Topics Clients required to be in a managed care or coordinated care plan for physical health Clients exempt from managed care or coordinated care enrollment for physical health The exemption process & exemption codes The exemption process for clients with Third Party Liability (TPL) How to enter an exemption in the MMIS

Terminology FCHP: Fully Capitated Health Plan PCO: Physician Care Organization CDO: Chemical Dependency Organization (available in Deschutes County only) MCO: Managed Care Organization CCO: Coordinated Care Organization MHO: Mental Health Organization PHP: Prepaid Health Plan PMP: Primary Medical Provider

Identifying clients required to be in an MCO or CCO plan for physical health

Who Must be Enrolled in an MCO or CCO Plan? Non-Medicare clients who live in mandatory enrollment areas are required to enroll in an MCO or CCO plan unless they are eligible for an exemption. If the client is eligible for an exemption, an appropriate exemption must be entered in the MMIS. If the client does not meet the exemption criteria, they will be auto enrolled in an MCO or CCO plan (if one is available).

Medicare Clients and Physical Health Managed Care Medicare OHP Plus clients have the option to enroll in an MCO or CCO plan for physical health or to remain fee for service.

Medicare Clients and Physical Health Managed Care Medicare OHP Plus clients must be choice counseled. The Medicaid MCO or CCO plan the client chooses may have a corresponding Medicare Advantage plan (may be Special Needs plan).

Medicare Clients and Physical Health Managed Care Before CCO implementation - To be enrolled in a managed care plan, the client had to enroll into the Medicare Advantage plan offered by the MCO or the managed care plan would request the member to be disenrolled.

Medicare Clients and Physical Health Managed Care After CCO Implementation - Effective August 1, 2012, with CCO implementation, a CCO cannot ask for disenrollment if the member was enrolled in a Medicare Advantage Plan that wasnt specific to the CCO (OAR ).

Managed Care for Dental and Mental Health Local branch staff cannot add exemptions for dental or mental health. All clients with OHP Standard and Plus are required to enroll in dental and mental health plans. This includes both Medicare and non-Medicare clients. If the worker does not enroll them, the MMIS will auto enroll clients in areas of the state where plans are open for enrollment.

Identifying clients exempt from MCO or CCO enrollment for physical health

Managed Care Exemptions Workers have a select group of exemption reasons they can use to exempt a client from MCO or CCO enrollment. If you are setting up a new case through UCMS, please refer to the following guide: The New PHP Enrollment Screens at the URL below.

Managed Care Exemptions FCHP and PCO enrollment types: When entering an exemption, be sure to add it to both FCHP & PCO even if the client lives outside an area serviced by the PCO. This prevents auto enrollment if a client moves to an area serviced by Kaiser, or in the event the PCO expands their service area to where the client currently lives. Kaiser is the only PCO at this time.

Managed Care Exemptions For Medicare OHP Plus clients choosing to remain fee for service: Due to a system limitation, you will need to enter a Medical Medicare Choice exemption for them until MMIS programming is changed to bypass Medicare clients. Use the Medical Medicare Choice exemption code instead of Continuity of Care.

Managed Care Exemptions End Stage Renal Disease (ESRD) Only Client Enrollment Services (CES) can add an exemption for a client with ESRD. Local branch offices do not have authority to add an ESRD exemption. Failure to follow this protocol may result in losing access to the MMIS exemption panels.

Exemption Codes

Access to Care. This code can only be added by DMAP DSU/CES staff. Access to Care is Monitored by CMS. Contractually, MCOs and CCOs are obligated to provide specialty care. If they do not have a provider available in their service area, they must allow the client to go out of area for specialty treatment. The plans reimburse the specialist for providing the service.

Exemption Codes Access to Care, cont… If care cannot be coordinated, DMAP DSU/CES will disenroll the client and exempt the client for Access to Care. If you feel there is an access issue, contact CES or a DMAP PHP Coordinator.

Exemption Codes Continuity of Care – This code should only be used when a clients health will be harmed by a move into an MCO or CCO plan. Use of this code requires documentation in the case file from the physician regarding the clients need. Example: A client requires long-term services from a primary physician for a complicated medical condition and the physician does not participate with any MCO or CCO plan in the clients area. This code is not used for Medicare clients who choose not to enroll.

Exemption Codes Client is Hospitalized – This code is used if the client is in the hospital when their MCO or CCO enrollment would have begun if they hadnt been hospitalized. The client will be fee for service until their discharge from the hospital. Upon discharge, the client will be enrolled in a plan. Hearing Scheduled – Enrollment is delayed. End Stage Renal Disease (ESRD) – Only entered by DMAP. Contact CES to have the exemption added.

