1. Long Term Care Medicaid Managed Long Term Care

2. Objectives
Understand the basic policies of the Family Care, Partnership, PACE, and IRIS programs
Understand the roles and responsibilities of the main players involved in managing the MLTC Programs
The Aging and Disability Resource Center (ADRC)
The County Income Maintenance unit
The Long Term Care Managed Care Program (LTMCP), e.g. the Managed Care Organization (MCO)
Understand how to enroll and disenroll members in the MCO through CARES
DHS/DHCAA/BEPS Training
April 2010

3. Introduction to MLTC
Managed Long Term Care Programs deliver long-term care services through a Managed Care Organization (MCO) instead of the ‘Fee for Service’ delivery method.  When enrolled in the MCO the individual receives medical services through a health plan or network of providers which coordinates the services provided. Medicaid pays a fixed rate (Capitation Payment) in advance for each enrollee
DHS/DHCAA/BEPS Training
April 2010

4. Fee for Service vs Managed Care
FFS
Under the Home and Community Based Waivers (HCBW) programs, LTC Services are provided on a Fee for Services basis
Each instance that a LTC service is provided to a member, a separate charge is incurred.
Managed Care
Managed Care is an integrated service package with a provider network that enables LTC services
MCOs receive a per person per month “capitation (cap)” payment, based on the LOC, to manage care for their members.
vs.
DHS/DHCAA/BEPS Training
April 2010

5. Managed Long Term Care (MLTC) Medicaid Programs
Family Care
Partnership
PACE
IRIS Program (Not Managed Care)
Participation in MLTC Programs is voluntary. Members are allowed to choose from these programs and switch to other available programs as they wish.
DHS/DHCAA/BEPS Training
April 2010

6. Managed Care AdministrationIM
ADRC (or Partnership Organization)
Determine and certify Medicaid eligibility
Enter MCO enrollments and disenrollments in CARES
Provide information & assistance
Provide counseling about LTC Options
Conduct functional eligibility determination
Gather Financial/MRE Information for IM
MCO
Complete a comprehensive assessment and develop a plan of care
Provide and/or coordinate LTC services
DHS/DHCAA/BEPS Training
April 2010

7. Family Care
Family Care enrolls people who meet the functional level of care and are:
65 years of age or older, or
At least 18 years old and physically disabled, or
At least 18 years old and developmentally disabled, or
Under 65, not determined disabled, and eligible for one of the following Medicaid/BC+ categories
BC+ Standard Plan
Well Woman Medicaid
Medicaid through Adoption Assistance
Foster Care Medicaid
DHS/DHCAA/BEPS Training
April 2010

8. Family Care Functional Eligibility
ADRC staff use the Long Term Care Functional Screen to assess a Family Care applicant’s long term care needs and to determine level of care (LOC).
The functional LOC information is provided to the IM Worker, along with the med/remedial and MA card coverable expenses so that s/he can determine eligibility for Family Care.
The Community Waiver Page must be completed even if the applicant is not waiver eligible so LOC can be updated.
DHS/DHCAA/BEPS Training
April 2010

9. CWW Functional Eligibility Entries
Initial screening results are communicated to IM from the ADRC and are entered directly on the Family Care and Community Waiver pages.
Subsequent screenings are auto-populated to CWW through the Community Waiver page.
You can tell the LOC was auto-updated by the verification codes, D2 and D3.
If the auto-update fails, the screener will send a form to the IM worker for a manual update in CWW
The history of updates is available on the Family Care and Community Waivers pages.
DHS/DHCAA/BEPS Training
April 2010

10. Family Care Functional Eligibility
The Family Care levels of care are:  
Nursing Home
Individuals who are found functionally eligible for Nursing Home LOC are subject to Waiver logic in determining their financial eligibility for Family Care (if they are 65 or older, or have been determined disabled).
DHS/DHCAA/BEPS Training
April 2010

