PrimeWest Health System Minnesota Senior Health Options MSHO Program Effective August 1, 2005

What is MSHO? State-defined program State-defined program Members have combined Medicare and Medicaid coverage Members have combined Medicare and Medicaid coverage PrimeWest responsible for adjudicating benefits PrimeWest responsible for adjudicating benefits Eligibility determined by MN DHS Eligibility determined by MN DHS Includes pharmacy benefit (effective 1/1/06) Includes pharmacy benefit (effective 1/1/06)

Billing: Medicare Covered Services Bill using CMS guidelines Bill using CMS guidelines Check with PrimeWest for exceptions Check with PrimeWest for exceptions All MSHO plans must waive the 3-day qualifying hospital stay prior to SNF or home care All MSHO plans must waive the 3-day qualifying hospital stay prior to SNF or home care Reimbursement based on CMS rates Reimbursement based on CMS rates Combined Medicare and Medicaid payment on one claim Combined Medicare and Medicaid payment on one claim Generally no deductibles/coinsurance Generally no deductibles/coinsurance Check your contract for payment rates Check your contract for payment rates

Billing: Medicare NON-Covered Services Bill using DHS guidelines Bill using DHS guidelines Reimbursement based on DHS rates Reimbursement based on DHS rates Generally based on MA rates Generally based on MA rates Subject to State coinsurance determinations Subject to State coinsurance determinations Check your contract for payment rates Check your contract for payment rates

Coordination of Benefits (COB) When no secondary insurance: When no secondary insurance: No need to submit multiple claims No need to submit multiple claims Medicare/Medicaid payment combined into one claim Medicare/Medicaid payment combined into one claim Supplemental policies Supplemental policies PrimeWest will recoup payment from supplement. PrimeWest will recoup payment from supplement.

Checking Eligibility Check eligibility on all MN Health Care Plan enrollees each month. Check eligibility on all MN Health Care Plan enrollees each month. Verify eligibility through the Electronic Verification System (EVS) at or through ProviderInsite.org Verify eligibility through the Electronic Verification System (EVS) at or through ProviderInsite.org A member’s coverage will never be terminated in the middle of a month. PW coverage is not retroactive, but if a member is eligible during a month, they will be covered throughout the whole month. PW does not determine a member’s eligibility. This is determined by the county. A member’s coverage will never be terminated in the middle of a month. PW coverage is not retroactive, but if a member is eligible during a month, they will be covered throughout the whole month. PW does not determine a member’s eligibility. This is determined by the county.

Benefits for the Members Enrolled in MSHO This is Total Coordinated Health care, including Medicaid and Elderly Waivered Services. This is Total Coordinated Health care, including Medicaid and Elderly Waivered Services. Each member is assigned a Care Coordinator and a County Case Manager. Each member is assigned a Care Coordinator and a County Case Manager. Minimum Yearly assessment of individual. Minimum Yearly assessment of individual. 3-day qualifying hospital stay waived to access Medicare A benefits for SNF or home care. 3-day qualifying hospital stay waived to access Medicare A benefits for SNF or home care.

Benefits for the Members Enrolled in MSHO (Continued) No limit on blood transfusions No limit on blood transfusions Diabetic shoes. Diabetic shoes. Automatic enrollment into Medicare Part D program through PrimeWest. Automatic enrollment into Medicare Part D program through PrimeWest.

