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Octobe r 30, 2007 V olume 1, Issue 1 R ESOURCE C ENTERED Technical Assistance for Wisconsin Aging and Disability Resource Centers Department of Health and Family Services, Office for Resource Center Development (ORCD) Resource Centered: Technical Assistance for ADRCs Welcome to the first issue of “Resource Centered.” INSIDE THIS BULLETIN This series of bulletins will offer technical assistance as to how to operate an Aging and Disability ADRC Enrollment Plan Template Resource Center (ADRC) in Wisconsin. We hope that Partners in Enrollment: Best Practices you find the information contained in these bulletins Steps of the Enrollment Process to be resourceful. Model Wait List Management Policy Sample Urgent Services Agreement This first bulletin will contain information related to Notice of Denial of Functional Elig. Sample enrolling individuals into publicly funded long-term care programs and provides assistance with Sample Medical Remedial Expenses Checklist developing your ADRC enrollment plan and process. The plan is required of ADRCs located in counties where an MCO is operating. ADRC Enrollment Plan and Process Aging and Disability Resource Centers are the entry-way to the publicly funded long-term care system. As an ADRC, you are responsible for determining functional eligibility, providing the enrollment counseling that is critical for making informed decisions, and enrolling eligible consumers into the program of their choice. In order to ensure that Wisconsin consumers have easy and informed access to publicly funded services, ADRCs are required to develop an enrollment plan (previously referred to as an Access Plan) that outlines the process by which individuals can access publicly funded long-term care. In order to assist you in the development of your ADRC’s enrollment plan and process, the following documents are included in this bulletin: 1. ADRC Enrollment Plan Template. This template provides an outline and instructions to guide you through the development of your enrollment plan. Following the outline ensures that all contractually required areas are incorporated. Additionally, the Department will use this template when reviewing and approving your enrollment plan. 2. ADRC Enrollment Plan: Supporting Documents. The enrollment plan requires you to develop policies and/or documents that support the enrollment process. Model forms and policies for meeting such requirements are attached. These include: Resource Centered: Volume 1, Issue 1 Page 2 a. Partners in Enrollment: Best Practice Strategies for Facilitating Communication Among Partners b. Steps of the Enrollment Process: For Non-Medicaid Individuals c. Model Wait List Management Policy d. Sample Urgent Services Agreement e. Notice of Denial of Functional Eligibility Sample f. Sample Medical Remedial Checklist Note: Technical assistance and model documents related to Enrollment Counseling will provided in a subsequent “Resource Centered” bulletin. Plan Submission and Due Date The enrollment plan requires Department approval. ADRCs that are in a Managed Care service area that do NOT have previously approved enrollment plans, must develop and submit their plan 60 days prior to the start of the Managed Care Organization (MCO). If it is not feasible for ADRCs to meet this deadline in areas where the MCO is scheduled to begin in early 2008, an extension may be considered. Please contact the Office for Resource Center Development to request an extension. ADRCs with Department approved enrollment plans may wish to utilize the model forms, but are not required to do so. Please send your final enrollment plan, via e-mail, to: RCteam@dhfs.state.wi.us for review and approval. Contact Information If you have any questions about the materials or information found in this bulletin, you can contact your ADRC liaison at the Department of Health and Family Services, Office for Resource Center Development, or send an e-mail to: RCteam@dhfs.state.wi.us. ADRC Enrollment Plan Template 1 ADRC Enrollment Plan Template Note: The Aging and Disability Resource Center (ADRC) contract requires an ADRC to submit a plan to the Department that describes how the ADRC will ensure that individuals have access to public long-term care programs. Pending DHFS approval, completion of this template satisfies this requirement. Name of ADRC: _____________________________________________________ Area Served by ADRC: _____________________________________________________ Submitted by: _____________________________________________________ Template Outline Section 1: Process for Medicaid Recipients This section describes the process that you will follow when assisting individuals, who are currently Medicaid recipients, in accessing publicly funded long-term care. Section 1A will describe the centralized enrollment process; and Section 1B will describe the local enrollment process. Note: Using the centralized process is