11. Family Care Functional Eligibility
Non-Nursing Home
Individuals who are found functionally eligible for Non-Nursing Home LOC can enroll in FC but  can not be tested for Medicaid using Waiver logic. These individuals must meet the criteria for another program of Medicaid to enroll in FC.
Note: There are specific Managed Care capitation rates associated with these levels of care, so it is important that level of care and level of care effective date information are entered accurately in CARES.
DHS/DHCAA/BEPS Training
April 2010

12. Family Care and Disability Determinations
Individuals who are under 65 years of age can be enrolled in Family Care without a disability determination if they are:
a) Functionally eligible for Family Care and
b) Eligible for one of the following Medicaid/BadgerCare categories:
BadgerCare Plus Standard Plan
Well Woman Medicaid
Medicaid through Adoption Assistance or
Foster Care Medicaid
DHS/DHCAA/BEPS Training
April 2010

13. Family Care and Disability Determinations
If the individual is under 65 and not eligible for one of the above Medicaid/BadgerCare Plus categories, s/he must be determined disabled and eligible for an EBD category of Medicaid to enroll in Family Care.
MAPP
Waivers
SSI-Related MA (MS, NS, or met deductible)
DHS/DHCAA/BEPS Training
April 2010

14. Family Care Enrollment Date
The enrollment date is always the date the member is enrolled in the MCO. The ADRC provides the enrollment date to the IM worker. This is the date the MCO will begin providing services to the member.
The enrollment date is entered on the Family Care Page in CWW.
The enrollment date determines the date the capitation payments to the MCO begin.
DHS/DHCAA/BEPS Training
April 2010

15. Family Care Page

16. FC Waivers Page
This page must be completed to ensure LOC auto updates.
If the member has a Non-NH LOC, then Functionally Eligible should be answered “No”.

17. Eligibility vs Enrollment
A FC enrollee must be Medicaid eligible. Enrollment cannot be updated on Forward Health interChange (iC) if there is no eligibility. CARES will fail FC if the person is not eligible for Medicaid.
If the Medicaid is pending, CARES will fail the FC. The FC AG should not be confirmed in this situation. If the fail is confirmed, a disenrollment date will be automatically populated on the FC Page. Confirmation of Medicaid and FC should be done at the same time.
DHS/DHCAA/BEPS Training
April 2010

18. Eligibility vs Enrollment
Enrollment is sent to iC based on the information on the most current FC page. You don’t have to run with dates to send past enrollment or a disenrollment but you do have to confirm the FC AG on AGEC.
The FC AG will display the reason codes 331 and 332. These codes indicate whether the member is an SSI recipient (331) or has been determined eligible for a different category of Medicaid (332).
DHS/DHCAA/BEPS Training
April 2010

19. Eligibility vs Enrollment
Medicaid Eligibility must be sent for each month to update iC. You do have to run with dates to send past eligibility if it has not already been confirmed and sent. Check iC to identify information already sent.
Medicaid Eligibility can be updated with an F Enrollment can not be updated with an F
DHS/DHCAA/BEPS Training
April 2010

20. Eligibility Run Results

21. Family Care Cost Share
When the Medicaid eligibility is determined using Waiver logic, the Waiver cost share is the FC cost share.
When the Medicaid eligibility is Institutional Medicaid, the patient liability is the FC cost share.
Both of these types of cost shares are identified as “Waiver Cost Share” amounts in iC. These “Waiver Cost Share” amounts are used to offset the member’s Family Care capitation payments to the MCO.
DHS/DHCAA/BEPS Training
April 2010

22. Community Waiver Budget

23. Family Care Budget

24. Family Care Disenrollments
Disenrollment from the MCO may occur for a variety of reasons. Some of the more common reasons for disenrollment include:
The loss of Medicaid eligibility (disenroll with timely notice)
A change in functional eligibility (disenroll with timely notice)
In both of these situations CARES will automatically populate the disenrollment date when the FC Fail has been confirmed on AGEC.
DHS/DHCAA/BEPS Training
April 2010

