Participant Eligibility

Transcription

1 Eligibility 1

2 Overview Importance of checking eligibility Define the eligibility receipt Review examples of eligibility responses Review benefit plans and coverage Identify resources available to check benefit plan and coverage 2

3 Participant Eligibility Why should you check eligibility? To verify a participant has Medicaid coverage on actual date of service To review a participant s eligibility plan and coverage codes Note: Medicaid card does not guarantee current Medicaid coverage. 3

4 Verifying Eligibility Three ways to check eligibility: MACS Medicaid Automated Customer Service 1(866) HIPAA compliant vendor software Health PAS-OnLine Trading Partner To obtain eligibility information from one of these systems, submit two pieces of identifying information from the following list: Medicaid ID number (10 digits) Social Security Number (SSN) Last Name, First Name Date of Birth 4

5 Verifying Eligibility Trading Partner Eligibility 5

6 Verifying Eligibility Trading Partner Eligibility 6

7 Verifying Eligibility Trading Partner Eligibility Two pieces of identifying information required 7

8 Verifying Eligibility Trading Partner Eligibility 8

9 9 Verifying Eligibility

10 10 Benefit Plans

11 Benefit Plans Benefit Plans: Idaho Medicaid Benefit Plan Part B Premium Medicare Medicaid Coordinated Plan (MMCP) For more information on these plans, visit or contact your regional Healthy Connections representative. Note: All plans and coverage are determined by IDHW. Molina Medicaid Solutions has no role in these decisions. 11

12 12 Coverage Codes

13 Coverage Medicaid offers several coverages that are aligned with health needs and include an emphasis on prevention and wellness. Coverage codes: Basic Coverage Enhanced Coverage (includes Katie Beckett) Pregnant Women Coverage (PW) Medicare Co-insurance & Deductible (QMB) Part B Premium Coverage (SLMB) MMCP Coverage 13

14 Coverage The following are considered secondary coverages. They are always preceded by a primary coverage. Long Term Care Aged and Disabled Waiver (A&D) Developmentally Disabled Waiver (DD) 14

15 Coverage The following are additional programs always preceded by a primary coverage. Preventative Health Assistance (PHA) Traditional DD Children s Waiver 15

16 Coverage Basic Coverage The Medicaid Basic Coverage type is for healthy, lowincome children, and adults with eligible dependent children. Provides complete health, prevention, and wellness Note: Most Medicaid participants will be enrolled with this coverage type. Visit for list of detailed services. 16

17 Coverage Basic Plan Example 17

18 Coverage Enhanced Plan The Medicaid Enhanced Coverage type is for participants with disabilities or special health needs. Includes all benefits in Basic Coverage, plus additional benefits: o Nursing Facility o ICF/ID o Private Duty Nursing o Home & Community Based Waiver Services o Service Coordination Many of the services in this plan have medical eligibility and prior authorization requirements 18

19 Coverage Enhanced Plan Example 19

20 Coverage The Pregnant Women (PW) program is for pregnancy-related services only. Pregnant Women Program This coverage ends on the last day of the month in which the 60 th day after delivery occurs Women have access to prenatal and postpartum care, including: o Normal prenatal services o Nutrition counseling o Risk reduction follow-up o Social service counseling o Chiropractic and physical therapy services o Family planning, including sterilization w/consent 20

21 Coverage PW Program Example 21

22 Coverage Medicaid and Medicare Not everyone qualifies for regular Medicaid, but they may be eligible for Qualified Medicare Beneficiary (QMB) programs where Medicaid helps pay for Medicare costs including: Monthly Medicare premiums Medicare co-insurance Medicare deductibles 22

23 Coverage QMB Example 23

24 Coverage Specified Low-Income Medicare Beneficiary Program What expenses does SLMB cover? Specified Low-Income Medicare Beneficiary (SLMB) Medicare Part B premium only Note: No Medicaid coverage for services. 24

