1. Presented by: Dana Pepmeier, Janice Shields & Lisa Brockman
Medicaid Eligibility Provider responsibilities regarding Medicaid eligibility & financial eligibility processes for the Children’s Mental Health Waiver (CMHW)
February 21, 2018
Presented by: Dana Pepmeier, Janice Shields & Lisa Brockman

2. Who is responsible for the eligibility process?
The ultimate responsibility for enrollment/re-enrollment with Medicaid rests on the applicant or their guardian
Medicaid is an important resource for many Wyoming residents it maintain health and wellness
Learning how to manage the enrollment/re-enrollment process is an essential skill and there are tools and supports to assist with the process
Medicaid clients have access to a client portal on the Medicaid fiscal agent’s website here:
Clients can check their own eligibility status on the website and there is a tutorial on how to register and use the site
Clients can also ask Medicaid questions, complete transportation requests, find a Medicaid provider, and order replacement Medicaid ID cards from the portal
Clients can share this information with their HFWA provider
Only for clients who are currently enrolled in Medicaid (not pending enrollment)

3. Who is responsible for the eligibility process?
Medicaid provider agreement requires enrolled providers to be familiar with the Medicaid policies, including verifying client eligibility
One (1) Medicaid ID Card is issued to each client. Their eligibility information is updated every month. The presentation of a card is not verification of eligibility. It is each provider’s responsibility to ensure that their patient is eligible for the services rendered. A client may state that he/she is covered by Medicaid, but not have any proof of eligibility. This can occur if the client is newly eligible or if his/her card was lost.
Authorization of service is not a guarantee of Medicaid eligibility

4. Provider Responsibilities
Provider responsibilities are outlined in Chapter 3 of the CMS manual and include the following language in bold:
Providers must verify eligibility each month as programs and plans are re- determined on a varying basis, and a client eligible one (1) month may not necessarily be eligible the next month. [Pg. 23-Provider Responsibilities]
Adults are eligible in one month spans and children’s eligibility usually runs in year long (12 month) spans per the Medicaid State Plan, however, there are exceptions which makes month to month verification a good practice

5. CMS 1500 manual
While a best practice is to assist clients to use the client portal to confirm eligibility and share that information with their provider, Chapter 3 of the manual also lists additional free resources for providers to check client eligibility:
Contact Provider Relations. There is a limit of three (3) verifications per call but no limit on the number of calls
Fax a list of identifying information to Provider Relations for verification. Send a list of beneficiaries for verification and receive a response within ten (10) business days
Call the Interactive Voice Response (IVR) System. IVR is available 24-hours a day, seven (7) days a week. The IVR System allows 30 minutes per phone call
Use the Ask Wyoming Medicaid feature on the Secured Provider Web Portal

6. Care Management Entity (CME) Eligibility
Children and youth who are enrolled with Medicaid can become eligible to receive the CME benefit by meeting clinical eligibility requirements
Children and youth who aren’t eligible for “regular” Medicaid may access the CME through the Children’s Mental Health Waiver (CMHW)
CMHW applicants must meet both the clinical eligibility criteria and the financial eligibility criteria
The CMHW financial eligibility criteria only looks at the child/youth’s income and resources (bank account, CD’s, bonds, life insurance cash value, etc.) not that of the whole household (family)
It is essential that Appendix D of the financial application be completed with the youth’s information only
The financial application needs to be part of the application packet submitted to Magellan and is forwarded to the appropriate eligibility worker for processing

7. CMHW Eligibility Process
The Long Term Care Eligibility Unit determines the financial eligibility for the CMHW
When the State’s CMHW Program Manager receives a waiver application, it’s entered in the States electronic waiver management system (EMWS)
The clinical eligibility is determined and a certified letter is issued to the guardian or young adult applicant to let them know if they met the clinical eligibility criteria
If they met clinical criteria, the certified letter directs the guardian to contact a specific eligibility worker in the LTC Unit
The letter also discusses the required documentation that needs to be provided to help determine financial eligibility

8. CMHW Eligibility Process
The certified letter cannot be forwarded and is returned to the State if it was not claimed or was deemed undeliverable by the USPS
The financial eligibility follow up required by the family or young adult applying for the CMHW is the process that stalls the most
It’s not that unusual to see a few cases sitting for months waiting for completion of the financial eligibility process which requires a call from the family/guardian to the designated eligibility worker
The CMHW program manager will copy a FCC on the certified letter via if there is a signed COP in the application packet

9. CMHW Eligibility Process
Once financial eligibility is determined, the waiver system sends a task to the CMHW program manager to confirm the date of Medicaid enrollment and the youth is activated for CME enrollment with a specific funding date that comes from the funding letter sent by certified mail to families and young adult applicants
If the CMHW waiver funding opportunities are full for the month, the youth will go on a waitlist to be activated for the next available slot
Wait list management may change due to urgent need or to accommodate a youth already enrolled with the CME who lost regular Medicaid and are transferring to the CMHW to continue in HFWA

10. Medicaid Eligibility Resources
Customer Service Center or online application at
LTC Unit (CMHW) or the direct line of the eligibility worker assigned which is listed in the financial eligibility process letter that goes to the family/guardian
LTC Unit fax # Can fax CMHW financial eligibility documents directly to the LTC Unit

11. Questions??