25. Family Care Disenrollments
Other common disenrollment reasons include:
A move out of the MCO’s service area
The member expresses a desire to disenroll
The MCO requests to disenroll the member
In these situations, the worker must enter the disenrollment date on the Family Care Page. There is no need to run with dates. CARES will send the entered disenrollment date to iC once the FC fail has been confirmed.
DHS/DHCAA/BEPS Training
April 2010

26. Family Care Disenrollments
Certain disenrollments, listed below, can only be approved by the Aging and Disability Resource Center or by the Department of Health Services (DHS) Office of Family Care Expansion (OFCE) (Ops Memo 08-58):
Member Requested:
Must be submitted first to the ADRC and then to the IM agency. IM agencies must receive this request from the ADRC. If the request is sent directly from the MCO, it should be returned unprocessed to the MCO along with the ‘Unprocessed Disenrollment Request Form.
DHS/DHCAA/BEPS Training
April 2010

27. Family Care Disenrollments
MCO Requested:
If the disenrollment request is for the following reasons:
Loss of Contact
MCO cannot assure member’s health/safety
Member has jeopardized health/safety of others
The disenrollment request must be approved by the OFCE. OFCE will the CARES coordinator with the disenrollment information, if approved. Any disenrollments for this reason that are sent directly by the MCO to the IM agency should be returned to the MCO with the ‘Unprocessed Disenrollment Request’ Form.
DHS/DHCAA/BEPS Training
April 2010

28. Family Care Disenrollments in CARES
FC disenrollments are entered in CWW on the Family Care page. A disenrollment date more than three months in the past cannot be entered in CWW.
Do not run with dates when processing a disenrollment. Timely notice must be given when ending Medicaid eligibility.
If disenrollment is due to loss of functional eligibility or loss of Medicaid eligibility, CARES will populate the correct disenrollment date using Adverse Action logic.
DHS/DHCAA/BEPS Training
April 2010

29. Family Care Disenrollment

30. Disenrollment Due to Death
If a FC member dies, the date of death must be entered on the Permanent Demographics page and the same date entered as the disenrollment date on the Family Care page.
Eligibility must be run and confirmed. It is not necessary to run with dates.
DHS/DHCAA/BEPS Training
April 2010

31. Family Care and Inter-County Moves
When a FC enrollee moves permanently to a non-MCO county, s/he can remain enrolled in the MCO only if the ADRC worker informs IM that all of the following four conditions are met:
S/he is eligible for COP or Waiver services.
After moving to the new county, the enrollee resides in a long-term care facility (Nursing Home, Community Based Residential Facility, or Adult Family Home).
The enrollee’s placement in the long-term care facility is done under and pursuant to a plan of care approved by the MCO.
The enrollee resided in the MCO county for at least six months prior to the date on which s/he moved to the non-MCO county.
DHS/DHCAA/BEPS Training
April 2010

32. Family Care and Inter-County Moves
A single MCO may serve multiple counties.  A FC member may:
move from one FC county to another served by the same MCO and
wish to remain enrolled in FC in the new county and
wish to continue to be served by the same MCO
Disenrollment from the MCO would not be necessary under these circumstances.  Disenrollment from the MCO would be necessary only if the member changed MCOs, changed programs (e.g., from FC to Partnership) or ended services.
EXCEPTION: When a member enrolled in CCE moves to anther county and continues enrollment in CCE in the new county, disenrollment information must be entered.
DHS/DHCAA/BEPS Training
April 2010

33. Disenrollment for Non-Payment of Cost Share
When ES is informed in writing by the MCO that an enrollee has not met the cost share obligation for past months’ services, the member will be disenrolled. ES should enter “N” to the question “Are you meeting your cost share/spend down obligation?” on the Managed Care section of the Family Care page in CWW, run eligibility and confirm.  This will populate a Family Care disenrollment date using adverse action logic.
DHS/DHCAA/BEPS Training
April 2010