25 Coverage SLMB Example 25

26 Coverage Medicare and Medicaid Eligible What expenses are covered for participants who are Medicare and Medicaid eligible? QMB benefits Medicaid covered services 26

27 Coverage Medicare and Medicaid Eligible Example 27

28 Coverage Medicare-Medicaid Coordinated Plan The Medicare-Medicaid Coordinated Plan (MMCP) is for participants who are 21 years old or older, enrolled in Medicare Part A and Part B, eligible for full Medicaid, and reside in an MMCP coverage area. Participants voluntarily enroll in MMCP; after the participant is selected as part of the plan, it is administered by Blue Cross of Idaho. Note: Once a participant is on MMCP, they can choose to revert back to Medicare or Medicaid. 28

29 Coverage MMCP Example 29

30 Coverage Preventive Health Assistance Preventive Health Assistance (PHA) has a benefit designed to help participants and their families live a healthy lifestyle: Behavioral PHA Weight Management Note: To bill for this service, you must have the specialty set up on your provider record. For more information about the Preventive Health Assistance program, call 1 (877) or visit medicaidphaprogram@dhw.idaho.gov. 30

31 Coverage PHA Weight Management Example 31

32 Coverage Long Term Care Long Term Care (LTC) Assistance is available for participants who require hospice services, or if the provider states the participant needs to live in a Skilled Nursing Facility or Intermediate Care Facility for the Intellectually Disabled (ICF/ID). These services are approved by IDHW. The Medicaid Division determines whether or not the participant meets the level of care. These services require LTC coverage. 32

33 Coverage LTC Example 33

34 Secondary Coverage Idaho's Waivers for adults include: Waivers Aged and Disabled Waiver: Allows a person to receive services in his/her home, rather than a skilled nursing facility. Developmentally Disabled Waiver: Allows for increased flexibility and choices for enrollees who would traditionally receive services in an intermediate care facility. 34

35 Secondary Coverage Waiver Example 35

36 Secondary Coverage Idaho's programs for children include: Children s Programs Traditional DD Children s Waiver (Levels 1-5): Families who choose to access services through the traditional model will receive services from DD agencies who are paid for providing defined Medicaid benefits. Family-directed Services (FDS) DD Children s Waiver: Families who choose to access services through this model will continue to receive services and supports defined by the family from persons and businesses of their choice. 36

37 Secondary Coverage Waiver Example 37

38 Share of Cost Participants may be required to pay for some of the costs of their Medicaid services. Share of Cost (SOC) Co-pays 38

39 Share of Cost Did You Know? Participants may have to pay a share of cost for some services if they are on Long Term Care or have A&D or DD waiver coverage. SOC amounts are available online for a series of 365 days. Information is not available for future months. When verifying eligibility to retrieve SOC, you must enter the first day of the month in which you are requesting SOC. 39

40 Coverage SOC Example 40

41 Co-pays Did You Know? A small percentage of Medicaid recipients are required to pay a $3.65 co-pay. Check Medicaid eligibility for IDHW co-pay status each time you provide services. A guide to co-pay services and exemptions can be found under Hot Topics on the homepage. 41

42 42 Co-pay Verification

43 Therapy Limitations Effective January 1, 2012, physical, occupational, and speech therapy services now have capitations. Available CAP amounts will be validated on the eligibility response. $1870 per calendar year for speech language pathologists (speech therapy) services and physical therapy combined. $1870 per calendar year for occupational therapy services. 43

44 Therapy Limitations For questions relating to caps, contact the Division of Medicaid at 1 (208) , visit or refer to the Annual Benefit Cap FAQ under Hot Topics on the homepage. 44

45 Therapy Limitations Caps 45

46 Therapy Limitations Caps 46

47 47 No Medicaid Enrollment

48 Further Information Where to obtain more information: The Provider Handbook General Billing Instructions and General Provider and Participant Information, available at Idaho Medicaid Programs are listed in the Idaho Health Plan Coverage booklet available from Division of Medicaid, Department Regional Offices, or online at 48

49 49 Did You Know?

