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Coordination of Benefits

Coordination of Benefits

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Coordination of Benefits

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  1. Coordination of Benefits Self-Study Module Updated November 2010

  2. Overview This module will cover the following topics: • Overview / Introduction • Review of Arizona Health Care Cost Containment System (AHCCCS) • Programs • Eligibility • Coverage / Services • Funding and co-payments • Applying for AHCCCS • Changes in eligibility and re-applying • Third Party Liability • Medicare Part D • Your role in Coordination of Benefits

  3. Learning Objectives After you’ve finished this training module, you will: • Understand Arizona’s Medicaid Program (AHCCCS and KidsCare) including programs, eligibility screening and coverage • Know the procedures and policies associated with Third Party Liability • Be familiar with the implications of Medicare Part D • Explain how you are involved in Coordination of Benefits

  4. The Arizona public behavioral health system is mandated to use available resources to its full advantage. This regulation means all other available funding must be exhausted before using federal and state monies for health and behavioral health care. The processes involved in ensuring public funds are used last is referred to as “Coordination of Benefits.” You are responsible for coordinating benefits for the clients with whom you work. In this module, you will learn about these benefits, and about the processes involved in coordination. Introduction

  5. Provider agencies are to ensure that individuals requesting or receiving behavioral health services who are not enrolled in AHCCCS are screened for AHCCCS eligibility. All applicants that are financially screened and are determined to be potentially Title XIX/XXI eligible shall be assisted by the Comprehensive Service Provider (CSP) or Service Provider (SP) in completing an application for AHCCCS health insurance. This responsibility, all or in part, may fall to the behavioral health staff member, or to a benefits/financial eligibility staff member at the provider agency. Note: all RBHA enrolled Non-Title XIX/XXI behavioral health applicants must be screened - initially, and annually and/or when significant changes occur in their lives - for AHCCCS eligibility. Introduction

  6. The Importance of Coordination of Benefits Why is coordination so important? State and federal funds are extremely limited, and must be conserved for the individuals/families who need them the most. Those who have other funding sources available to them must utilize these resources first, as public funds (including AHCCCS) must be the payer of last resort. The term benefits includes a wide range of programs and coverage in healthcare and behavioral health services. An individual may have private insurance (i.e., United Health Care, Cigna or Blue Cross Blue Shield), co-insurance, Medicaid (AHCCCS in Arizona), and/or Medicare (which serves adults over age 65 or disabled).

  7. The CPSA Provider Manual is a statewide document adopted by ADHS/DBHS to articulate the requirements of the behavioral health system. The Provider Manual & AHCCCS The Provider Manual is a resource for information on Coordination of Benefits. Since the requirements in the Manual relate to your job and responsibilities, both knowing and understanding them is very important. Applicable references to the Provider Manual are included throughout this training module. To find specific information on AHCCCS eligibility see the Provider Manual, Section 3.1.

  8. A Look at Arizona’s Publicly-Funded Health Care Systems

  9. Publicly Funded Health Care Systems Today’s publicly funded health care is a result of the Social Security Act of 1965 - Medicaid Each state is responsible for providing health care to lower income individuals/families. The Medicaid program is supported by federal grants and is administered by each individual state. Medicaid is limited to these specific groups of lower income individuals and families. It is not an entitlement program and therefore recipients must prove their eligibility according to their income and family size. In Arizona, the Medicaid program is administered through the Arizona Health Care Cost Containment System (AHCCCS).

  10. Arizona’s Title XIX services are delivered through a variety of programs that AHCCCS oversees. Many people seeking out or receiving behavioral health services are eligible for Title XIX or special state funding that covers the cost of services. There are many specific programs available for adults, families and children. This module will address the two main publicly-funded programs that cover the majority of assistance-eligible people in Arizona: AHCCCS KidsCare & These two programs work similarly. In fact, they: > use the same application process > use the same providers

  11. As of October 2010, AHCCCS was providing health care coverage to over 1,384,338 AZ residents - almost 16% of the state’s entire population! What is AHCCCS?? AHCCCS stands for Arizona Health Care Cost Containment System. It is the state’s Medicaid program, which means it is the publicly funded health care program for AZ residents who qualify due to low income. AHCCCS: • Administers the Federal Medicaid program in Arizona, also referred to as Title XIX. • Is designed to deliver quality health care to those who couldn’t otherwise afford it - for adults, families and kids. • Receives federal, state and county funds to operate in Arizona.