34. Re-enrollment in Family Care
Family Care enrollees who lose Medicaid eligibility, reapply and again are found eligible for Medicaid may be re- enrolled in Family Care for up to three calendar months prior to the Medicaid application month, only if all of the following conditions are met:
The person (or his/her representative) requests backdated Medicaid.
The person is determined to have met Medicaid financial and non-financial requirements in the month(s) being considered for re-enrollment in Family Care.
The person is determined to have been functionally eligible for Family Care in the month(s) being considered for re-enrollment in Family Care.
The person is determined to have received services, in addition to care management, under the Family Care (MCO) plan of care during the month(s) being considered for re-enrollment in Family Care.    .
DHS/DHCAA/BEPS Training
April 2010

35. Re-enrollment in Family Care
The local income maintenance (IM) agency is not authorized to re-enroll anyone in Family Care earlier than the first of the month, three months prior to the application month.    
DHS/DHCAA/BEPS Training
April 2010

36. Partnership Long Term Care Medicaid MEH 30.1
The Wisconsin Partnership program is a comprehensive waiver program integrating health and long term support services for people who are elderly or disabled. Services are delivered in the participant’s home or a setting of his or her choice, including a medical institution. Through team based care management, the participant, his or her physician, nurses and social workers together develop a care plan and coordinate all service delivery.
DHS/DHCAA/BEPS Training
April 2010

37. Partnership Long Term Care Medicaid
To participate in the Partnership program, individuals must be eligible for Long Term Care Medicaid (Waivers or Institutional MA) and meet the nursing home level of care requirement. Unlike FC, individuals must meet the NH LOC to be enrolled in Partnership. A person not yet 18 years of age may be enrolled in Partnership effective the first day of the month in which he or she turns 18, if that the person meets all other Partnership financial and non-financial eligibility requirements.
DHS/DHCAA/BEPS Training
April 2010

38. Partnership Medicaid Eligibility
Based on his/her living arrangement, an individual enrolling in Partnership will be tested using either Institutional Medicaid or Home and Community Based Waivers Medicaid criteria. Individuals living in non-institutional settings are tested using the same financial and non-financial criteria as HCBW Medicaid. This includes a person living at home, in a CBRF, an AFH, an RCAC, etc. Individuals living in a medical institution (NH, ICF, Hospital) are tested using the same financial and non-financial criteria as Institutional Medicaid.
DHS/DHCAA/BEPS Training
April 2010

39. Partnership Enrollments
The enrollment date is always the date the member is enrolled in the MCO. The ADRC provides the enrollment date to the IM worker. This is the date the MCO will begin providing services to the member.
The enrollment date is entered on the Community Waiver Page in CWW.
The enrollment date determines the date capitation payments to the MCO begin.
DHS/DHCAA/BEPS Training
April 2010

40. Partnership Enrollment
Partnership enrollments are entered on the Community Waiver page in CWW by entering the following information:
Program Type: PR
Program Start date: Enrollment date
PACE/Partnership
Level of Care?: ICF/ISN/SNF
SMCP: Code for the MCO
**No Family Care Page entries for Partnership.**
DHS/DHCAA/BEPS Training
April 2010

41. Partnership

42. Partnership Enrollment (resides in the community)
After entering the information on the Community Waiver page and initiating eligibility, the Partnership Assistance Group (MCWR) will display on the eligibility run results.
The MCWR cost share displayed in the CWW budget is the Partnership cost share.
DHS/DHCAA/BEPS Training
April 2010

43. Eligibility Run Results

44. Partnership

45. Partnership Enrollment (resides in a medical institution)
When a Partnership member resides in a medical institution:
Enter ’08’ living arrangement code on the Current Demographics page.
Enter the institutional information on the Institutions page.
Enter the Partnership program code, Partnership level of care, Partnership start date and the SMCP code on the Community Waiver page.
CARES will build the MI R Assistance Group. The patient liability displayed on the Institutions budget page is the Partnership cost share.
If MI S AG builds, there can be no Partnership Enrollment.
DHS/DHCAA/BEPS Training
April 2010

46. Partnership Enrollment (resides in a medical institution)
When entering a Partnership case for an individual residing in an institution, the entries must also be made on the Community Waiver Page. CARES knows this is a Partnership case from the PR Waiver type entered on that page and will not build MI R unless the Community Waiver page is also filled out.
DHS/DHCAA/BEPS Training
April 2010

