COst Assist Program ELIGIBILITY CRITERIA AND GENERAL PROGRAM PROTOCOLS EFFECTIVE JULY 1, 2015
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1 COst Assist Program ELIGIBILITY CRITERIA AND GENERAL PROGRAM PROTOCOLS EFFECTIVE JULY 1,
2 Which ADAP Clients Can Also Enroll in COst Assist? ADAP Clients Currently Eligible for Assistance with Medical Claim Costs HIAP: Health Insurance Assistance Program* ADAP Clients who will be Eligible for Assistance with Medical Claim Costs Effective 7/1/2015 under COst Assist HIAP: Health Insurance Assistance Program* BTGC: Bridging the Gap, Colorado* SWAP: Supplemental Wrap Around Program Note: The approximate 200 ADAP clients currently without health insurance who are enrolled in HMAP, or HIV Medication Assistance Program, will not be eligible for COst Assist. CHN will be attempting to assist these clients with procuring health insurance and moving into the HIAP program. *In some cases, out of pocket maximums may apply. Additionally, specific clients in these programs may not meet all eligibility criteria for medical cost assistance. 2
3 ADAP Clients Who Will Also Be Eligible for COst Assist HIAP: Health Insurance Assistance Program* Clients enrolled in employer-based or marketplace insurance plans Approx. 1,200 total current clients (half from employer-based plans and half from marketplace plans) HIAP clients are currently eligible for medical claim financial assistance Secondary medical claim administration is scheduled to transition from CHN to COst Assist effective July 1, 2015 BTGC: Bridging the Gap, Colorado* Clients enrolled in Medicare Part D or Medicare Advantage Approximately 900 current clients Not currently eligible for medical claim financial assistance, but will become eligible July 1, 2015 SWAP: Supplemental Wrap Around Program Clients enrolled in Medicaid Approximately 900 current clients Not currently eligible for medical claim financial assistance, but will become eligible July 1, 2015 *In some cases, out of pocket maximums may apply. Additionally, specific clients in these programs may not meet all eligibility criteria for medical cost assistance. 3
4 COst Assist Administration Compared to Current ADAP Medical Secondary Payment Program Administration 4
5 COst Assist vs. Current Claim Process New claim submission process Currently, clients / patients must submit their own secondary claims to CHN for reimbursement. Many claims are delayed or never submitted, resulting in Accounts Receivable issues and write-offs for providers. Under COst Assist, participating providers will submit secondary claims directly to CNIC via EDI. New claim payment process Currently, CHN reimburses all providers via check. Under COst Assist, participating providers will sign up with CNIC to receive one ACH payment per month, with an 835 Electronic Remittance Advice available for automatic posting of payments to many provider billing systems. 5
6 COst Assist Program Responsibilities Effective 7/1/15 Client/ Patient Responsibility Colorado ADAP (at CO Dept of Public Health & Environment) Responsibility AIDS Service Organization (ASO) Responsibility CHN Responsibility CNIC Responsibility Provider Responsibility Enrollment Applies for enrollment independently or with assistance of an ASO Processes initial applications and recertifications, making all final eligibility determination decisions Assists clients with Enters eligibility into Ramsell Coordination of Benefits. system, sends weekly (Can assist clients in enrolling eligibility to CNIC in COst Assist program.) electronically (via Ramsell) Loads eligibility weekly into claims system to facilitate claim payment Submitting Claims Claims Payment Questions Regarding Eligibility Can still submit paper claims to ASO if necessary. (Preferred process is for provider to submit claims electronically to CNIC.) Responds to client and eligibility Submits paper claims received from clients to CHN for processing. (Preferred process is for provider to submit claims electronically to CNIC.) Issues checks for paper claims submitted to CHN by providers or ASOs Responds to client and eligibility Issues ACH/EFT payments for claims submitted electronically to CNIC by providers After receiving payment from primary carrier, submits claims for secondary payment based on information on client/patient's Ramsell ID card. (Preferred approach is to submit claims electronically to CNIC, but paper claims can be submitted to CHN if necessary.) Signs up for ACH/EFT payments from CNIC Contacts CHN or CO ADAP at CDPHE with questions regarding eligibility Questions Regarding Claim Payment Responds to all client questions. Respond to claims paid by CHN. Responds to provider questions regarding claims paid by CNIC Contacts CNIC regarding claims paid by CNIC. (Contact information will be on EOB.) Contacts CHN regarding claims paid by CHN. 6
7 Current Process (Goes Away 7/1/2015) Client/ Patient Responsibility Colorado ADAP (at CO Dept of Public Health & Environment) Responsibility AIDS Service Organization (ASO) Responsibility CHN Responsibility Provider Responsibility Enrollment Submitting Claims Claims Payment Questions Regarding Eligibility Questions Regarding Claim Payment Applies for enrollment independently or with assistance of an ASO Responsible for submitting claims for secondary payment to ASO Processes initial applications and recertifications, making all final eligibility determination decisions Assists clients with Coordination of Benefits. (Can assist clients in enrolling in ADAP programs.) Submits claims received from clients to CHN for processing Contacts CHN regarding claim payment questions Enters eligibility into Ramsell system Issues checks for all secondary payments. Responds to client and eligibility Responds to client and claims After receiving payment from primary carrier, gives client/patient claim information to give to ASO Contacts CHN or CO ADAP at CDPHE with questions regarding eligibility Contacts CHN with questions regarding claim payment 7
8 Additional Communications Program Overview (available May 1, 2015) Provider Submission of Electronic Claims to CNIC Health Solutions (available early May 2015) Provider Enrollment for Electronic/ACH Payment from CNIC Health Solutions (available early May 2015) Frequently Asked Questions (available May 2015, updated periodically) 8
9 Resources for Questions on COst Assist and ADAP Programs Todd Grove General ADAP and COst Assist Program Information Health Access Unit Lead ~ CO AIDS Drug Assistance Program P: F: Helpdesk: todd.grove@state.co.us Dana Kennedy Patient enrollment in COst Assist and ADAP programs Insurance Subsidy Program Manager Colorado Health Network P: ext 318 F: Dana.kennedy@coloradohealthnetwork.org 9
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