required for current Medicaid recipients that have at least 60 days of Medicaid eligibility after the desired enrollment date. Section 2: Process for Non-Medicaid Individuals This section describes the process that will be followed when assisting individuals, who are NOT Medicaid recipients currently, with obtaining Medicaid and accessing publicly funded long-term care. Section 3: ADRC Wait List Policy This section describes the ADRC’s wait list policy. A model waiting list policy is included. Customizing this model, where indicated, ensures that all necessary topic areas are addressed and Department requirements are incorporated. Section 4: Urgent Services Agreement This section describes the Urgent Services process and agreement. Section 5: Enrollment Counseling This section describes your process and procedure for assisting individuals in selecting a long-term care option and/or Managed Care Organization (MCO). Department of Health and Family Services, Office for Resource Center Development. October, 2007 ADRC Enrollment Plan Template 2 Section 6: Disenrollment This section describes the process that you will follow when assisting individuals in deciding whether or not to disenroll from a Managed Care Organization (MCO). Section 7: Forms This section describes the forms that you will use to support the enrollment process. Section 8: Signatures. This section includes the signatures from the organizations that were involved in the development of the enrollment plan. Enrollment Plan Overview Information and Assistance (I&A) Specialists who help individuals with the enrollment process will interact with people who currently have Medicaid and with individuals who do not. This chart illustrates the different sections of the enrollment plan template where ADRCs, along their partners, Income Maintenance (formerly called Economic Support) and Managed Care Organizations, document their processes. Enrollment Counseling: The ADRC supports the individual who decides which Note: Throughout the benefit option best meets their template and supporting needs. documents, you will find flowchart icons. The highlighted box in the icon corresponds with this flow chart. 1A. Centralized Enrollment 1B. Local Process for 2. Local Process for Non- for Medicaid Recipients: Medicaid Recipients: Medicaid Individuals: The individual already has The individual already has The individual does NOT have Medicaid and is going to be Medicaid. However, the Medicaid. The I&A Specialist enrolled via the centralized individual does not meet the supports the individual enrollment process. criteria for centralized through the eligibility and enrollment so the enrollment enrollment process. process occurs locally. Department of Health and Family Services, Office for Resource Center Development. October, 2007 ADRC Enrollment Plan Template 3 Section 1: Process for Medicaid Recipients Describe the centralized and local enrollment processes that you will follow when assisting individuals who already have Medicaid to access publicly funded long-term care. Section 1A: Centralized Enrollment Current Medicaid recipients that have at least 60 days of Medicaid eligibility after the desired enrollment date that now need assistance with accessing publicly funded long-term care will be enrolled via centralized processing. How do you intend to operationalize the centralized enrollment process in your ADRC? (Note: Instructions for using centralized enrollment will be provided when they are available.) Section 1B: Local Processing What steps are used when assisting an individual whose Medicaid status has been verified and now needs assistance in accessing publicly funded long-term care? These individuals do not meet the criteria for centralized enrollment and require local processing. Include time frames that ensure that applications are processed in a timely manner. Highlight what and how information will be exchanged between the ADRC, Income Maintenance (IM) and the Managed Care Organization(s). Indicate how you will coordinate between the ADRC, IM, and MCO(s) to ensure that consumers experience an efficient and effective process. (See “Partners in Enrollment: Best Practice Strategies for Facilitating Communication Among Partners” for ideas on completing this section.) Department of Health and Family Services, Office for Resource Center Development. October, 2007 ADRC Enrollment Plan Template 4 Section 2: Process for Non-Medicaid Individuals Describe the process that you will follow when assisting individuals who are NOT Medicaid recipients in applying for Medicaid and accessing publicly funded long-term care. Include time frames that ensure that Medicaid applications are processed within 30 days of the application being signed. Highlight what and how information will be exchanged between the ADRC, Income Maintenance and Managed Care Organization(s). Also describe your use of www.access.wisconsin.gov, which is the online Medicaid screener and Elderly