47. Current Demographics Page Institutional Living Arrangement

48. Institutions Page
Is it accurate to have the institution type as an IMD for Partnership?

49. Partnership-Community Waivers Page

50. Partnership Institutional AG

51. Partnership Institutional Budget

52. Partnership Disenrollments
Partnership disenrollments are entered on the Community Waiver page in CWW.
The rules for processing a disenrollment are the same for Partnership as they are for FC.
DHS/DHCAA/BEPS Training
April 2010

53. PACE (Program of All-Inclusive Care for the Elderly)
PACE is a program that provides comprehensive community based services, including both acute and chronic care for elderly individuals. Currently the PACE program is operated only in Milwaukee and Waukesha Counties.
DHS/DHCAA/BEPS Training
April 2010

54. PACE (Program of All-Inclusive Care for the Elderly)
Most services are provided in a day health center with an emphasis on continuity and coordination of care. Health and supportive services are also provided in the home, and transportation is provided to specialized care sites as needed.
PACE participants must be non-financially and financially eligible for Long Term Care Medicaid and must meet the MA nursing home level of care requirement.
DHS/DHCAA/BEPS Training
April 2010

55. PACE – Partnership Comparison
Requires use of day health center
Must receive services from PACE physician
Serves only elderly members
Partnership
Services provided in any setting including a medical institution
May use any physician who serves Partnership members
Serves elderly and younger disabled adults
DHS/DHCAA/BEPS Training
April 2010

56. PACE Enrollment
PACE enrollment is entered on the Community Waiver page using the same process used for Partnership except the Program Type code used is PA.
The PACE Assistance Group is MCWP for non-institutional members and MI P for institutionalized members.
Disenrollments from Pace are processed the same as disenrollments for Partnership.
DHS/DHCAA/BEPS Training
April 2010

57. MLTC Loss of Eligibility Disenrollments
Loss of functional or financial eligibility
Failure to pay cost share
Disenrollment date based on Adverse Action logic
DHS/DHCAA/BEPS Training
April 2010

58. MLTC Loss of Eligibility Disenrollments
Death/date of death
Incarceration/date of incarceration
Admission to an IMD/date of IMD admittance
Move out of state or service area/date of Move
DHS/DHCAA/BEPS Training
April 2010

59. Loss of Eligibility Disenrollments PACE/ Partnership Only
Refusal to select a PCP in MCO network/ disenroll as of the date of refusal
Disenrollment from any part of Medicare/disenroll as of the date of Medicare disenrollment
Disenrollment from MCO’s SNP/disenroll as of the date of the SNP disenrollment
DHS/DHCAA/BEPS Training
April 2010

60. MLTC Member Requested Disenrollments
Member requests disenrollment (May include requests to transfer to IRIS)
Disenrollment date= the date member requested but not prior to the last date of accepted services.
DHS/DHCAA/BEPS Training
April 2010

61. MLTC Loss of Contact Disenrollment
The member is no longer accepting services and the MCO has lost contact with the member for 30 days or more.
Disenrollment date based on Adverse Action logic following approval by OFCE.
DHS/DHCAA/BEPS Training
April 2010

62. MLTC MCO Requested Disenrollments
MCO requests to disenroll because:
Cannot assure health and safety/Adverse Action following OFCE approval
Member threatening acts/Date approved by OFCE
DHS/DHCAA/BEPS Training
April 2010

63. IRIS (Include, Respect, I Self-Direct) Ops Memo 08-38
MLTC counties also provide IRIS as a choice for long term care support. Under IRIS, the participant is able to access services comparable to those provided under the current Home and Community Based Waivers (HCBW) while managing an individual budget to meet their service needs.
DHS/DHCAA/BEPS Training
April 2010

64. Roles of ADRC, ICA and IM
Aging and Disability Resource Centers are responsible for informing participants of all available options through an objective enrollment counseling process.
ADRCs will refer the IRIS applicant to the Independent Consulting Agency (ICA) who then will inform the IM agency of the persons choosing to enroll in IRIS.
The ICA will provide IM with certain information necessary to determine medical/remedial expenses, and program start date.
DHS/DHCAA/BEPS Training
April 2010

