Eligibility 1
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
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
Verifying Eligibility Three ways to check eligibility: MACS Medicaid Automated Customer Service 1(866)686-4272 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
Verifying Eligibility Trading Partner Eligibility https://www.idmedicaid.com 5
Verifying Eligibility Trading Partner Eligibility 6
Verifying Eligibility Trading Partner Eligibility Two pieces of identifying information required 7
Verifying Eligibility Trading Partner Eligibility 8
9 Verifying Eligibility
10 Benefit Plans
Benefit Plans Benefit Plans: Idaho Medicaid Benefit Plan Part B Premium Medicare Medicaid Coordinated Plan (MMCP) For more information on these plans, visit http://healthandwelfare.idaho.gov/medical/medicaid 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 Coverage Codes
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
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
Coverage The following are additional programs always preceded by a primary coverage. Preventative Health Assistance (PHA) Traditional DD Children s Waiver 15
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 www.healthandwelfare.idaho.gov for list of detailed services. 16
Coverage Basic Plan Example 17
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
Coverage Enhanced Plan Example 19
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
Coverage PW Program Example 21
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
Coverage QMB Example 23
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
Coverage SLMB Example 25
Coverage Medicare and Medicaid Eligible What expenses are covered for participants who are Medicare and Medicaid eligible? QMB benefits Medicaid covered services 26
Coverage Medicare and Medicaid Eligible Example 27
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
Coverage MMCP Example 29
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) 364-1843 or visit medicaidphaprogram@dhw.idaho.gov. 30
Coverage PHA Weight Management Example 31
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
Coverage LTC Example 33
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
Secondary Coverage Waiver Example 35
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
Secondary Coverage Waiver Example 37
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
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
Coverage SOC Example 40
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 www.idmedicaid.com homepage. 41
42 Co-pay Verification
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
Therapy Limitations For questions relating to caps, contact the Division of Medicaid at 1 (208) 364-1897, visit www.medunit.dhw.idaho.gov, or refer to the Annual Benefit Cap FAQ under Hot Topics on the www.idmedicaid.com homepage. 44
Therapy Limitations Caps 45
Therapy Limitations Caps 46
47 No Medicaid Enrollment
Further Information Where to obtain more information: The Provider Handbook General Billing Instructions and General Provider and Participant Information, available at www.idmedicaid.com. Idaho Medicaid Programs are listed in the Idaho Health Plan Coverage booklet available from Division of Medicaid, Department Regional Offices, or online at www.healthandwelfare.idaho.gov. 48
49 Did You Know?
Did You Know? Announcements & IRs 50
Did You Know? Provider Handbook 51
Did You Know? MedicAide Newsletters 52
Did You Know? MedicAide Newsletter 53
Did You Know? User Guides 54
Did You Know? Training 55
Did You Know? Training 56
Did You Know? Training Opportunities Monthly WebEx Trainings Available to all providers Calendar is located at www.idmedicaid.com Regional Workshops Yearly Information will be posted to www.idmedicaid.com Individual Training or Questions Contact your local Provider Relations Consultant 57
Did You Know? Molina Partnership Contacts Contact Description Phone/E-mail Website Health and www.healthandwelfare.idaho.gov Welfare (DHW) Idaho Smiles Dental 1 (800) 936-0978 www.dentaquest.com Magellan Pharmacy Claims Contractor Providers: 1 (800) 922-3987 https://idaho.fhsc.com Participants: 1 (888) 773-9466 Medical Care Unit Optum Idaho PHA (Preventive Health Assistance) Pharmacy Unit with DHW Veyo Disease Management, Durable www.medunit.dhw.idaho.gov 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) 202-0983 https://m1.optumidaho.com/web/optumid aho/home 1 (877) 364-1843 www.medicaid.idaho.gov (Preventive Health Assistance link) medicaidphaprogram@dhw.idaho.gov 1 (866) 827-9967 www.medicaidpharmacy.idaho.gov Fax: 1 (800) 327-5541 Telligen Prior Authorization 1 (866) 538-9510 http://idmedicaid.telligen.com Non-Emergency Medical Participant & Non-Transport Providers: http://idahotransport.com Transportation 1 (877) 503-1261 Transport Providers: 1 (877) 986-7421 58
Enrollment and Maintenance 59
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 Enrollment/Maintenance
Enrollment/Maintenance New Enrollment 62 Note: If enrolling with an NPI, it must be approved prior to beginning the enrollment application.
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 Maintenance Forms
Maintenance Forms General Category 65
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
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
Tips License Updates The Molina Medicaid website (www.idmedicaid.com) has the following resources: o Provider Enrollment - Verifying Enrollment Application Status o Provider Handbook o User Guides Contact Molina at 1 (866) 686-4272 or e-mail idproviderenrollment@molinahealthcare.com for assistance with enrollment or maintenance 68
Provider Relations Consultants Region 1 and the state of Washington 1 (208) 559-4793 Region.1@MolinaHealthCare.com Region 2 and the state of Montana 1 (208) 991-7138 Region.2@MolinaHealthCare.com Region 3 and the state of Oregon 1 (208) 860-4682 Region.3@MolinaHealthCare.com Region 4 and all other states 1 (208) 373-1343 Region.4@MolinaHealthCare.com Region 5 and the state of Nevada 1 (208) 484-6323 Region.5@MolinaHealthCare.com Region 6 and the state of Utah 1 (208) 870-3997 Region.6@MolinaHealthCare.com Region 7 and the state of Wyoming 1 (208) 991-7149 Region.7@MolinaHealthCare.com 69
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