50 Did You Know? Announcements & IRs 50

51 Did You Know? Provider Handbook 51

52 Did You Know? MedicAide Newsletters 52

53 Did You Know? MedicAide Newsletter 53

54 Did You Know? User Guides 54

55 Did You Know? Training 55

56 Did You Know? Training 56

57 Did You Know? Training Opportunities Monthly WebEx Trainings Available to all providers Calendar is located at Regional Workshops Yearly Information will be posted to Individual Training or Questions Contact your local Provider Relations Consultant 57

58 Did You Know? Molina Partnership Contacts Contact Description Phone/ Website Health and Welfare (DHW) Idaho Smiles Dental 1 (800) Magellan Pharmacy Claims Contractor Providers: 1 (800) Participants: 1 (888) Medical Care Unit Optum Idaho PHA (Preventive Health Assistance) Pharmacy Unit with DHW Veyo Disease Management, Durable Medical Equipment, Therapy Services, Ambulance Auths, Hospice, Surgery, Breast and Cervical Cancer, Vision, Dental, Lead Screening Program, Non- Emergency Medical Transportation Idaho Behavioral Health Plan 1 (855) aho/home 1 (877) (Preventive Health Assistance link) medicaidphaprogram@dhw.idaho.gov 1 (866) Fax: 1 (800) Telligen Prior Authorization 1 (866) Non-Emergency Medical Participant & Non-Transport Providers: Transportation 1 (877) Transport Providers: 1 (877)

59 Enrollment and Maintenance 59

60 Enrollment/Maintenance Be sure to keep your information up to date. Current contact Mailing/W9/physical addresses Adding and terming rendering providers Adding and terming service locations Change of ownership 60

61 61 Enrollment/Maintenance

62 Enrollment/Maintenance New Enrollment 62 Note: If enrolling with an NPI, it must be approved prior to beginning the enrollment application.

63 Provider Maintenance Maintenance is required when any information changes: Address Add, term, update service locations Rendering or service provider changes Name changes Change in ownership Note: Contact updates are made through Maintenance Demographic. 63

64 64 Maintenance Forms

65 Maintenance Forms General Category 65

66 Tips Use current forms Complete all sections of the form use N/A when appropriate Utilize the Provider Enrollment Requirements document in the Provider Handbook for type and specialty information, as well as additional requirements New W9 for 1099 changes W9 name and tax ID must match IRS records Update provider credentials (licenses, certifications, insurance, etc.) 66

67 Tips License Updates Updated Credentials: License As long as there are no changes to information, license updates are not required if you are licensed with the following: Idaho State Board of Nursing Idaho State Board of Medicine Idaho State Board of Pharmacy 67

68 Tips License Updates The Molina Medicaid website ( has the following resources: o Provider Enrollment - Verifying Enrollment Application Status o Provider Handbook o User Guides Contact Molina at 1 (866) or idproviderenrollment@molinahealthcare.com for assistance with enrollment or maintenance 68

69 Provider Relations Consultants Region 1 and the state of Washington 1 (208) Region.1@MolinaHealthCare.com Region 2 and the state of Montana 1 (208) Region.2@MolinaHealthCare.com Region 3 and the state of Oregon 1 (208) Region.3@MolinaHealthCare.com Region 4 and all other states 1 (208) Region.4@MolinaHealthCare.com Region 5 and the state of Nevada 1 (208) Region.5@MolinaHealthCare.com Region 6 and the state of Utah 1 (208) Region.6@MolinaHealthCare.com Region 7 and the state of Wyoming 1 (208) Region.7@MolinaHealthCare.com 69

70 Thank you for attending our Eligibility Training. Please take a few minutes to complete the evaluation. This provides us with valuable information for future trainings. 70