SMMC Long-term Care Provider Webinar: Medicaid Pending
Welcome to the Agency for HealthCare Administration TrainingPresentation for PotentialLong-term Care Providers.The presentation will begin momentarily.Please dial in ahead of time to:1-888-670-3525Passcode: 771 963 1696
Medicaid PendingStatewide Medicaid Managed Care (SMMC)Long-term Care ProgramMarch 28, 2013
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Today’s Presenters Cheryl Young• Bureau Chief of Long-Term Care & SupportServices• Department of Elder Affairs Damon Rich• Manager, Choice Counseling Unit• Agency for Health Care Administration6
Objectives Define/explain Medicaid Pending Explain how Medicaid Pending will affectSMMC long-term care applicants in nursingfacilities vs. community settings Clarify the differences between MedicaidPending under the Nursing Home Diversionwaiver and the Long-term Care (LTC) program7
Legislative and Technical AdvisoryWorkgroup Direction409.9841(e), Florida Statutes, directs the Agencyfor Health Care Administration (AHCA) todevelop a process for the “enrollment of andpayment for individuals pending determinationof Medicaid eligibility.”8
Workgroup RecommendationNursing Facility Care The Agency shall ensure nursing facilities receive payment (thestate will maintain a separate fee-for-service payment system fornursing facilities) for individuals whose Medicaid eligibility isdetermined retroactively prior to their enrollment with a managedcare organization.Home and Community Based Care The Agency shall develop and incorporate a retroactive eligibilityand payment process that allows individuals access to home andcommunity based care as quickly as possible even if their financialeligibility for Medicaid has not yet been determined.9
What is Medicaid Pending?Medicaid Pending is when recipients electto enroll and receive services before theirapplication for financial eligibility isapproved.10
Reasons for Medicaid Pending Individuals that qualify for a Long-term Care planmay be elders or disabled individuals that havechronic illnesses and require long-term care servicesright away. Individuals are given the option to either receiveservices without verified Medicaid financial eligibilityor wait for Medicaid financial eligibility to be verifiedto start receiving services.11
Medicaid Pending Process After the Medicaid application has been completed (no eligibilityyet), the DCF application information will be sent to HealthTrack, asystem that is used to complete enrollments. HealthTrack will store the information until the CARES assessment isreceived stating the member is clinically eligible for the Long-termCare program. Therefore, HealthTrack will be receiving the Department of Childrenand Families (DCF) application information stating the individual hasapplied for Medicaid and the CARES assessment indicating theindividual is clinically eligible for long-term care services. In order to enroll with an SMMC Long-term Care managed care plan(MCP) as “Medicaid Pending,” applicants must have completed thefollowing steps: Filed a Medicaid application with DCF Received clinical eligibility (met “Level of Care” requirement).12
Once an SMMC Long-term Care applicant has completed these twosteps, they have two options:1. Now: Clients can choose to enroll with a managed care plan in a“Medicaid Pending” status. This will allow the recipient to receiveservices immediately, but puts them at risk for the cost of servicesreceived if their application for Medicaid is later denied.OR2. Later: Clients can choose a managed care plan, but have theEnrollment Broker hold the choice until their Medicaid applicationhas been approved by DCF. They are not formally enrolled in ahealth plan and do not receive services until Medicaid is approved. There is also the option to “Wait” when choosing to receiveservices “Later.” Choosing to “Wait” means you opt to wait untilyou receive approval of eligibility to both choose a plan andreceive services.13Medicaid Pending Process
What does the choice “Now” mean? If the individual chooses to get LTC services “Now,” they will beenrolled into the plan of their choice for the next enrollment cycle. The plan choice will be sent to the managed care plan and themember will receive a confirmation letter stating the planchoice, effective date and another reminder about getting services“Now” without approved Medicaid eligibility. During this Medicaid Pending period, the managed care plan cannotdeny or delay services based on the individuals pending Medicaideligibility status. There is a financial risk to the Medicaid recipient associated withreceiving services prior to receiving verification of Medicaideligibility.14