65. IRIS
The IRIS option is available to people when they come to the ADRC and are found in need of publicly-funded long term care services. It is also available to Family Care members (and Partnership members, if Partnership is also operated in the county) if the member requests to change to IRIS. Individuals must be disenrolled from their managed long term care program in order to participate in IRIS.
DHS/DHCAA/BEPS Training
April 2010

66. IRIS Eligibility
Individuals who wish to participate in IRIS must meet the following criteria in order to qualify:
Reside in a county operating Family Care and/or Partnership
Have a nursing home level of care as determined by the LTC Functional Screen
Meet Medicaid Home and Community Based waiver financial and non-financial eligibility criteria
DHS/DHCAA/BEPS Training
April 2010

67. IRIS Eligibility
IRIS follows the financial and non-financial eligibility policies for the Home and Community Based Waiver programs. IRIS eligibility and cost-sharing requirements are identical to those associated with the current waivers.
When processing an IRIS application in CWW, enter the ‘OP’ code in the Program Type field on the Community Waiver Page in CWW. No information should be entered on the FC page when the person is enrolling in IRIS.
From an IM perspective, IRIS eligibility and cost sharing determinations are identical to those associated with Home and Community Based Waivers.
DHS/DHCAA/BEPS Training
April 2010

68. SSI Recipients and MLTC Programs
Because the SSI recipient is already eligible for Medicaid through SSA, a full Medicaid application or review is not necessary for an SSI recipient who requests to enroll in a Managed Long Term Care Program or IRIS.
The ADRC will provide the IM worker with the information necessary to process the request in CARES.
A yearly Medicaid renewal is not required. The care manager, ADRC or ICA will provide current med/remedial expenses.
An updated LOC (within the past 12 months) must be done.
DHS/DHCAA/BEPS Training
April 2010

69. SSI Recipients
At application, the ADRC will supply the IM worker with the following information:
Name
Residence Address
Mailing Address
SSN (and MAID number if different)
Sex
Primary Language (English or Spanish)
Guardian/Power of Attorney Name and Address
Date of Birth
Race (optional)
DHS/DHCAA/BEPS Training
April 2010

70. SSI Recipients
At application, the ADRC will supply the IM worker with the following information (con’t):
Citizenship Status (Alien registration number, if not a citizen)
Disability Status (if not age 65 or older)
All information necessary to complete the Community Waiver, Medical Expense, and the Medical Coverage pages (LOC, med/remedials, etc.)
If the individual has transferred any assets in the last 36 months or created a trust in the last 60 months, the IM worker must contact the applicant and ascertain if divestment has occurred.
DHS/DHCAA/BEPS Training
April 2010

71. iC Enrollment Update Timeline
DHS/DHCAA/BEPS Training
April 2010

72. Enrollment/Disenrollment Processing Basics
CARES sends up to 1 (and no more) enrollment transaction per day. If there are multiple confirmations with MLTC information, the last information confirmed is what is sent to iC.
Only current enrollment information is sent by CARES from information on the FC or Waiver page.
Historical enrollment or LOC change information is never sent to iC.
DHS/DHCAA/BEPS Training
April 2010

73. Enrollment/Disenrollment Processing Basics (cont.)
Running with dates does not fix MC enrollment, because only the most current enrollment information is sent and it is only sent 1 time per day.
Running with dates should be done to correct member cost share information.
Neither a manual F (3070) or the Partner portal certification process will correct MC enrollment.
DHS/DHCAA/BEPS Training
April 2010

74. Enrollment/Disenrollment Processing Basics (cont.)
Members must be disenrolled from one MLTC program before s/he can be enrolled in a different MLTC program.
Members must be disenrolled from one MCO before s/he can be enrolled in another MCO.
The disenrollment must be completed and confirmed in one day and the new enrollment completed and confirmed the next day.
DHS/DHCAA/BEPS Training
April 2010

