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NM Medicaid PE Program: Immediate Coverage and Ongoing Eligibility Determination

The NM Medicaid PE Program provides short-term coverage for eligible individuals, granting access to immediate coverage and assistance with ongoing Medicaid applications. PEDs determine eligibility based on self-attestation, and if screened correctly, applicants are likely to be approved for ongoing Medicaid coverage. PE coverage begins on the day it is granted and ends on the last day of the following month unless an ongoing Medicaid application is submitted. PEDs are certified and trainings are available. The YESNM-PE tool is used for screening, granting PE, and submitting ongoing Medicaid applications.

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NM Medicaid PE Program: Immediate Coverage and Ongoing Eligibility Determination

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  1. Jeanelle Romero PE Program Manager

  2. NM Medicaid • PE Program • JUST Health • System & Customer Service Updates • HSD Forms & Applications

  3. Presumptive Eligibility (PE) • Short-term Medicaid coverage for eligible individuals • Provides access to immediate coverage to eligible recipients • Ensures assistance with submitting an application for possible ongoing Medicaid coverage • Based on self-attestation • MAD Certified PEDs determine eligibility • If screened correctly, applicant will most likely be approved for ongoing Medicaid coverage • Individuals may only receive one PE approval in a 12 month period (or one PE per pregnancy)

  4. Presumptive Eligibility (PE) coverage • Begins on the day the PE is granted by PED • Retroactive coverage not available during PE span • Ends on the last day of the following month unless ongoing Medicaid application is submitted • PE will continue until final determination has been made for ongoing eligibility • PE coverage ends on the last day of the month that final determination is made • If more information is needed to determine ongoing eligibility, ISD will send a Help Us Make A Decision (HUMAD) form to client • Client must supply information within the timeframe specified on the HUMAD

  5. Presumptive Eligibility Determiners (PEDs) • PEDs are employees of participating hospitals, clinics, FQHCs, DOH, schools, IHS providers, jails, prisons and community organizations • Two types of PEDs • 170 – Determine PE for Children and pregnant women (clinics, FQHCs, DOH, CYFD, schools and community organizations) • 171 – Determine PE for children and pregnant women but also for COEs 100 & 200 (employees of hospitals, IHS facilities and prisons and jails)

  6. PE Program Trainings • PED Certification Trainings • Second Tuesday of the month – full day webinar 8:30am to 4:30pm • PED Certification Trainings for Jails\Prisons • Two-day training at one of our HSD training labs – trainings conducted at request • YESNM-PE Demos • YES Fridays: 3rd Friday of each month

  7. PE Program Tools • NM Medicaid Web Portal • Used to check Medicaid eligibility • YESNM-PE • Used exclusively by certified PEDs • Allows PEDs to screen, grant PE and submit ongoing Medicaid applications • After YESNM-PE screening, if PE is granted, there is a direct data feed from YESNM-PE to ASPEN • PED is notified immediately of applicant’s MCO enrollment • If applicant is not immediately enrolled with an MCO, a task is generated for our PE Processors to work

  8. YESNM-PE Check Client Benefits Click “Check Clients’ Benefits; Takes you to Linking Account page. Enter the SSN or ASPEN ID of the individual who want to view Medicaid benefits for. **Reminder, you will only be able to view Medicaid benefits**

  9. YESNM-PE Check Client Benefits After you successfully link to the client’s account, you will see their account information, the status of the case, current client contact information (mailing address, phone number), authorized representative (if one exits on case); and if any HUMADs have been sent with details on what has been requested. Click on “Learn More”

  10. YESNM-PE Check Client Benefits You will be able to review 3 months of potential benefit issuance. If you click on the hyperlink In this example, the client is not receiving any Medicaid benefits for the month of February 2018, March 2018 and or April 2018. We are still waiting for proof of income to be received.

  11. YESNM-PE Check Client Benefits You can see if an individual has been sent a HUMAD, what the HUMAD is requesting, when the HUMAD was sent and when it’s due. If you are able to get the requested documents from the client, you can upload them directly into client’s case through YESNM-PEby clicking “upload”.

  12. YESNM-PE Check Client Benefits This individual has been approved for Medicaid. When viewing eligibility, the client’s status will always show for the current month. This screen shot shows the individual is getting Medicaid for March 2018. To get more details on that eligibility you would click “Learn More” The next screen will give you benefit details like the COE the client is receiving and the MCO. In this scenario the client has MAGI for Adults and the client is enrolled with United Health Care.