Exemption Codes Medical Medicare Choice – This code should only be used in the following circumstances. the client has chosen a Medicare Advantage plan, or the client has chosen a Medicare Part D plan that does not coordinate with the managed care plans available where they live, or the only managed care plans available require the client to be enrolled in a Medicare Advantage plan not of their choosing

Exemption Codes Other – APD/AAA workers should not use this code for exemptions from physical health plans. If you believe that a client needs the Other exemption, send a request to Dr. Tina Kitchin at or via fax at (503) Case workers requesting this exemption should request documentation from the clients physician.

Exemption Codes Proof of Indian Heritage – Exemptions are no longer required for Native Americans or tribal members. This group must opt-in if they wish to be enrolled in an MCO or CCO plan. The worker codes the clients medical eligibility with the HNA Case Descriptor, which excludes the client from the auto enrollment process for all plan types. The worker must manually enroll the tribal member into their chosen plan.

Exemption Codes Religious Consideration – This code is rarely used. An example might be if the clients religion only allows them to be seen by a female physician and the MCO or CCO plan does not have any female physicians available. Surgery Scheduled for Client – Use this code when a surgery is already scheduled and the provider does not participate with any of the available plans. After the post- surgery period has passed, the client must be enrolled in an MCO or CCO plan.

Exemption Codes Rehabilitation/Inpatient/Facility – This code should be used for clients in the Blue Mountain Recovery Center, the Oregon State Hospital, or for those clients in a nursing facility who meet both of the following conditions: 1. The client needs to use the facilitys in-house physician. AND 2. The physician is not a member of an MCO or CCO plan.

Exemption Procedures

Exemptions for physical health are for temporary situations and cannot exceed one year from the date of entry. Exemptions must be reviewed annually at the time of eligibility re-determination. Retroactive exemptions cannot be done by local office staff. Send retro exemption requests to CES.

Exemption Procedures If the client is already enrolled in a physical health plan, the enrollment must be ended before you can add an exemption. Contact CES for any questions about enrollment issues. Adding an exemption does not automatically disenroll a client from an MCO or CCO plan. Note: The Health Insurance Group (HIG) takes care of disenrollments for TPL exemptions.

Exemption Procedures The exemption start date cannot be earlier than the first day of the next new month. Unless approved by DMAP, the MCO or CCO enrollment will end the last day of the current month. You can then add the exemption to begin on the first of the next new month.

Exemption Procedures If you need the disenrollment to occur earlier than the last day of the month, contact CES. Retroactive disenrollments impact capitation payments, enrollment history, and services that have already been delivered. These disenrollments must be done by CES. If you want to end an exemption and enroll a client in a physical health plan, you must end the exemption with a date that is prior to the new enrollment beginning.

Exemptions for TPL

TPL Exemptions Case workers should not add or end TPL exemptions. When HIG receives information that a client has TPL, HIG enters the exemption. HIG then verifies and records the status of the TPL in the MMIS. If the client reports changes to their private health insurance situation, send a completed form MSC 0415H to HIG. (Use form DHS 0156 for emergencies.) HIG will verify the status of the policy and will update the exemption as appropriate.

TPL Exemptions, cont… If the client is enrolled in an MCO or CCO plan, HIG will process the disenrollment effective at the end of the month in which the TPL is added. If the client already has a TPL or ESRD exemption, do not change it to another code type. TPL exemptions can only be ended by HIG. ESRD exemptions can only be ended by CES.

TPL Exemptions, cont… When in doubt, check with CES or HIG before changing an existing exemption code. HIG only handles exemptions for TPL. If the exemption is related to third party insurance, contact HIG. For all other exemption reasons, contact CES.

New CCO Exemption Codes With the inception of CCOs, the Managed Care Special Conditions panel in the MMIS will now display additional exemption codes for the new CCO plan types.

New CCO Exemption Codes CCO exemptions: A - EXQ - Mental / Physical / Dental B - EXR - Mental / Physical C - EXS - Physical / Dental D - EXT - Physical E - EXU - Mental

How to enter a managed care exemption in the MMIS.

Health Insurance Group (HIG) Phone: Fax:

For assistance with exemptions or MCO & CCO enrollments and disenrollments, please contact Client Enrollment Services. Client Enrollment Services (CES)

Questions about MMIS Training Bob Costa MMIS Training Manager Oregon Health Authority