Disabled Blind (EDB) application tool. List printed materials (from the ADRC and IM) that will be given to an individual applying for Medicaid and publicly funded long-term care. (See “Steps of the Enrollment Process” and “Partners in Enrollment: Best Practice Strategies for Facilitating Communication Among Partners” for ideas on completing this section.) Department of Health and Family Services, Office for Resource Center Development. October, 2007 ADRC Enrollment Plan Template 5 Section 3: ADRC Wait List Policy In accordance with state requirements, what local policies and procedures are followed to help individuals who are currently registered on the Human Service Reporting System (HSRS) as eligible for Waiver services, in moving off the list and receiving services? What is your policy/protocol for establishing your wait list and selecting who will be served in the 24 month transitional period, including any local priorities for serving persons from the wait list? Address how people will be served who are relocating from institutions, receiving court-ordered services, transitioning from school and moving into the ADRC service area. Describe how you intend to manage and/or serve new applicants who are added to the list after the enrollment target is set. (See “Model Wait List Management Policy” for ideas on completing your policy. Customizing this model, where indicated, ensures that all necessary topic areas are addressed and Department requirements are incorporated.) Department of Health and Family Services, Office for Resource Center Development. October, 2007 ADRC Enrollment Plan Template 6 Section 4: Urgent Services Agreement Managed Care Organizations (MCOs) may choose to provide “urgent” services to individuals who have been determined to be functionally eligible for Family Care but who are waiting for their financial eligibility to be determined. If the MCO is willing to serve such individuals during this waiting period, please describe the process and protocol that will be followed. Describe the protocols used by the ADRC to refer people to the MCO for urgent services, and explain any parameters or guidelines that the MCO has in providing services to these individuals. Include the time frames for monitoring the eligibility process. Also include the form that consumers sign to indicate their acceptance of financial responsibility (agreement to pay) for services if eligibility is not established. (Note: The MCO is not required to serve applicants during this eligibility determination waiting period.) (See “Sample Urgent Services Agreement” for ideas on completing this section.) Department of Health and Family Services, Office for Resource Center Development. October, 2007 ADRC Enrollment Plan Template 7 Section 5: Enrollment Counseling Enrollment counseling involves assisting individuals who are found eligible for publicly funded long term care in deciding which benefit option best meets their needs. During this process, individuals may decide to enroll in a Managed Care Organization (MCO), choose a fee-for- service option such as the Self-Directed Supports Waiver (SDS), or select regular Medicaid. In this section, describe your process for helping people make these important decisions. Highlight your process for helping people select an enrollment date. In your description, include the printed materials you will review with individuals receiving enrollment counseling. Key materials might include: MCO provider network(s), Being a Full Partner booklet and the MCO Member Handbook(s). Individuals who receive enrollment counseling also need to learn the appeal and grievance procedure for the MCO. Please indicate how you will review the appeal and grievance procedures with consumers. (Note: Sample enrollment counseling tools and ideas will be provided in a subsequent “Resource Centered” bulletin.) Department of Health and Family Services, Office for Resource Center Development. October, 2007 ADRC Enrollment Plan Template 8 Section 6: Disenrollment Participants may be voluntarily or involuntarily disenrolled from the Managed Care Organization (MCO) or Self Directed Supports Waiver (SDS). The ADRC is required to offer counseling to these individuals before they disenroll. Describe the communication plan between the MCO and the ADRC which supports an individual who is disenrolling, which may include enrolling in a different MCO or SDS waiver (if applicable). Describe the content of the counseling provided (i.e., other MCO options if available, Self Directed Supports Waiver, Medicaid card services or private pay service options). Department of Health and Family Services, Office for Resource Center Development. October, 2007 ADRC Enrollment Plan Template 9 Section 7: Forms What forms, flow charts and other documents are used internally to support the enrollment process? What printed materials are given to consumers? Please include the forms that you intend to use, including the following: MCO appeals and grievances (if different from member handbook), urgent services agreement, enrollment counseling forms and notifications provided to individuals who are either functionally eligible or ineligible. (Note: It is not necessary to submit forms that you intend to use that have been issued by the Department.) (See “Sample Urgent Services Agreement” and “Notice of Denial of Functional Eligibility Sample” and “Sample Medical Remedial Expenses Checklist” for examples that can be used to complete this section. You may also want to go to: http://dhfs.wisconsin.gov/ltc_cop/waiverbasics/section3.pdf (page 100) for another example of a medical/remedial checklist.) Department of Health and Family Services, Office for Resource Center Development. October, 2007 ADRC Enrollment Plan Template 10 Section 8: Signatures Please include the signatures of the organizations that agree to implement the enrollment plan and that were involved in its development. ____________________________________________________________________ Signature of ADRC authorized representative ____________________________________________________________________ Signature of Income Maintenance authorized representative ____________________________________________________________________ Signature of Managed Care Organization authorized representative ____________________________________________________________________ Signature of Additional authorized representative ____________________________________________________________________ Signature of Additional authorized representative Department of Health and Family Services, Office for Resource Center Development. October, 2007 ADRC Enrollment Plan: Partners in Enrollment 1 Partners in Enrollment Best Practice Strategies for Facilitating Communication Among Partners The Aging and Disability Resource Center (ADRC), Income Maintenance (IM) unit, and the Managed Care Organization (MCO) are partners in the enrollment process- each with an important role to play. Effective communication is critical in order to ensure that the process is effective and efficient for consumers. This document contains examples of the communication that needs to occur among the partners on behalf of a consumer applying for Medicaid as well as key communication that occurs after a person has been enrolled. This list serves as a reference or guide when developing local processes in the enrollment plan. Initial Communication Among Partners 1. The ADRC sends a referral to the income maintenance (IM) worker notifying them that an individual who receives or who has applied for Medicaid is being counseled about Family Care. 2. The ADRC makes a referral to IM via the Family Care enrollment form. The ADRC provides IM with an estimate of the medical/remedial expenses for new applicants. 3. IM provides the ADRC with the 30-day eligibility deadline and a list of verifications and other information that is requested of the applicant. 4. ADRC gives the following to IM: a. The individual’s functional screen results. b. Estimated medical/remedial expenses for potential Group B participants. c. Medical/remedial expenses and Medicaid expenses to IM for Group C participants. d. Any information pertaining to guardianship, power of attorney, etc., discovered during the counseling process. e. The applicant’s current living arrangement and household composition. f. Any information pertaining to life insurance, trusts, annuities, etc., discovered during the counseling process. g. Any information pertaining to divestment discovered during the counseling process. 5. If necessary, IM informs the ADRC if the verification requested of the applicant has NOT been received and whether the 30-day eligibility deadline has been extended. 6. For applicants who are determined to be financially ineligible, IM sends notification of ineligibility and appeal rights to the applicant and informs the ADRC. The ADRC contacts the individual to offer I&A and options counseling. Department of Health and Family Services, Office for Resource Center Development. October, 2007 ADRC Enrollment Plan: Partners in Enrollment 2 7. For applicant’s who are determined to be financially eligible, IM informs the ADRC and the applicant of eligibility and cost share if there is one. (Note: if there is no cost share, the consumer can be referred directed to the MCO to begin the care planning process.) 8. ADRC updates the consumer about cost share information and answers questions. If consumer decides to enroll, informs IM of applicant’s choice of MCO and the preferred enrollment date. 9. ADRC informs IM if the applicant wants to withdraw their application or delay enrollment. 10. If applicant chooses to enroll, IM confirms enrollment with the ADRC. 11. If an enrollee has a Medicaid deductible, IM informs the MCO of the deductible period end date and amount so that the MCO may assist the member in planning to meet the deductible. On-Going Communication Among Partners 1. MCO gives medical/remedial expenses to IM if different than initially estimated by the ADRC, or if they later change. 