcumented, and maintained in the cnsumer s medical recrd Curtesy Review Prcess fr Grant Funded Services Only The entire uninsured eligibility applicatin can be bypassed in PrviderCnnect if the substance use disrder service prvider knws that the nly payment they will receive fr these services will be thrugh the LAA, using grant funds. Hw t bypass the uninsured eligibility applicatin fr prviders prviding substance use disrder services thrugh grant funds nly If the uninsured eligibility applicatin is bypassed, the cnsumer will be assigned an M number under a curtesy review span. The curtesy review span allws the prvider t enter all required service data regarding nn-medicaid (grant funded) substance use disrder services. A curtesy review span als allws the prvider t seek a medical necessity review fr Medicaid cvered services. If the service is deemed medically necessary, Beacn will pay fr these services when/if the cnsumer becmes Medicaid eligible Uninsured Certificatin Perids When a request fr uninsured eligibility meets the state s eligibility criteria, the uninsured eligibility span will be fr three mnths. This is the eligibility span fr bth new requests and fr when these spans are Beacn Health Optins Maryland Prvider Manual 7

8 eligible fr renewal. Individuals must meet financial need criteria f incme f n mre than 250% f federal pverty level and ther required cnditins. RECERTIFICATION PROCESS If the cnsumer has had any changes during the three-mnth perid, the cnsumer r prvider must reprt t Beacn any changes which may impact eligibility. The PBHS requires every prvider t request that each cnsumer/applicant apply fr any Medicaid benefits r EID fr which he/she may be eligible. Requests fr uninsured eligibility will nt be backdated unless the cnsumer has an pen authrizatin with an end-date beynd the end-date f the cnsumer s current uninsured eligibility span. Backdating f uninsured eligibility spans will be allwed in the fllwing scenaris: The cnsumer was discharged frm a hspital will backdate t discharge date The ntificatin f terminatin f Medicaid is within 30 days f the requested uninsured start date The cnsumer is receiving care in a designated hspital diversin prgram Beacn Health Optins Maryland Prvider Manual 8