FAQ of West Virginia Medicaid Redesign by jackl17



              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:

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

    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.

A map describing the county-specific expansion of Mountain Health Choices is
available on the BMS website, at:

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:

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.


   •   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

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.

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.

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

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.

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