2. MCO gives medical/remedial expenses to IM at recertification time. 3. MCO gives to IM any information that is discovered that pertains to a change in a member’s income or assets. 4. MCO gives any information discovered pertaining to divestment to IM. 5. MCO notifies ADRC and IM if any of the following apply: a. Member goes into a correctional institution or IMD no matter how long the stay. b. A member goes into a hospital for more than 30 days. c. A member dies. d. A member moves to another county. e. A member wants to voluntarily disenroll. f. A member is involuntarily disenrolled. g. A member no longer meets the level of care requirements for the program. 6. MCO notifies IM if any of the following apply: a. The member’s living arrangement changes (i.e., enters a nursing home). b. Anyone living with the member moves or dies. c. The member’s spouse becomes institutionalized. 7. IM notifies the MCO whenever there is a change in eligibility or cost sharing to allow the Care Manager to review the member’s medical/remedial expenses. Department of Health and Family Services, Office for Resource Center Development. October, 2007 Steps of the Enrollment Process for Non-Medicaid Individuals 1 Steps of the Enrollment Process For Non-Medicaid Individuals Step One: Aging and Disability Resource Center (ADRC) Verifies lack of Medicaid eligibility (via MMIS). Completes Long-Term Care Functional Screen (LTCFS). If functionally ineligible, sends a notice of denial of functional eligibility with appeal rights to the consumer. Establishes Level of Care (LOC) for individuals who are functionally eligible. Reviews consumer’s financial and non-financial circumstances and, based on that information, helps consumers decide whether or not to formally apply for Medicaid. May use “Am I Eligible” tool on www.access.wisconsin.gov. Assists consumer in gathering information to support the Medicaid application including Medical/Remedial Expense information if appropriate. Assists consumer in connecting with Income Maintenance (IM) regarding a Medicaid application. People can apply on line, over the telephone, mail in a paper application, or have a face-to-face interview with an IM worker. Reviews printed material with the consumer (i.e., “Being a Full Partner”, member handbook, provider network, appeal and grievance rights information in the member handbook). Performs enrollment counseling and explains benefit packages (Family Care, Partnership, Self- Directed Supports Waiver). Discusses potential preferred enrollment date with consumer and answers any questions. Provides IM with signed enrollment form including projected enrollment date. Note: Administration of the long term care functional screen and the Medicaid application can occur concurrently. Step Two: Income Maintenance (IM) If Medicaid ineligible, CARES sends notification of ineligibility and appeal rights to the consumer. IM refers the individual back to the ADRC for I&A and Options Counseling.* If Medicaid eligible without a cost share, CARES sends notification of eligibility and appeal rights to the consumer and notifies the ADRC and MCO of enrollment. Proceed to Step 5. If MA eligible with a cost share, IM “pends” the case, provides cost share amount to ADRC/Consumer and waits for final confirmation of the enrollment date from the ADRC. Department of Health and Family Services, Office for Resource Center Development. October, 2007. Steps of the Enrollment Process for Non-Medicaid Individuals 2 Step Three: Aging and Disability Resource Center Updates consumer about cost share information and answers questions. Learns if consumer still wants to enroll and if the projected enrollment date still meets their needs. If consumer chooses to enroll, communicates decision and enrollment date to IM. Step Four: Income Maintenance (IM) Confirms eligibility and cost share in CARES; CARES generates eligibility and cost-share notification and sends it to the consumer.* IM/ADRC notifies the MCO of enrollment and if the enrollee has a Medicaid deductible, IM informs the MCO of the deductible period end date and amount so that the MCO may assist the member in planning to meet the deductible. Step 5: Managed Care Organization (MCO) Contacts the consumer, begins assessment, care planning and service delivery processes.