75. How to Change MCO Enrollment
Day 1
Enter the disenrollment date on the Family Care or Waiver page.
Run and confirm eligibility
Day 2 – enrollment into another managed care program
Create new Family Care and/or Waiver pages as needed.
Enter the new enrollment date (it should not be equal to or less than the member’s disenrollment date) for managed care.
Enter the new level of care
Enter the new SMCP Organization Choice
Run and confirm eligibility with dates if necessary to ensure that the correct cost share information is sent from CARES and updates in iC.
Day 2 – enrollment into the IRIS program
Enter the new IRIS waiver program type
Enter the new IRIS waiver start date
Remove the SMCP and member level of care information
Run and confirm eligibility with dates if necessary to establish the correct waiver med stat for the IRIS program.
DHS/DHCAA/BEPS Training
April 2010

76. Day 1 Disenrollment date entered and confirmed in CARES
DHS/DHCAA/BEPS Training
April 2010

77. Day 2 New enrollment information entered and confirmed
DHS/DHCAA/BEPS Training
April 2010

78. MCO enrollment Correction
An MCO enrollment may need to be removed or corrected when:
The member changed his/her mind and has chosen not to enroll in the MCO.
The enrollment date already confirmed in CARES is incorrect and earlier than the correct or new enrollment date.
To correct the MCO enrollment in iC:
Disenroll the member from the incorrect MCO on the Managed Care page with a date 1 day before the enrollment date, run eligibility and confirm.
The next day or later, enter the correct date of enrollment and the correct SMCP code, run eligibility and confirm.
DHS/DHCAA/BEPS Training
April 2010

79. How to remove an incorrect enrollment from iC
DHS/DHCAA/BEPS Training
April 2010

80. When to contact the CARES Call Center?
When CARES edits prevent the correct enrollment or disenrollment date from being entered into CARES on the FC or CW pages.
When an incorrect disenrollment date was entered and confirmed in CARES.
If the disenrollment date is more than 3 months in the past and CARES can no longer be updated, the MCO should follow the process to notify the state of the discrepancy.
Examples: 4/25/09 was confirmed in CARES on Tuesday. On Wednesday the IM Worker learns that the correct date is 5/1/09, but a LTC Functional screen has updated with an effective date greater than 4/25/09.
If the 4/25/09 was confirmed on Tuesday and later in the same day the IM Worker finds that the correct date is 5/2/09, the correct date can be entered into CARES, eligibility run, and confirmed and the correct dates are sent to iC. No paper form is needed.
DHS/DHCAA/BEPS Training
April 2010

81. Cost Share Updates Family Care, Partnership, PACE
Both the Waiver Cost Share and the NH Liability amounts from CARES are updated in iC as a Waiver Cost Share.
The capitation payment and adjustment cycles use the Waiver Cost Share amount in iC to offset the member’s capitation payment.
When enrolling a member into Family Care it is necessary to run and confirm eligibility (with dates if necessary) for both Medicaid and Family Care for all of the initial months of enrollment to ensure that the Family Care member’s cost share amount is accurate for initial and ongoing months of enrollment.
I cut the following out of Heidi’s slide. I think that we need to find a way to explain the correct procedure rather than show the negative.
If this is not done with dates for initial months the cost share for those months will not be sent to iC. An example of how it looks when dates are not run follows on the next several slides.
DHS/DHCAA/BEPS Training
April 2010

82. Cost Share (con’t) Changing Waivers to NH and Vice Versa
When a waiver eligible member moves to a NH there can still be a waiver cost share amount for the month of the move to a NH.
When a NH eligible member becomes eligible for Waiver MA, CARES will automatically zero out the NH liability amount (Medicaid Cost Share) for the month of the move and any subsequent months that were open for NH MA. This does not display in the NH MA budget in CARES but is sent to the iC system via the interface.
CARES does not zero out the Family Care cost share amount (Waiver Cost Share amount) for the same timeframe. So, this can create a residual NH liability cost share amount for Family Care that is not correct.
ESS can run eligibility with dates to ensure that the correct Family Care cost share (Waiver Cost Share) information is calculated in CARES and sent to iC.
DHS/DHCAA/BEPS Training
April 2010

