Express Enrollment FAQs

Transcription

1 Express Enrollment FAQs Below is a list of questions received during the Express Enrollment Training for Plans webinar and the corresponding Agency responses. Q: How is the plan determined for a new Medicaid recipient if they do not select a plan? A: If a new Medicaid recipient does not make a plan choice and they are mandatory to enroll into MMA, they will be auto-assigned to a plan using the Agency s existing auto-assignment algorithm. Q: Is there a delay in auto-assignment and therefore a delay on the daily file if a plan is not picked? A: No. If a new Medicaid recipient does not make a plan choice they will be auto-assigned to a plan. Q: Will there be a cap placed on the number of plan changes the enrollee may make during the 120 day change period? A: No. Q: Will plans be required to meet current contract requirements with regards to mailing/ providing new member materials if the recipient is enrolled at the end of one month and chooses to disenroll and change plans at the beginning of the next month? A: Plans are required to provide enrollee materials within five (5) days of receipt of the 834 daily file for each recipient. For example, if the recipient chooses a plan on October 27th and subsequently disenrolls October 31st, the plan is still responsible for services that may have been provided between October 27th through the 31st. Please note, the SMMC November contract amendment allows plans to only provide a hard copy of the enrollee handbook and provider directory at the request of the enrollee. Q: How will newborn enrollment be handled in the case of a baby born at the end of the month and mom moves to another plan the next month? How is the plan expected to handle the baby claim? A: Newborn enrollment will continue to operate as it does today. Express Enrollment does not change the current policy for newborn enrollment. If a mom changes plans the month after she gives birth the newborn will not automatically follow unless she makes that request. December 15,

2 Q: Will enrollees still have an option to select a primary care provider (PCP) through this process? A: If the recipient selects a plan through the Express Enrollment website and indicates which PCP they would like through that process, yes. If the recipient does not select a plan there will not be a PCP associated with the recipient when they are enrolled into a plan. Q: Is choice counseling still available for recipients who are enrolled through Express Are Choice Counseling home visits/private sessions still available? A: Choice counseling is still available for all recipients online or by calling the Call Center. Home visits/private sessions will not be available prior to enrollment via the Express Enrollment process but will be available during the 120 day change period if requested. Q: Is there any discussion regarding specialty plans being included in Express A: Yes. A recipient may select a MMA Specialty Plan through the Express Enrollment process if they have an active specialty plan eligibility indicator on file. Q: When a recipient changes plans during the initial 120 day timeframe will the recipient receive another 120 day change period? A: Yes. Q: Will Express Enrollment be limited to those who choose a plan through the Express Enrollment website? A: No, all recipients who gain Medicaid eligibility and are mandatory for MMA will be subject to the Express Enrollment process. Q: How do continuity of care requirements work for individuals who enrolled through Express A: Health plans are responsible for coordination of care for new enrollees transitioning into the health plan. In the event a new enrollee is receiving prior authorized ongoing course of treatment with any provider, the health plan must be responsible for the costs of continuation of such course of treatment in accordance with requirements in Attachment II, Exhibit II-A, Section VII.H. of the contract. December 15,

3 Q: Who is responsible for payment of an inpatient stay for an individual who is enrolled through Express A: Implementation of Express Enrollment will not change the continuity of care provisions around hospitalization and payment. The entity responsible for payment on the date of admission for the hospital inpatient stay is responsible for payment of the entire hospital stay. For a recipient who is retroactively eligible for Medicaid fee-for-service (FFS) prior to Medicaid health plan enrollment, the hospital stay will be covered under fee-for-service. Physician services, which are billed separately, must to be billed to the entity responsible for coverage of the recipient on the date of service. If there is no prospective or retroactive period of Medicaid eligibility prior to the individual s enrollment in a health plan, the health plan will cover the hospital stay beginning on the date of eligibility and enrollment, and health plans paying through a DRG methodology may adjust the DRG payment. Q: When will the Express Enrollment website go live? A: The Express Enrollment website will go live in early January, when Express Enrollment goes live. Q: What does the eligibility cycle look like? For example, if an individual is deemed eligible on the 8 th of the month is their eligibility retro-active to the first of the month or prospective to the first of the following month? A: In the scenario above, the Medicaid eligibility is retro to the first of the month but the recipient would be enrolled in the plan effective on the 8 th of the month. The enrollment is neither retrospective nor prospective, but occurs on the day of eligibility determination. Q: Will the recipient's plan effective date and plan appear in FMMIS and the Medicaid Eligibility Verification System (MEVS) on the same day the member became Medicaid eligible? A: No. The recipient s eligibility will be reflected in FMMIS and MEVS with their plan enrollment effective date on the day following eligibility determination. Q: How will this impact Medicaid Redetermination dates provided on the 834 file? A: There are no changes to the redetermination information provided within the 834 file. December 15,

4 Q: Will express enrollments come in with a "021" maintenance code on the 834 daily file? A: Yes. Q: Will the Benefit Begin date on the 834 daily file be the same date a recipient became Medicaid eligible? Will this be the same as the Plan Enrollment date on the 834 file? A: The Benefit Begin date will be the first date of Medicaid eligibility but not the date the recipient is enrolled in the plan, as Medicaid eligibility will cover the entire month a recipient is deemed eligible. The benefit begin date will not change from the way it looks on the 834 daily file now. The Plan Enrollment Date will be the day the recipient is determined Medicaid-eligible and enrolled in the plan. For Example: If someone was determined Medicaid-eligible on 10/8/16, the Benefit Begin date would be 10/1/16 and the plan enrollment date would be 10/8/16. Q: Will the State provide an identifier on the 834 and/or 820 files indicating members are Express A: The 834 file will not have an identifier but the 820 file will have the identifier of H6. More information about changes to the 820 file will be provided in an update to the Companion Guide prior to implementation. Q: If a member is Express Enrolled on 10/8/16, will the enrollment show on both the 10/9/16 daily file and on the monthly magic file on 10/24/16? A: No. The member will only show on one 834 daily file. The monthly magic 834 file is just another 834 daily file. Q: Is Express Enrollment replacing the Monthly Magic enrollment cycle? A: The penultimate Saturday of every month will continue to be used as a cut-off date for calculating capitation payments in the monthly financial cycle. Q: What type of rate methodology will Milliman use to determine the rates for members that are assigned to the Plans for a partial month? A: Milliman developed separate rates for the period after implementation of Express Enrollment. The rates are on a PMPM basis, and FMMIS will handle reimbursing portions of this rate depending on the December 15,

5 days of enrollment into the plan. The plans will receive a prorated capitation payment for the first month for recipients enrolled if the recipient is enrolled in the plan for less than the full month. Prorated capitation payment is only applicable for enrollments on the 2nd of the month or later. In these cases, FMMIS will calculate and pay the pro-rated amount, based on the following formula: Formula: (1-((D-1)/M))*C D: The effective enrollment day of the month a person comes into a plan M: Number of days in the month C: The monthly capitation rate for the plan Example A: If the rate is $ and the person comes into the plan effective the 6th of January 2016, the payment would be calculated as follows: (1- ((6-1)/31))*$100 =.8387*100 = $83.87 Example B: If the rate is $ and the person comes into the plan effective the 2nd of February 2016, the payment would be calculated as follows: (1 - ((2-1)/29))*$100 =.9642*100 = $96.55 December 15,