  13. JUST Health • Justice-Involved Utilization of State Transitioned Healthcare • HSD enters into an agreement with agency/county for data sharing • HSD receives daily interface with correctional facilities to suspend rather than close Medicaid eligibility for individuals defined as inmates (per NMAC) • Release information sent to HSD to reinstate benefits upon release

  14. JUST Health Program Numbers Currently participating counties/agencies: CY 2017 • 7,324 suspensions; 5,876 reinstatements • 128 Presumptive Eligibility determinations • 3,285 ongoing applications filed • 3,005 ongoing application approved

  15. Suspended Benefits The suspension will be viewable in the New Mexico Medicaid Portal with the original Category of Eligibility (COE) the individual is eligible for.

  16. Suspended BenefitsMCO Enrollments

  17. Short Term Medicaid for Incarcerated Individuals (STMII) Program • The incarcerated individual must be approved for Medicaid and have benefits suspended for services to be covered under STMII program • STMII claims may only be Medicaid-covered services for inpatient hospital stays of 24 hours or more • STMII claims: the individual may be eligible for STMII multiple times a year • STMII is only covered for correctional facilities that have a GSA contract with HSD • contact MAD PE Program Staff for STMII questions

  18. JUST Health New Counties • Next Phase “Live” Spring/Summer, 2018 • Chaves County • Curry County • Eddy County • Roosevelt County • Quay County

  19. PE Program Numbers January – December, 2017 • Access to YESNM-PE is ONLY available to certified PEDs • 635 Current PEDs statewide • PE Type 170: 359 • PE Type 171: 276 • 2,661 PEs Granted in 2017 • 2,593 PEs (or 97%) of all PEs granted had an ongoing Medicaid application submitted • 23,519 individuals have been assisted with Medicaid applications through YESNM-PE • 19,981 individuals (84.96%) were approved for ongoing Medicaid

  20. NM Systems & Customer Service Updates • System Updates: • November through December 2017 – Expanded Conduent Call Center to assist with ISD Customer Service Center calls • Medicaid Call Center 888-997-2583 • ISD Customer Service 800-283-4465 • December 2017 – Movement of Medicaid enrollment functions to ASPEN • PE approvals feed directly into ASPEN instead of Omnicaid

  21. NM Systems & Customer Service Updates • Medicaid ID Cards • Hard-plastic, blue Medicaid ID Card no longer issued • FFS clients • Receive heavy-weight paper version of card • Request replacement cards through YESNM or the Conduent Call Center • Managed Care enrollees • Only receive MCO-issued cards • Request replacement cards directly from MCOs

  22. HSD Forms & Applications • PED & Provider Forms • Current forms should always be utilized • Most up to date versions of forms on the NM Medicaid Web Portal: • https://nmmedicaid.portal.conduent.com/static/index.htm

  23. Applications & Information for Clients • YESNM www.yes.state.nm.us • Apply for benefits • Renew Benefits • Request Change of MCO (if in allowable switch period) • FFS Clients may Request Replacement Medicaid ID card • HSD Paper Applications • MAD 100 (Medicaid Only Application) • HSD 100 (All HSD Programs) • Available on the HSD web site http://www.hsd.state.nm.us/LookingForAssistance/apply-for-benefits.aspx

  24. PED & JUST Health Information • Request YES-NM demo session schedules • Request PED Training session schedules • For information on PED enrollment status • Questions regarding JUST Health HSD.PEDeterminers@state.nm.us

  25. Opt In/Out of MCO Enrollment • Conduent Call Center 1-888-997-2583 • HSD/MAD/CEB • Armando Muñoz • Orlando Vasquez HSD.PEDeterminers@state.nm.us

  26. MAD/CEB PE Program Staff • PE Program Unit • Jeanelle Romero – PE Program Unit Manager • Vanessa Medina – PE Program Trainer\Auditor • Edmundo Barraza – Enrollment\Reporting Specialist • Roberta Roybal – Enrollment Specialist • Pam Champion – PE Program Auditor • Kimberly Lucero – Application Processing Manager • Esli Ornelas- Application Processor • Elaine Martinez- Application Processor • Carol Baca – Application Processor HSD.PEDeterminers@state.nm.us

  27. Questions?

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