* Monitors enrollment via enrollment report from EDS. Monitors and collects cost-share as reported on CARES cost-share report. *If the consumer decides not to enroll at any time, he/she may receive additional I&A and Options counseling and should be referred back to the ADRC for these services. Department of Health and Family Services, Office for Resource Center Development. October, 2007. ADRC Enrollment Plan: Model Wait List Management Policy 1 Model Wait List Management Policy Note: Only italicized bold print should be customized or deleted based on ADRC preferences. I. Purpose The purpose of this document is to define the policies and procedures of the Aging and Disability Resource Center (ADRC) related to the state requirements for the management of a waiting list of qualified applicants who are registered on the Human Service Reporting System (HSRS). This policy is in effect during the 24 month transition to Family Care in insert name of County. II. Establishing a Waitlist A. Current Waitlist All individuals who are registered on HSRS as qualified for the waiting list, on a date that is three months prior to the initiation of any enrollments, are automatically on the established waiting list to be enrolled over the 24 month transitional period. B. Youth Transitioning to the Adult System: Individuals on a Waiting List Children on a Waiver waiting list who are registered on HSRS, and who will attain age 18 years during the 24 month transitional period, will be incorporated into the established wait list based on the date that their name was placed on the children’s wait list. C. Moves: Individuals on a Wait List in Another County Individuals who are on a Waiver waiting list who are registered on HSRS in another county, who remain functionally and financially eligible, and who move to insert the name of your County, will go on the insert the name of your County waiting list based on the date in which their name was placed on the waiting list in the originating county. D. Timeframe for Adding People to the Waitlist Eligible applicants may be added to the waiting list at any time. III. Serving Persons From the Waiting List During the Transition to Family Care A. Enrollment Target for insert name of County The number of people that will be enrolled over the two year transitional period is based on the number of people who are registered as waiting on HSRS as of the date that is three months prior to the initiation of any enrollments from insert name of County. The monthly enrollment target for insert name of County is 1/24 of the number on the wait list as of insert local date here. Enrollment is managed in this way in order to allow both the ADRC and Managed Care Organization(s) sufficient time to reach their operational capacity and to effectively manage Family Care transitions within state budget parameters. This monthly target is managed by the ADRC. B. Applicant Selection and Notification The ADRC will contact individuals that are registered on the HSRS waiting list to discuss the possibility of enrolling in a Family Care program or receiving services under the Self-Directed Supports (SDS) Waiver. Information and Assistance (I&A) Specialists will contact individuals in Department of Health and Family Services, Office for Resource Center Development. October, 2007. ADRC Enrollment Plan: Model Wait List Management Policy 2 the order in which their name appears on the waiting list and/or in accordance with any local prioritization (identified below). C. Local Priorities Insert Local Priorities HERE related to serving people from the wait list, if any. EXAMPLES include, but are not limited to: Individuals who are at high risk of institutionalization, someone who presents an urgent or emergency situation, a person with a terminal condition, a person who is self abusive or neglectful, an individual who is court ordered to receive services, or a child who is required to leave the school system where the absence of school services may cause a crisis for the family or child. D. Notification of Wait List Status Individuals who continue to wait will be contacted every Insert number of months regarding their status on the waiting list and the estimate of when managed long-term care funds may be available. IV. Serving New Applicants in Transitional Period A. New Applicants Prior to Entitlement The names of applicants whose initial request for Family Care occurs after the monthly enrollment target has been set for insert name of County, will be placed at the end of the waiting list. This list will be managed by the ADRC. These applicants will be informed that they will be enrolled at the end of the 24 month period, unless individuals from the established waiting list leave the list due to loss of eligibility, death, or by request. The enrollment target does not change. B. Court Ordered Services The names of individuals who are eligible for Family Care and who are court ordered to receive services will also be placed on the waiting list in the order in which they apply. These individuals will be treated as new applicants (see A., above). An ADRC may choose to prioritize these individuals in the local priorities section of this policy and reference that HERE. C. ADRC Services While Waiting While waiting for Family Care, applicants may receive other services provided by the ADRC such as information and assistance, options counseling, and benefits counseling. V. Persons Eligible for Immediate Services The following individuals may not be placed