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Long Term Care Medicaid Managed Long Term Care. 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
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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
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
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
Managed Long Term Care (MLTC) Medicaid Programs 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 • Family Care • Partnership • PACE • IRIS Program (Not Managed Care)
Managed Care Administration IM 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
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
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
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
Family Care Functional Eligibility The Family Care levels of care are: DHS/DHCAA/BEPS Training Nursing Home • Individuals who are found functionally eligible for Nursing Home LOCare subject to Waiver logic in determining their financial eligibility for Family Care (if they are 65 or older, or have been determined disabled).
Family Care Functional Eligibility • 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 Non-Nursing Home
Family Care and Disability Determinations 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 Individuals who are under 65 years of age can be enrolled in Family Care without a disability determination if they are:
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
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
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”.
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
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
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-10110. Enrollment can not be updated with an F-10110. DHS/DHCAA/BEPS Training
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
Family Care Disenrollments • 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 Disenrollment from the MCO may occur for a variety of reasons. Some of the more common reasons for disenrollment include:
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
Family Care Disenrollments 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 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):
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 e-mail 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
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
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
Family Care and Inter-County Moves • 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 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:
Family Care and Inter-County Moves A single MCO may serve multiple counties. A FC member may: 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 • 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 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
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
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
Partnership Long Term Care MedicaidMEH 30.1 DHS/DHCAA/BEPS Training 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.
Partnership Long Term Care Medicaid DHS/DHCAA/BEPS Training 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.
Partnership Medicaid Eligibility DHS/DHCAA/BEPS Training 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.
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
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
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
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 Institutionsbudget page is the Partnership cost share. • If MI S AG builds, there can be no Partnership Enrollment. DHS/DHCAA/BEPS Training
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