Authorizations For all members enrolled in MSHO, PrimeWest pays the Medicare and Medicaid benefit in one combined payment. If a member chooses to go to a non-contracted provider, prior to seeing the member, the provider must obtain a service authorization. For all members enrolled in MSHO, PrimeWest pays the Medicare and Medicaid benefit in one combined payment. If a member chooses to go to a non-contracted provider, prior to seeing the member, the provider must obtain a service authorization. This authorization may be obtained by calling Medical Administration at (866) This authorization may be obtained by calling Medical Administration at (866)

Claim Submission Member’s ID number for Part A, B, or D is their PrimeWest ID number. Member’s ID number for Part A, B, or D is their PrimeWest ID number. Claims for Covered Services rendered to MSHO members should be submitted to and received by PrimeWest no later than one-hundred and eighty (180) days from the date of service. Claims for Covered Services rendered to MSHO members should be submitted to and received by PrimeWest no later than one-hundred and eighty (180) days from the date of service. Claims should be sent to PrimeWest Health System at: Claims should be sent to PrimeWest Health System at: 822 South 3 rd St., Ste 150 Minneapolis, MN 55415

180 day benefit 180 day benefit: (Nursing Home Residents) 180 day benefit: (Nursing Home Residents) Any PrimeWest Health System enrollee admitted to a nursing home from the community is entitled to 180 days of care paid for by PrimeWest. After the initial 180 days, billing for nursing facility care should be submitted to the Minnesota Department of Human Services (DHS). If a PrimeWest Health System enrollee is currently residing in the nursing home at the time they enroll in MSHO or MSC, they are NOT entitled to the 180 day benefit.

180 Day Benefit (cont.) Medicare SNF days. Medicare SNF days. PrimeWest is responsible for services covered under the Medicare Advantage Special Needs Population (SNP) benefit regardless of whether NF liability is indicated on the State’s Medical Assistance file. PrimeWest is responsible for services covered under the Medicare Advantage Special Needs Population (SNP) benefit regardless of whether NF liability is indicated on the State’s Medical Assistance file. Medicare SNF days for the Enrollee incurred prior to the begin date of the 180-day NF benefit do not count toward the 180 day benefit. This section does not apply to the 90-day NF benefit. Medicare SNF days for the Enrollee incurred prior to the begin date of the 180-day NF benefit do not count toward the 180 day benefit. This section does not apply to the 90-day NF benefit.

180 Day Benefit (cont.) Swing Beds These include Medicare SNF days and Medicaid room and board days provided in swing beds that meet all other requirements for use of swing beds, including claims processing procedures and Minnesota Department of Health approval. These include Medicare SNF days and Medicaid room and board days provided in swing beds that meet all other requirements for use of swing beds, including claims processing procedures and Minnesota Department of Health approval.

180 Day Benefit (cont’d) Swing Beds PrimeWest Health System must be notified when a member is in a Swing Bed. Use the appropriate notification form based on the member’s enrollment. PrimeWest Health System must be notified when a member is in a Swing Bed. Use the appropriate notification form based on the member’s enrollment. MSHO members-MSHO notification form MSHO members-MSHO notification form PMAP members – PMAP form PMAP members – PMAP form

Hospice When MSHO member chooses to enroll in hospice, they remain in MSHO; but Medicare assumes direct responsibility for all Part A & B services for that member, including but not limited to the hospice services. When MSHO member chooses to enroll in hospice, they remain in MSHO; but Medicare assumes direct responsibility for all Part A & B services for that member, including but not limited to the hospice services. Institutional SNF or NF days that accrue during a hospice election period do not cound toward the 180 day SNF/NF benefit period. Institutional SNF or NF days that accrue during a hospice election period do not cound toward the 180 day SNF/NF benefit period. Institutional room & board for these days is paid by the State on a fee-for-service basis (DHS contract section C-4) Institutional room & board for these days is paid by the State on a fee-for-service basis (DHS contract section C-4) Days accrued in the hospice setting do not count toward the 180 day SNF/NF benefit. Days accrued in the hospice setting do not count toward the 180 day SNF/NF benefit.

Hospice (cont.) Essentially a hospice member is still officially enrolled in MSHO, but the coverage reverts to a status more like Minnesota Senior Care (MSC), with PrimeWest responsible only for the Medicaid-covered services not covered by Medicare. Essentially a hospice member is still officially enrolled in MSHO, but the coverage reverts to a status more like Minnesota Senior Care (MSC), with PrimeWest responsible only for the Medicaid-covered services not covered by Medicare.