on the waiting list because they are currently receiving Waiver services or are eligible to immediately receive Family Care or SDS Waiver services: A. Youth Transitioning to the Adult System: Current Waiver Participants Children who are turning 18, who have been served by the Children’s Long-Term Support (CLTS) Waivers or the Community Integration Program (CIP) Waiver, who meet Family Care eligibility, must enroll in either Family Care or the Self-Directed Supports Waiver to continue receiving long-term care services. They may enroll upon reaching age 18. Department of Health and Family Services, Office for Resource Center Development. October, 2007. ADRC Enrollment Plan: Model Wait List Management Policy 3 B. Current Waiver Participants Who Move Adult Waiver participants who move to a county transitioning to Family Care can enroll in Family Care without going on a waiting list. C. Current Family Care Participants Who Move Adults served by Family Care who move to a county transitioning to Family Care may immediately enroll in a Family Care Managed Care Organization in insert the name of your County without going onto the waiting list. D. Relocations from Institutions Adults who meet the criteria for relocation from a skilled nursing facility (SNF) or an Intermediate Care Facility for the Mentally Retarded (ICF-MR) may be served immediately. Therefore, they do not need to go onto a waiting list. Department of Health and Family Services, Office for Resource Center Development. October, 2007. ADRC Enrollment Plan: Sample Urgent Services Agreement 1 SAMPLE Urgent Services Agreement For individuals who are Functionally Eligible, but Whose Financial Eligibility is Pending I have applied to receive services through the Family Care benefit and I understand that in order to be eligible for services I must meet certain functional and financial eligibility requirements. I understand that I have been determined to be functionally eligible and that my financial eligibility is still pending. Due to my current condition or circumstances, I understand that I may be able to begin receiving some “urgent” services while I am waiting for a final decision about my financial eligibility. I would like to be referred to the Managed Care Organization (MCO) now so that I can begin to get the services I need to meet my urgent care needs. I understand that if it is determined that I am not financially eligible for the Family Care benefit, or if I am found financially eligible but decide not to enroll, that my services through the Managed Care Organization will end. I further understand that I will be responsible for the cost of any services provided to me through the Managed Care Organization, and I agree to pay the MCO according to a mutually agreed payment schedule. Signed, ______________________________________ ______________________________ ____________________ Family Care Applicant Guardian/Legal Representative Date ______________________________________ ADRC Authorized Representative Department of Health and Family Services, Office for Resource Center Development. October, 2007. ADRC Enrollment Plan: Sample Notice of Denial 1 Notice of Denial of Functional Eligibility Insert Date SAMPLE Insert Name Street Address City, State, Zip Dear Mr./Mrs./Ms. Insert Last Name: Thank you for contacting the Aging and Disability Resource Center of Insert name of County. When we met recently, you may recall that we completed a Long-Term Care Functional Screen, which is the tool that is used to determine if you need the level of care that makes a person eligible for the Family Care benefit. I regret to inform you that your determination of care needs indicates that you are NOT functionally eligible for Family Care at this time. However, if your health or ability to do everyday activities change, please contact us again so that we can reassess your functional eligibility and/or assist you in getting the help that you need. If you have reason to believe that an error has occurred in your functional eligibility determination, you have a right to appeal this decision within enter the number of days. As described in the appeals and grievance procedure that was shared with you at the time of your screen OR that is attached to this letter (select one), you can contact our agency to express your concerns or to submit a formal complaint or grievance. You can fill out the attached form and/or contact us directly at: Insert ADRC name & contact person Insert ADRC address Insert ADRC phone number Insert ADRC e-mail address If you do not wish to contact our agency or, if after contacting us you continue to be dissatisfied with the result, you have the right to appeal this decision with the Division of Hearings and Appeals. You can request a hearing by writing to the Division of Hearings and Appeals, P.O. Box 7875, Madison, WI 53707-7875. Please include your name, mailing address, a brief description of the problem, the ADRC name, your social