DRAFT FAQ of West Virginia Medicaid Redesign 1. What is Medicaid? Medicaid is the primary source of health and long-term care assistance for one in seven Americans. It is only available to certain low-income individuals and families who fit into an eligibility group that is recognized by federal and state law. MEDICAID AT A GLANCE is a valuable resource that can be viewed at: http://www.cms.hhs.gov/MedicaidGenInfo/Downloads/MedicaidAtAGlance2005.pdf 2. What is Medicaid Redesign? Medicaid Redesign, also referred to as “Mountain Health Choices” is West Virginia’s new Medicaid program. Its purpose is to ensure that members receive the right care, at the right time, by the right provider. Members now have a choice of benefit plans. Members who are eligible for Mountain Health Choices may choose between the Basic and the Enhanced benefit plan. Members who are not eligible for Mountain Health Choices continue to be served by Traditional Medicaid. At this time, only certain members (those who fall within the eligibility categories shown in the table below) are eligible to participate in Mountain Health Choices: Medicaid Coverage Group Definition of Coverage Group AFDC Medicaid Recipients Includes adults with children under age 19 in the home. The (MAAR, MAAU) monthly family income cannot be more than the former AFDC payment levels. If a WV WORKS check is received, the income cannot exceed the former AFDC payment level. Assets cannot be more than $1000. Deemed AFDC Recipients - Extended A family is eligible to receive extended coverage when child or Medicaid spousal support has increased and the family has received (ME C, ME S) AFDC Medicaid three out of the previous six months. Transitional Medicaid This coverage group consists of families who lose eligibility for (ME I, ME T, ME D) AFDC Medicaid because of earned income, the loss of earned income disregards, or the number of hours worked. This coverage can be extended up to one year depending on the families' circumstances. Qualified Children Born On Or After The child must be under 19 years of age with income less 10-1-83 (MQCA) than 100% of the Federal Poverty Level. Children have no asset limit and they cannot be eligible for SSI. Poverty-Level Children Under Age 1 The child's income must be less than 150% of the Federal (MFPI) Poverty Level and not be SSI eligible. There is no asset test. Poverty Level Children, Ages 1-5 Child's income cannot exceed 133% of the Federal Poverty (MFPC) Level, cannot be SSI eligible, and has no asset test. Poverty Level Children, Ages 6-18 Child's income is less than 100% of the Federal Poverty Level, (Born On Or After 10-1-83) (MFPN) is not eligible for SSI, and has no asset test. Mountain Health Choices is only available to Medicaid members in the eligibility categories indicated in the chart above. Those not eligible for participation in Mountain Health Choices include, but are not limited to those receiving SSI, waiver clients, pregnant women, nursing home residents and foster care children. DRAFT A map describing the county-specific expansion of Mountain Health Choices is available on the BMS website, at: http://www.wvdhhr.org/bms/county_map/county_mapMHC.html 3. When will members’ benefits change? Benefits will change for members the first day of the month in which their eligibility is re-determined. For most members, this date occurs annually. The Mountain Health Choices expansion map, which indicates the dates in which the program will be available in specific counties, is available at: http://www.wvdhhr.org/bms/county_map/county_mapMHC.html 4. How are members notified about Mountain Health Choices? Members receive a package in the mail sixty (60) days before their eligibility re- determination date. This packet contains an explanation of benefits, a copy of the member agreement, a health improvement plan and a pamphlet encouraging them to call their health care provider for a well-visit and to sign up for the enhanced plan. A post-card reminder is sent at a later date. AHS staff also calls members to explain the packet. 