What does the choice “Later” mean? If the recipient decides to receive long-term care services“Later,” their services will not start until Medicaid eligibilityhas been approved. Although the recipient chooses to get services “Later,” theymay still choose a managed care plan. The managed care plan choice will be saved in the system as apending enrollment until Medicaid eligibility is approved. A confirmation letter with the managed care plan will be sent;however, since there is no eligibility yet, it will not indicate aneffective date.15
Enrollment Timeframe Examples Example 1If a recipient begins enrollment with the plan effective 9/1/13, butMedicaid eligibility is approved effective 10/1/13, then the recipient isresponsible for paying the plan for services rendered for the month ofSeptember. Example 2If a recipient begins enrollment with the plan effective 9/1/13, Medicaideligibility is approved effective 8/1/13, then the plan will only be paid forservices rendered September forward.16
What does the choice to “Wait” foreligibility to enroll mean? Recipients can also choose to get services later and wait tomake their managed care selection when eligibility isverified. When eligibility is granted, these recipients will receive aletter that lets them know that they have 30 days to choose aplan and informs them of the health plan they will beautomatically enrolled in if they do not make this choicewithin that timeframe. They will have 90 days from the initial effective date indicatedin this letter to try out either their chosen or automatically-assigned plan and change it for any reason.17
Managed Care Plan“Medicaid Pending” Protocol Managed care plans (MCPs) are not allowed todelay or limit services provided to MedicaidPending members. If a member is denied Medicaid eligibility (for some orall of the enrollment months spent in MedicaidPending status), the MCP can seek reimbursement ofthe cost of services from the member for the ineligibletime period. If a member gains Medicaid eligibility, the MCP will bereimbursed for the months in which the enrolleereceived services in a Medicaid Pending statuspursuant to the rates established in the Long-termCare program contract.18
“Medicaid Pending” Recipient Protocol Medicaid Pending recipients are not allowed tochange plans while in a Medicaid Pending status. Members can choose to opt out of MedicaidPending, and stop receiving services until Medicaid isapproved. Once a member receives Medicaid eligibility, he/shewill have a 90 day change period to switch MCPs, ifdesired. After the change period is over, members are locked in forthe rest of the year and can only change MCPs with anapproved “just cause” request.19
LTC vs. Nursing Home Diversion Medicaid Pending under SMMC LTC differs from NursingHome Diversion’s version of Medicaid Pending in thefollowing ways: SMMC LTC applicants must file a Medicaid Application beforethey are enrolled with an MCP. SMMC LTC MCPs will only receive Medicaid Pending memberswho wish to receive services, and have filed their applicationwith DCF. The “606” vs. “608” process under Nursing Home Diversion will end. SMMC LTC MCPs will not assist with initial DCF applications. MCPs willonly assist if they are providing services and also assist with financialeligibility completion as a part of case management. Medicaid Pending members will show up as enrolled with theirMCP in FMMIS while Medicaid Pending.20
Medicaid Pending & Nursing Facilities LTC applicants who reside in nursing facilities will be subjectto the same retroactive eligibility process under LTC thatthey were under Institutional Care Program (ICP) Medicaid. This is technically different from the SMMC LTC MedicaidPending process, which only applies to recipients in communitysettings. Individuals in nursing homes will not have the option to enroll ina managed care plan until their eligibility for Medicaid has beenapproved by DCF. According to the Medicaid Nursing FacilityHandbook, Medicaid eligibility can be granted retroactivelyby DCF for up to three months before the date of Medicaidapplication if the applicant meets all eligibilitycriteria, including level of care.21
Resources Questions can be emailed to:FLMedicaidManagedCare@ahca.myflorida.com Updates about the StatewideMedicaid Managed Care programare posted at:http://ahca.myflorida.com/Medicaid/statewide_mc Upcoming events and news can befound on the “News and Events” tab. You may sign up for our mailing list byclicking the red “Sign Up for ProgramUpdates” box on the right hand side ofthe page.22