180 Day Benefit (cont.) Medicaid NF days Medicaid NF days These may include Medicaid leave days. Leave days must be for hospital or therapeutic leave of an Enrollee who has not been discharged from a long term care facility. These may include Medicaid leave days. Leave days must be for hospital or therapeutic leave of an Enrollee who has not been discharged from a long term care facility. According to current MA standards, payments for hospital leave days are limited to 18 consecutive days for each separate and distinct episode of Medically Necessary hospitalization, and payments for therapeutic leave days are limited to 36 leave days per calendar year. According to current MA standards, payments for hospital leave days are limited to 18 consecutive days for each separate and distinct episode of Medically Necessary hospitalization, and payments for therapeutic leave days are limited to 36 leave days per calendar year. Respite days do not count towards the Medicaid or Medicare Benefit Period. Respite days do not count towards the Medicaid or Medicare Benefit Period.

180 Day Benefit (cont.) If a PrimeWest enrollee is in the middle of their 180 day benefit and they enroll in MSHO, this benefit ends. DHS is responsible for this member’s nursing care. If a PrimeWest enrollee is in the middle of their 180 day benefit and they enroll in MSHO, this benefit ends. DHS is responsible for this member’s nursing care.

180 Day Benefit Cont. New Admission: Example: New admit on (currently does not have PrimeWest). 1/1/06 person signs up for PrimeWest/MSHO – This resident is NOT entitled to the 180 day benefit, as he/she was residing in the nursing facility at the time of enrollment. New Admission: Example: New admit on (currently does not have PrimeWest). 1/1/06 person signs up for PrimeWest/MSHO – This resident is NOT entitled to the 180 day benefit, as he/she was residing in the nursing facility at the time of enrollment.

100 Medicare Days MSHO enrollees are entitled up to 100 days of Medicare coverage if the Medicare qualifications have been met. MSHO enrollees are entitled up to 100 days of Medicare coverage if the Medicare qualifications have been met. The nursing facility should notify PrimeWest Health System of when the resident became a Medicare skilled level of care using the MSHO notification form. The nursing facility should notify PrimeWest Health System of when the resident became a Medicare skilled level of care using the MSHO notification form. Once the 100 days of Medicare coverage are used, the person is not entitled to another 100 days, unless there has been a 60 day break from the Medicare skilled level. Once the 100 days of Medicare coverage are used, the person is not entitled to another 100 days, unless there has been a 60 day break from the Medicare skilled level.

100 Medicare Days (cont) Claims for the Medicare days for an MSHO enrollee would be sent to PrimeWest. Claims for the Medicare days for an MSHO enrollee would be sent to PrimeWest. A resident is entitled to the 100 Medicare days no matter how long they have been a resident at the nursing facility, as long as they meet the requirements of a skilled level of care. A resident is entitled to the 100 Medicare days no matter how long they have been a resident at the nursing facility, as long as they meet the requirements of a skilled level of care. If a resident remains at a Medicare skilled level and has used up their 100 days, they are NOT entitled to an additional 100 days. If a resident remains at a Medicare skilled level and has used up their 100 days, they are NOT entitled to an additional 100 days.

MSHO Notification Form This form is used ONLY for PrimeWest MSHO members. Use this form to notify PrimeWest and MHP of Medicare days used and notification of the 180 day benefit. This form must be faxed to both PrimeWest and MHP. The only time this form is sent to the State is to notify them of the end of the 180 day benefit. This form is used ONLY for PrimeWest MSHO members. Use this form to notify PrimeWest and MHP of Medicare days used and notification of the 180 day benefit. This form must be faxed to both PrimeWest and MHP. The only time this form is sent to the State is to notify them of the end of the 180 day benefit. This form can be found on our website: (Partners & Providers>Resources>SNF Notification Form) Instructions for completing this form are also on the website. This form can be found on our website: (Partners & Providers>Resources>SNF Notification Form) Instructions for completing this form are also on the website.