5. Can Medicaid members who are enrolled in an enhanced benefit package remain in that plan if they move to a county where Mountain Health Choices has not yet been implemented? A Medicaid member enrolled in an enhanced benefit package will remain in it, even if they move into another county where implementation has not yet taken place. Enhanced services will still be available from the original medical home or may be obtained from a provider in the county to which they move. 6. Does a health care provider bill for the initial discussion of member agreements and responsibilities with the member for health plan goals? The provider who serves as a medical home for a Medicaid member in Mountain Health Choices and who develops a health improvement plan with the member will be compensated. To receive compensation for this service, providers must: • Fax either the page of the Member Agreement declining enhanced benefits and bearing the member’s signature OR the Member Agreement and Health Improvement Plan signed by the member within 90 days of the member’s re-determination date. DRAFT AND • Bill for the development of the plan using the code 99420. Providers may only receive reimbursement for developing plans with new members or with current members who are eligible for Mountain Health Choices and in the re-determination phase of their eligibility. 7. What is a health improvement plan? The health improvement plan is a plan which outlines mutually agreed upon steps the patient will take in the coming year to improve or maintain his or her health. The plan indicates how many times in the coming year the patient needs to see their doctor for well-visits, what vaccinations are due, what screenings or tests are necessary and what health improvement classes the member wishes to participate in. The health care provider should work in cooperation with the member to decide what steps are beneficial, reasonable and achievable. The completed health improvement plan should be faxed to 1-888-731-4314 and is reimbursable using billing code 99420. The patient should also receive a copy of the signed plan. The number of visits indicated on the health improvement plan are for well-visits, or check-ups, only. Patients are not limited in any way by the health improvement plan or by Mountain Health Choices, in the number of times a year they see their physicians or access their medical homes. In fact, members are encouraged to utilize the care provided in the medical homes rather than receiving non-emergent care in emergency rooms. 8. How often will compliance with the health improvement plan be evaluated? At this time, the Bureau intends to evaluate the plan annually. Evaluation will be based on claims data and not reporting from the medical home. 9. Following the initial discussion of the member’s responsibilities, what is the time frame for the member to choose a plan? The Member Agreement and Health Improvement Plan must be returned to Automated Health within 90 calendar days of the member’s re-determination date in order to obtain Enhanced Benefits. Members must make an appointment for a check-up and to discuss the Health Improvement Plan within this timeframe. If the member takes no action or chooses not to sign the Member Agreement, he/she will remain in the Basic Benefit package for the year. DRAFT 10. Who does the member contact if he or she does not know who is their primary care physician? Members may call their Health Maintenance Organization or Automated Health at 1-800-449-8466. 11. How do providers obtain preauthorization for services for members in Mountain Health Choices? The process for preauthorization of services has not changed. 12. How does a provider find out what plan a patient is in? It is very important to look at the members’ medical cards. The cards indicate if the member is in the Basic, Enhanced or Traditional plans. If the member is calling for an appointment, they can indicate what plan they have. Providers need to be familiar with the card. The New Medical Card File Layout Changes: * New fields have been indicated with XX. SMITH, JANE D 9001234567 123 ANYSTREET 0000000000 ANYTOWN, WV 12345 12345678900XX SMITH, JOHN D 01/01/2000 HMO A (800) 98765432100XX SMITH, JACK D 01/01/2005 HMO B (800) XX indicates one of the following: EA – Enhanced Adult EC – Enhanced Child BA – Basic Adult BC – Basic Child TR – Traditional Medicaid The specific plan the member chooses needs to be shared with APS Healthcare, Inc. when requesting a prior authorization or registering a service. DRAFT 13. If a member is currently receiving services and fails to sign up for the Enhanced plan in the time period allowed, will reimbursement for services stop? No. Members will still have coverage under the Basic plan. However, only Basic Plan services will be reimbursed. 14. Will Medifax reflect Basic or Enhanced plan coverage? Currently, neither Medifax nor the 270 HIPAA eligibility transaction will give the benefit plan information. BMS and Unisys are working to update this information. The Automated Voice Response System (AVRS) does give the current benefit plan information.
Pages to are hidden for
"FAQ of West Virginia Medicaid Redesign"Please download to view full document