  12. What is KidsCare? KidsCareis the program that provides healthcare to low income children (under age 18) statewide. It is also known as Title XXI. It is Arizona’s State Health Insurance Program (SCHIP). This program is intended for families with incomes too high for Medicaid/AHCCCS eligibility, but within KidsCare guidelines (200% of the federal poverty level). KidsCare benefits are very similar to those of TXIX. With KidsCare, however, monthly premiums and co-pays may be required.

  13. AHCCCS - SSI CASH/SSI Medical Assistance Only(SSI/MAO) This is another AHCCCS program that some individuals may qualify for. This is determined through eligibility screening which will be discussed in later slides. The Supplemental Security Income / Medical Assistance Only program (SSI/MAO) provides medical coverage for individuals who are age 65 and over, blind or disabled, but do not receive monthly cash benefits under the Supplemental Security Income program. Let’s look at the publicly-funded behavioral health component of the state system…

  14. What role does AHCCCS play in Behavioral Health? • Behavioral health services are delivered through an Intergovernmental Agreement between AHCCCS and Arizona Department of Health Services (ADHS) and its behavioral health arm: Division of Behavioral Health Services (DBHS) • ADHS contracts with Regional Behavioral Health Authorities (RBHAs) to deliver behavioral health services to members. In 1995, AHCCCS completed a five year phase in of behavioral health care services for the Medicaid program. Therefore, it is imperative for Comprehensive Service Providers and Service Providers to screen people who are not currently enrolled in AHCCCS or KidsCare to determine their eligibility for these benefits…

  15. Determining Eligibility for Publicly-Funded Services

  16. Eligibility Must Be Determined Eligibility status is essential for knowing the types of behavioral health services a person may be able to access. In Arizona’s public health system, a person may: • Be eligible for Title XIX (Medicaid), Title XXI (KidsCare), or SSI/MAO covered services; • Not qualify for Title XIX/XXI services, but may be eligible for some services as a person determined to have a Serious Mental Illness (SMI); • Be covered under another health insurance plan, or “third party” (including Medicare, Military, Private Health Insurance etc.); or • Be without insurance or entitlement status and asked to pay a percentage of the cost of services (co-payments). Eligibility Screening for AHCCCS Programs is discussed in Provider Manual Section 3.1 The next several slides will examine how eligibility for publicly funded heath care is determined…

  17. Eligibility Must Be Determined Determining current eligibility and enrollment status is one of the first things a RBHA or behavioral health provider does upon receiving a request for behavioral health services. Upon this request for services, a service provider will verify the individual’s eligibility for state-funded services. Check with your supervisor to learn how this occurs at your agency. • If the individual is already receiving Title XIX/XXI benefits, this must be • verified. • If the individual is not receiving Title XIX/XXI services, screening for • benefits eligibility must be completed to determine potential eligibility… • ■You can assist the individual in determining eligibility by helping • them apply online using the Health-e-Arizona system ■ • (Health-e-Arizona will be discussed in the ‘Applying for Benefits’ module section) The Comprehensive Service Provider and Service Provider are mandated by ADHS/DBHS to assist the individual with the appropriate application for Title XIX or XXI.

  18. Eligibility Must Be Determined Who and when do you screen for Title XIX/XXI eligibility? • The Comprehensive Service Provider and Service Provider must screen all Non-Title XIX/XXI persons using the Health-e-Arizona online application for eligibility: • Upon initial request for behavioral health services • At least annually thereafter, if still receiving behavioral health services • When significant changes occur in the person’s financial status and/or family size Note: A screening is not required at the time an emergency service is delivered but must be initiated within 5 days of the emergency services if the person seeks or is referred for ongoing behavioral health services. Let’s look at what this screening will determine…

  19. Eligibility Must Be Determined The Comprehensive Service Provider or Service Provider staff completes the screening thru Health-e-Arizona online application which will indicate one of the following: • Potential eligibility for AHCCCS (Title XIX); • Potential eligibility for KidsCare (AHCCCS-Title XXI); • Potential eligibility for SSI/MAO (Title XIX); or • The person does not appear to be Title XIX/XXI eligible In this case the person may be provided services in accordance with Provider Manual Section 3.4: Co-payments and Provider Manual Section 3.21: Service Prioritization for Non-Title XIX/XXI Funding In identifying what programs the individual may qualify for, eligibility factors are considered as part of the application process. These eligibility factors are listed on the following slide…

  20. AHCCCS Eligibility Determinants There are seven main factors that affect a person’s eligibility. These include: • Financial criteria - income and family size • Citizenship or Qualified Immigrant • Arizona residency • Social Security Number • Identity • Third Party Liability • Childcare Expenses Let’s look at some of these eligibility factors…