PMAP Form This form is a notification form for all PMAP members that are NOT enrolled in MSHO. This form is a notification form for all PMAP members that are NOT enrolled in MSHO. Use this form to notify PrimeWest and MHP of any admission or change in RUG level. Use this form to notify PrimeWest and MHP of any admission or change in RUG level. Use this form to notify the State at the end of the 180 day benefit. Use this form to notify the State at the end of the 180 day benefit. This form must be faxed to MHP and PRIMEWEST. This form can be found on the DHS website. This form must be faxed to MHP and PRIMEWEST. This form can be found on the DHS website.

1503 Form Unless you are completing an original 1503 form, this form DOES NOT need to be signed by a physician. It can be signed by an RN, or Director of Nurses. Unless you are completing an original 1503 form, this form DOES NOT need to be signed by a physician. It can be signed by an RN, or Director of Nurses. The SNF must complete and submit to the county financial worker in a timely manner. The SNF must complete and submit to the county financial worker in a timely manner.

Medicare Reimbursement Program (MREP) At this time, this is still in place. At this time, this is still in place. Continue to file these as you have before MSHO. Continue to file these as you have before MSHO. As the entire State goes to MSHO, this may eventually be discontinued. As the entire State goes to MSHO, this may eventually be discontinued.

Billing 210 Bill – No need for this as PrimeWest Health System is paying both portions of the claim. 210 Bill – No need for this as PrimeWest Health System is paying both portions of the claim. The 60 day break in spell of illness will be tracked by the MSHO Notification Form. The 60 day break in spell of illness will be tracked by the MSHO Notification Form. Demand Bill – The member is entitled to receive one if they request it. Demand Bill – The member is entitled to receive one if they request it. Medicare Denials – These are still in place. Follow same guidelines as in the past. Medicare Denials – These are still in place. Follow same guidelines as in the past.

Durable Medical Equipment (DME) Supplies When ordering DME supplies for your residents, the vendor you order the supplies from may not be contracted with PrimeWest. When ordering DME supplies for your residents, the vendor you order the supplies from may not be contracted with PrimeWest. To assure that this vendor will be reimbursed for these supplies, we encourage you to call Medical Administration for a service authorization for the item. To assure that this vendor will be reimbursed for these supplies, we encourage you to call Medical Administration for a service authorization for the item.

Durable Medical Equipment (cont.) Medical Administration at (866) Medical Administration at (866) Needs to be done each time an item/supply is ordered for this MSHO member. Needs to be done each time an item/supply is ordered for this MSHO member. If the vendor is interested in contracting with PrimeWest Health System If the vendor is interested in contracting with PrimeWest Health System Robin Zimmerman, Credentialing Specialist (320) Robin Zimmerman, Credentialing Specialist (320)

“Bad Debt” Reconciliation PrimeWest is not part of this process PrimeWest is not part of this process We are not a fiscal intermediary We are not a fiscal intermediary We are a public program that receives funds from the State and CMS to cover only the medical services of our members. We are a public program that receives funds from the State and CMS to cover only the medical services of our members. We do not receive extra funds from CMS to reimburse this. We do not receive extra funds from CMS to reimburse this. Concerns regarding this need to be addressed directly with CMS. Concerns regarding this need to be addressed directly with CMS.

Other helpful information PrimeWest Web site: PrimeWest Web site: Check frequently for timely updates Administrative manual Prime Pointers Pharmacy Link Provider Insite Credentialing This presentation Much more!

Questions? Contact numbers: Contact numbers: (Provider Services) (Medical Admin-Service Auth) (Member Services) Provider Relations: Kathleen Lowden Becky Walsh Marcie Vickerman See hand out for additional contacts.

Thank-you!!