security number and your signature. Thank you again for contacting our agency and please let us know if we can be of further assistance. Sincerely, Insert Name of ADRC Representative Department of Health and Family Services, Office for Resource Center Development. October, 2007. Page 1 of 2 SAMPLE Medical Remedial Expenses Checklist The following are allowable monthly medical and remedial expenses for all Family Care members regardless of their type of Family Care eligibility. Please note these expenses must represent actual out-of-pocket purchases or costs. Amount Medical Remedial Expenses $ Deductibles or Co-payments for Medicaid, Medicare, and Private Health Insurance. $ Past medical bills: Allowable outstanding bills for medical services that were incurred prior to Medicaid eligibility and which are currently being paid by the participant. $ Deductible/Co-Payments/Medical Bills Sub-total Over the counter (OTC) medical services and supplies not covered by Medicaid (not all-inclusive): $ Skin care products such as Aloe, Intensive Care, KERI, or similar products $ Rubbing alcohol, swabs, and antiseptic $ Enema administration apparatus $ Hydrogen peroxide $ Lemon or glycerin swabs $ Lubricating jellies (Vaseline, KY jelly, etc.) $ Phosphate enema $ Tincture of Benozin $ Tongue depressors $ Distilled water $ Diapers/Underpads/Depends – disposable and reusable. $ Non-expendable reusable materials (e.g., bedpans, thermometers, rubber pants, etc.) $ OTC Medical Supplies Sub-Total Over the counter drugs (OTC’s – not all inclusive): $ OTC vitamins/mineral products $ OTC aspirin or aspirin substitutes $ OTC anti-diarrhea agents $ OTC laxatives and stool softeners $ OTC cough, cold and sinus products and antihistamines $ OTC ophthalmic products $ OTC hemorrhoid products $ OTC topical steroids, antibiotics, antifungal agenda, and pediculicides $ OTC vaginal preparations $ OTC digestive aids $ OTC quinine sulfate preparations $ OTC saliva substitutes $ Other prescribed OTC medications $ OTC Drugs Sub-Total Items that may be covered by MA but require a physician’s order (not all inclusive): $ Analgesic rubs – Ben Gay, Vicks, Iodine, Mercurochrome, Merithiolate, Basil Geland similar products $ Cotton balls and Cotton tipped applicators $ Dressings: adhesive pads, abdominal pads, gauze pads and rolls, eye pads, stockinette opsite, etc. $ Gloves: latex or vinyl $ Syringes and needles (disposable and reusable) $ Tracheotomy care sets and component pasts $ Irrigation solutions (urologic G, normal saline and sterile water), sets, component parts $ Catheters (Foley and Condom), catheter sets, component parts including tubing and urine collection bags. $ Supplies for stomas: creams, tapes, gloves, etc. $ Med/Remedials that Require Physician’s Order Sub-Total $ PAGE 1 TOTAL Department of Health and Family Services, Office for Resource Center Development. October, 2007. Page 2 of 2 Amount Medical Remedial Expenses Dietary Supplies: $ Not covered by MA: Artificial sweeteners Salt substitutes Sugar substitutes $ Covered by MA via prior authorization (which rarely occurs): Dietary supplements such as Ensure, Metrical, Vivonex, Nova, etc. $ Dietary Supplies Sub-Total Vision products: $ Anti-scratch coating $ Anti-glare coating $ Eyeglass frames or lenses beyond the original pair and one unchanged prescription repla cement pair from the same provider in a 12-month period denied by Medicaid. $ Vision Products Sub-Total Dental products and services: $ Fluoride mouth rinses $ Partial dentures and adjustments $ Panoramic radiographs which include bitewings $ Dispensing of drugs $ Surgical removal of erupted teeth $ Alveoloplasty and stomaplasty $ Bitewing x-rays $ Other dental services denied prior authorization but services which are necessary for independence in care (e.g., dentures, six month checkups for people with special dental problems such as people who take Dilantin, root canals, crowns, bridge work, etc.) Dental Products Sub-Total Other Medical/Remedial Expenses: $ Podiatry-foot care services performed by a podiatrist. (Foot care provided by a physical is covered by Medicaid.) $ Acupuncture $ Transportation (not covered by Medicaid or other program funding) $ Other supplies not listed above (attach a separate list if necessary) $ Other Medical/Remedial Expenses Sub-Total $ PAGE 2 TOTAL PAGE 1 TOTAL $ PAGE 2 TOTAL $ TOTAL DEDUCTIONS $ The medical remedial information listed above is true to the best of my knowledge. If I no longer require any of the items listed above I should notify my MCO Case Manager. I realize that this may change my cost share or cause me to have one. The MCO Case Manager will be monitoring my use of medical remedial supplies on a regular basis and will ask me to provide proof of expenses. (You should save receipts in an envelope.) Signature Date Department of Health and Family Services, Office for Resource Center Development. October, 2007.
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