  21. AHCCCS Eligibility Determinants • Financial Criteria: >Income must be under the limit specific to one of the programs. • Monthly income is determined after certain specific deductions allowed for as determined by AHCCCS • For the majority of medical categories there is no limit on resources or property except for the Medical Spend Down The 2010 limits are: • $903/month for an individual • $1215/month for a couple Be Aware: Income Limits change each year! The AHCCCS website provides updated information on current income limits - to see current income limits click HERE

  22. AHCCCS Eligibility Determinants A Note on Income Limits for KidsCare… Income limits for KidsCare change every April. For 2010, the following limits are in effect: Note:KidsCare cannot determine if a family qualifies withouta completed application. The AHCCCS website provides updated information on current income limits - to see current Income Limits click HERE

  23. AHCCCS Eligibility Determinants • Citizenship/Qualified Immigrant: > The applicant must be a U.S. citizen or a Qualified Immigrant. • As of July 1, 2006, per federal law, AHCCCS applicants are required to document their citizenship or immigrant status • AHCCCS/DES is available to help verify citizenship for individuals born in Arizona • Individuals receiving SSI Cash or Medicare benefits do not have to verify their citizenship as they are already verified via the Social Security Administration To document citizenship, a US passport, US naturalization certificate, or certificate of citizenship is most reliable. If an individual needs identification to establish citizenship, a driver’s license, government issued photo ID, or tribal governmental ID may be utilized for this purpose.

  24. Arizona Resident: > The applicant must live in Arizona and have the intent to reside in Arizona. Social Security Number: > The applicant must have a verified Social Security Number or must apply for a Social Security Number. Potential Benefits - Veterans, Medicare, Rail Road Retirement,Unemployment Insurance, Survivor’s benefits, etc.: > The applicant must apply for any income benefits that may be available to him/her. For example: If an applicant states that he is a veteran of the U.S. Armed Forces, he must apply for benefits from the Veterans Administration (V.A.) if he is not already receiving these AHCCCS Eligibility Determinants Contact the local AHCCCS office for assistance. Call 1-800-962-6690 to find out the nearest location. Or check the DES website

  25. AHCCCS Eligibility Determinants • Third Party Liability (TPL): > This situation occurs when individuals enrolled in the public behavioral health system also have behavioral health service coverage through another insurance plan. • By signing the application, the applicant is assigning his/her rights to any health insurance payments or medical care support available to the State of Arizona. (See Section 3.5 in the CPSA Provider Manual). • AHCCCS is the payer of last resort, which means that AHCCCS will attempt to obtain payment for services from these third party sources, and AHCCCS only pays if there is no other option. Third Party Liability will be discussed in greater detail later in this module…

  26. A Quick Quiz:What are the AHCCCS eligibility determination factors? Click on the box that contains only correct eligibility determination factors • Arizona resident • Must be pregnant • U.S. Citizen or qualified immigrant • Must have children • Financial criteria -income limits/family size • Cannot own property • Must have disability • Valid Social Security Number • Valid Social Security Number • Arizona resident • Financial criteria - income limits/family size • U.S. Citizen or qualified immigrant

  27. Do you know the AHCCCS eligibility determination factors? Sorry, you are incorrect!  • Financial criteria - income limits/family size • Cannot own property • Must have disability • Valid Social Security Number • Individuals may own property • The individual does not have to have any type of disability Return to quiz slide

  28. Do you know the AHCCCS eligibility determination factors? Sorry, you are incorrect!  • Arizona resident • Must be pregnant • U.S. Citizen or qualified immigrant • Must have children • Individuals do not need to be pregnant • Having a child/children is not a requirement Return to quiz slide

  29. Do you know the AHCCCS eligibility determination factors? You are correct!  • Valid Social Security Number • Arizona resident • Financial criteria - income limits/family size • U.S. Citizen or qualified immigrant These are all factors in determining a person’s eligibility for state-funded health services!

  30. What if an individual refusesto participate in the screening/application process for Title XIX/XXI or Medicare Part D enrollment? (Part D Will be addressed later in the module) • If a person refuses to participate in the AHCCCS screening/ application process, or to enroll in a Medicare Part D plan, the RHBA/Comprehensive Service Provider must actively encourage participation. • Arizona state law stipulates that persons who refuse to participate in the AHCCCS screening and eligibility process or to enroll in a Medicare Part D plan are ineligible for state-funded behavioral health services. • If the person refuses to participate in the screening, have them sign the ‘Decline to Participate in the Screening and Referral Process for AHCCCS’ form (PM Form ADHS AE-08). If they refuse to sign this form, document his/her refusal to sign this form in the clinical record. See Provider Manual Section 3.1.6-D for additional information. The following are not considered a refusal to participate:If a person is unable to obtain documentation for eligibility determination or if a person is unable or refuses to participate due to his/her mental status and does not have a guardian.