83. Cost Share (con’t) System Issues
Systems issues specific to Family Care members:
A systems issue caused by the incorrect interface and update of member eligibility information. The issue occurs because one MA type is closing and another MA type is opening while Family Care remains open.
Running eligibility with dates will resolve this issue that is specific to members transitioning between Waiver MA and NH MA and vice versa.
DHS/DHCAA/BEPS Training
April 2010

84. Cost Share (con’t) System Issues
A related system issue specific to members moving mid month from NH to Waiver MA with Family Care enrollment. In these situations, $0 is not sent to iC for the Family Care Waiver Cost Share amount while $0 is sent to iC for the NH Liability amount for the member.
Running with dates for Waiver MA and Family Care for the month of the move out of the NH and subsequent months should correct the Family Care cost share in CARES and iC.
DHS/DHCAA/BEPS Training
April 2010

85. Cost Share (con’t) System Issues
For the first month, the old Waiver Cost Share amount (the NH liability that was not zeroed out) will remain from the 1st of the month through the day before the Waiver MA Program Start Date. The waiver cost share amount will update with an effective date equal to the Waiver Program Start Date in CARES. A manual F (3070) must be sent to EDS to change the Waiver Cost Share amount to the correct amount for that month.
DHS/DHCAA/BEPS Training
April 2010

86. DHS/DHCAA/BEPS Training
April 2010

87. LTMC Reports interChange Reports
Enrollment – Paper and 834 HIPPA Transaction
The INITIAL MCO Enrollment Report is produced days before the upcoming capitation month. This report contains a listing of all recipients and their enrollment status for the next month in iC. This report also includes recipients who are “pending” or do not have Medicaid eligibility on file for the next month and therefore will not be enrolled unless Medicaid is updated for that month before the Final.
The FINAL MCO Enrollment Report is produced on the last business day before the 1st of the enrollment month. This report includes the final status of either enrolled or disenrolled for members identified as “PENDING” on the initial enrollment report as well as any other changes that have occurred since the initial report was created.
DHS/DHCAA/BEPS Training
April 2010

88. LTMC Reports (cont’d.)
Capitation Payments – Paper and 820 HIPPA Transaction
This report provides a detailed listing of the recipients for which managed care programs are receiving capitation payments. Regular capitation payments are created once a month while capitation adjustments are created weekly. MCOs have the option of receiving both the Capitation Payment Listing paper report and HIPAA 820 transactions or just the 820 transactions.
Coordination of Benefits Report
A monthly report that provides managed care programs with 1 year of private insurance and Medicare (Part A, Part B, both and Medicare Part D) information for all of their enrolled recipients.
DHS/DHCAA/BEPS Training
April 2010

89. LTMC Reports (cont’d.) CARES and interChange Report - Temporary
Cost Share Report
CARES: This is a monthly report that contains cost share information for Family Care, PACE and Partnership recipients. It contains three months (next month, current month, last month) of cost share information for each recipient. The report is sent from CARES staff to MEDS staff for distribution to the managed care programs.
interChange: This is still a monthly report with the same basic information for each member including three months of cost share information. There are currently issues with the interChange PACE and Partnership Cost Share report and until that issue is resolved the report will be generated out of both CARES and iC.
Note: This is not a comprehensive listing of MCO reports. It is a subset of reports related to member eligibility and MCO enrollment.
DHS/DHCAA/BEPS Training
April 2010

90. Summary of MLTC programs
Family
Care
Partnership
PACE
IRIS
LOC
Requirement
Non-NH NH
NH only
Population
- 65+ yr.
- Physically or
Developmentally disabled
- Eligible for other Medicaid programs or BC+ Standard Plan
65+
Disabled
65+ only
Any Waivers eligible members
Disability required
Yes, unless eligible for BC+ Standard Plan, Well Woman MA, Adoption Assistance, Foster Care MA
Yes
DHS/DHCAA/BEPS Training
April 2010