  31. REVIEW: What are your responsibilities in the AHCCCS screening/eligibility process? What steps must you take with regard to new clients and publicly-funded services? For answer, click on the icon below…

  32. ANSWER Your responsibilities… • You must determine the Title XIX/XXI status of all new behavioral health clients. • If individuals are not currently enrolled Title XIX/XXI, then they must be screened for eligibility. • If eligible, Comprehensive Service Providers or Service Providers must assist the individual in applying for the appropriate state- funded program - Title XIX (Medicaid), Title XXI (KidsCare), or Title XIX SSI/MAO covered services. Now that we have examined screening clients for AHCCCS eligibility, let’s look at what services are covered by AHCCCS…

  33. What is Covered by AHCCCS?

  34. AHCCCS Health Insurance Services includes these services: • Medical services • Specialized testing • Rehabilitation services • Support services (excluding case management) • Inpatient services • Residential services • Behavioral Health Day Programs • Transportation • Prescriptions

  35. Doctor visits Specialist care Transportation to doctor (coverage may be limited per program) Hospital services Emergency care Pregnancy care Podiatry care (only if provided by another clinician suchas a physician, NP or PA) Surgery services Comprehensive behavioral health Family planning Lab and X-rays Prescriptions and medical care Dialysis Annual well women exams Dental care (limited to extractions, anesthesia, and treatment for pain, per health plan) AHCCCS Health Insurance Services for Adults include:

  36. AHCCCS provides the following covered health services forChildren under age 21: • Doctor visits • Specialist care • Transportation to doctor (coverage may be limited per program) • Hospital services • Emergency care • Pregnancy care • Podiatry care • Glasses • Vision exams • Dental screening and treatment • EPSDT evaluations • Surgery services • Comprehensive behavioral health services • Family planning • Lab and X-rays • Prescriptions • Dialysis • Emergency dental care • Immunizations • Nutritional information • Hearing exams and aids Let’s look at the types of behavioral health services that are covered by AHCCCS…

  37. AHCCCS Covered Behavioral Health An AHCCCS eligible individual may access behavior health services by: • Requesting a referral from his/her primary care provider or • Calling the behavioral health telephone number on his/her AHCCCS ID card • Contacting CPSA Member Services or a Comprehensive Service Provider • Psychosocial services • Counseling and therapy, assessment, evaluations, and screenings • Rehabilitation services • Vocational training and development • Life skills • Medical Services • Medication • Medication management • Radiology, laboratory Behavioral Health Services Include:

  38. AHCCCS Covered Behavioral Health Additional Covered Behavioral Health Services Include: • Crisis Intervention Services • Crisis stabilization • Mobile crisis team • Inpatient Services • Hospitalization • Residential treatment centers • Residential Services • Short term • Long term • Behavioral Health Day Programs • Prevention Services • Transportation Along with these services, behavioral health supportservices are covered by AHCCCS as well…

  39. Support Services Support services are provided to facilitate the delivery of or enhance the benefit received from other behavioral health services. In addition to traditional services such as assessment, counseling, psychiatric services, medications, and case management, support services are available for behavioral healthrecipients with AHCCCS. • Personal Care Services • Home Care/Family Support • Self-Help/Peer Services • Respite Care • Interpreter Services • Case Management Examples of Support Services Let’s look briefly at funding for AHCCCS…

  40. AHCCCS funds are the foundation of our system State funds match federal funds, expanding the financial resources and allowing for more services to be offered to Arizona’s citizens. An individual must, however, apply for AHCCCS or KidsCare to access this matched funding. Premiums Most individuals do not pay for AHCCCS coverage. However, some individuals are only eligible if they pay a monthly premium. These fees are detailed in the AHCCCS Eligibility Requirementschart. The premiums vary; it is very important that individuals seeking AHCCCS coverage find out in advance about the costs they may incur. A final funding consideration is co-payments…

  41. Co-payments A co-payment is a fixed-fee amount an individual pays a health care provider when a medical service is provided. Individuals not covered by AHCCCS must contribute to the cost of their behavioral health services. Co-payments vary by program and AHCCCS eligibility. Many individuals who receive AHCCCS Medical Coverage might have a nominal or mandatory co-payments due to meeting specific criteria, and Non-Title XIX/XXI SMI individuals are on a sliding fee schedule based on the ability to pay. Co-payments are discussed in detail in the Provider Manual Section 3.4 Now that we have examined AHCCCS, let’s look at the application process…

  42. How does an individual apply for Benefits?

  43. Applying for AHCCCS / Benefits Once the financial screening has been completed and it indicates that the person is potentially eligible for state-funded services: • An Application for AHCCCS Health Insurance is completed (you should assist the individual with this application/online process). • The completed application, along with the individual’s necessary documentation detailed in the application summary and fax cover sheets, are faxed to Health-e Arizona. • You need to fax a manual signature and any documents the applicant provided to Health-e-Arizona the SAME DAY you submit the application. NOTE: In most cases, an eligibility determination is completed by the State within 45 days after the date of application, unless the person is pregnant (completed with 20 days), or hospitalized at the time of application (completed within 7 days).

  44. Applying for AHCCCS • The onlineapplication process used by Health-e- Arizona can be used for both an individual and an entire family. • The online application process permits a person to apply for all AHCCCS programs for all family members on one application. • The online application is available in English and Spanish The application can be completed at: In addition, applicants may visit a local DES office for assistance and forms. Note: Most programs do not require a face-to-face interview with DES if the applicant may be contacted by phone. More on Health-e-Arizona, an on-line application site that Comprehensive Service Providers can use for the application process…

  45. Applying for AHCCCS / Benefits There is an online system for applying for AHCCCS and other Benefits! Health-e-Arizona is an on-line service CPSA has made available to assist in the application process for AHCCCS and other benefits • Behavioral health staff must assist all individuals in applying for benefits using this system For assistance from CPSA regarding Health-e-Arizona call (520) 901-6835 Click on logo to access site

  46. Applying for AHCCCS / Benefits • Health-e-Arizona screens for / can be used • to apply for: • AHCCCS Health Insurance • AHCCCS Health Insurance - Medical Expense • Deduction Spend Down • AHCCCS for Seniors and People with Disabilities (SSI-MAO) • KidsCare • Nutritional Assistance (Food Stamps) • Freedom to Work • Medicare Savings Program • TANF Cash Assistance • Discounted Community Medical Programs Click on logo to access site

  47. Applying for AHCCCS Comprehensive Service Provider staff can utilize Health-e-Arizona to complete and submit with their clients/member Health-e-Arizona applications… (all accounts are secure and encrypted) How Health-e-Arizona works: 1) Inform the applicant of what documentation to bring/provide and review those documents with them - Information for clients and all other people living with them needs to be provided: wages and/orself-employment information; proof of other income; information about any current health insurance; proof of Citizenship; proof of Immigration status;  daycare costs/adult care costs; Social Security Number 2) Complete, with the client, the One-e-App Health-e-Arizona application 3) The individual/applicant will decide for which programs they would like to apply 4) The One-e-App application is submitted 5) Application verification is faxed to Health-e-Arizona 6) The application automatically downloads and registers at DES or AHCCCS 7) DES or AHCCCS completes the eligibility determination 8) This eligibility determination can be viewed in Health-e-Arizona 9) When possible, assist denied applicants

  48. Choosing an AHCCCS Health Plan All AHCCCS health plans provide all AHCCCS services! • When applying for AHCCCS the individual needs to choose a health plan that serves his/her county. • A Native American who can receive services from IHS (Indian Health Services) may choose IHS or another AHCCCS health plan. • If the individual does not choose a health plan when applying, one will be assigned upon approval. • An individual who has been enrolled in an AHCCCS health plan within the past 90 days will be enrolled with his/her previous health plan, if available. Available AHCCCS health plans vary by county…

  49. AHCCCS Health Plans(Pima County - as of June ‘10) PIMA County • Arizona Physicians, IPA • Health Choice Arizona • Pima Health Plan • Phoenix Health Plan • University Family Care • Mercy Care Plan • Indian Health Service AHCCCS contracts with health plans in each county which provide direct services.

  50. How does an AHCCCS Health Plan work? • An AHCCCS Health Plan is like a Health Maintenance Organization (HMO). Each AHCCCS health plan coordinates with health care entities (doctors, hospitals, pharmacies, etc.) that provide all covered services. • The Health Plan sends a Member Handbook to the individual upon enrollment. The plan’s Member Services/Customer Services number is provided either in the handbook or on the back of the ID card. • An individual may contact the Health Plan with questions about benefits or services, to request interpreter services, or to provide information on needs related to an accommodation for a disability. Note: As part of your responsibility to help individuals coordinate their benefits, answering questions and helping with contacting the Health Plan may be necessary. When an individual selects a Health Plan they must also select (or they will be assigned) a Primary Care Provider (PCP)…