Florida Medicaid Managed Care Long Term Care

Transcription

1 THE SURVIVAL GUIDE E Florida Medicaid Managed Care Long Term Care Prepared by: Orlando Miami Tampa Area Tallahassee 1201 South Orlando Avenue Suite 400 Winter Park, FL Toll Free: NW 77th Court Suite 306 Miami Lakes, FL Toll Free: Park Place Boulevard Suite 100 Clearwater, FL Toll Free: West Park Avenue Suite 202 Tallahassee, FL Toll Free:

2 Table of Contents Background Information... 1 Services Provided under the Long Term Care Program... 1 Regional Map... 2 Roll out Schedule... 3 Managed Care Organizations... 4 Managed Care Organization- Basic Contact List... 4 What about my current clients?... 5 Sample Letters... 6 How do I submit claims?... 6 Contracting Tips... 6 General Terms... 7 Payment Terms... 7 Operations Terms... 7 Credentialing & Quality Assurance... 8

3 Background Information During the 2011 session the Florida Legislature enacted House Bill 7107 ( F.S.) which will transition Nursing Home Diversion and Medicaid to a comprehensive Managed Care program called Statewide Medicaid Managed Care Under this program, most Medicaid Long Term Care and Nursing Home Diversion services will be delivered by managed care plans. In order to move most of the Florida Medicaid members requiring nursing home and Home and Community Based Care onto managed care, Florida had to request a waiver to the standard provisions of Medicaid to do this. This waiver was granted on February 1, Governor s press release following the approval: Governor Rick Scott today announced that the U.S. Department of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS) approved one of the state s two pending Medicaid waivers late Friday. The Governor urgently requested approval of the long-term care waiver and a waiver for the Statewide Medicaid Managed Care Program when he met with HHS Sec. Kathleen Sebelius on January 7th in Washington, DC. The approved waiver, called a 1915 (b/c) waiver, allows the Agency for Health Care Administration (AHCA) to move forward with the implementation of the Statewide Medicaid Managed Care (SMMC) Long-term Care program. Services provided under the Long Term Care Program LTC Program Minimum Covered Services Adult companion care Adult day health care Assisted living Assistive care services Attendant care Intermittent and skilled nursing Medical equipment and supplies Medication administration Medication management Nursing facility 1 P a g e

4 Regional Map The Managed Care Organizations take over paying claims on a roll out basis by county from August 1, 2013 through March 1, You can find your region using the map below: You can also view the full map HERE 2 P a g e

5 Roll out schedule Region Pre-Welcome Letter Welcome Letter Reminder Letter Last Day To Choose A Plan Before Initial Enrollment Date Enrolled in LTC Plans 1 11/1/ /23/2013 1/20/2014 2/13/2014 3/1/ /1/2013 8/26/2013 9/16/ /17/ /1/ /1/ /23/2013 1/20/2014 2/13/2014 3/1/ /1/ /23/2013 1/20/2014 2/13/2014 3/1/ /1/ /25/ /16/2013 1/16/2014 2/1/ /1/ /25/ /16/2013 1/16/2014 2/1/ /1/2013 5/20/2013 6/24/2013 7/18/2013 8/1/ /1/2013 6/24/2013 7/22/2013 8/22/2013 9/1/ /1/2013 6/24/2013 7/22/2013 8/22/2013 9/1/ /1/2013 8/26/2013 9/16/ /17/ /1/ /1/2013 9/23/ /21/ /21/ /1/2013 **Please note that all but the last column apply to what the patient needs to do 3 P a g e

6 Region Managed Care Organizations Here is the list of available Managed Care Organizations you may choose by region. American Eldercare, Inc. Amerigroup Florida, Inc. Coventry Health Plan Long-term Care Plans Humana Medical Plan, Inc. Molina Healthcare of Florida, Inc. Sunshine State Health Plan (Centene) 1 X X United Healthcare of Florida, Inc. 2 X X 3 X X X 4 X X X X 5 X X X X 6 X X X X X 7 X X X X 8 X X X 9 X X X X 10 X X X X 11 X X X X X X X Managed Care Organization- Basic Contact List American ElderCare All Regions 1-11 Brenda Evans bevans@americaneldercare.com Amerigroup Regions 10 & 11 Victoria McMath ext Victoria.McMath@amerigroup.com Coventry Regions 6 & 7, 9, 11 Mariangeli Cataluna mxcataluna@cvty.com Humana Region 4, 10, 11 Grace Rodriguez grodriguez@ilshealth.com 4 P a g e

7 Molina Healthcare Regions 5, 6, 11 Lisa Schwendel Phone: , ext Sunshine State Heath Plan Centene Regions 1, 3-11 Susan McCurry, Manager, Provider Relations , ext United Healthcare Region 2-9, 11 Sue Kever What about my current clients? Recipients have 30 days to enroll in a plan Recipients have 90 days after enrollment to change plans After 90 days, recipients must stay in their plan for the remainder of the 12 month period before changing plans again Members are encouraged to choose the SMMC LTC plan that best meets their needs If an individual who is required to enroll does not choose a plan within 30 days, AHCA will automatically assign the recipient to a SMMC LTC plan Individuals already in a SMMC LTC plan will remain with that plan unless they chose another plan Letters should have been sent to your patients and their families. 5 P a g e

8 Here are links to examples of letters sent: Pre-Welcome Letter: Sent to recipients four (4) months prior to enrollment English Version Spanish Version Welcome Letter: Sent to recipients two (2) month prior to enrollment Additional Resources: AHCA SMMC LTC Managed Care Plan - Provider Contract Checklist AHCA SMMC LTC Managed Care Plan Provider Directory Checklist English Version Spanish Version Reminder Letter: Sent to Recipients one (1) month prior to enrollment English Version Spanish Version How do I submit claims? If your patient has not been approved for Medicaid, treat them as pending as you already do with AHCA. American Eldercare is a Provider Service Network or PSN. This is like a mini plan and claims ultimately go to AHCA. Independent Living Systems or ILS is processing all of the claims for Coventry and Humana. All other MCOs have their own provider portals through which you can bill the claims, either individually or via batch submission. Contracting Tips 1. Define objectives. Do you want to take high acuity patient type(s) requiring rate add-on? Which types? If so, you need to increase lead time and expand pre negotiation work group; in addition to representatives from ownership, legal, and business operations, you ll want to 6 P a g e

9 include clinical (to determine tags), accounting (to determine cost), and Health Information Technology (to establish tracking methodology). 2. Know who you re dealing with. Independent Living Systems is representing Humana and Coventry, Optum/Evercare handles SNF contracting for UHC. General Terms Should be as clear as possible and require equal notice timelines on the part of SNF & MCO. Should be in compliance with FL & Fed laws and rules (don t unwittingly give away protections). CAPITALIZED terms should always be defined. External references (esp. Manuals) must be reviewed. Understand what clean claim means, what pre-authorization and reauthorization requirements you re agreeing to and quality indicators you have to report. Deadlines- get them as lenient as possible and make sure you can track them. Insurance Requirements should not exceed FL statutory requirement. Even if you have a certain amount now, that level may become unaffordable during contract period. Assignment- conditions imposed on either party (can you sell? What if HMO enters bankruptcy?) Payment Terms Rates and services, along with timing and conditions for changes in both, should be specified. Claim submission process, requirements and turnaround times need to be specified. What happens if not met? Define who assumes risk if patient later determined ineligible? Under what conditions? Bed Hold payment should agree with AHCA policy. Repayment of overpayments- should have reasonable process and time. Operations Terms Transfer/Discharge of problematic residents (needs too great or patient dangerous to self/others) 7 P a g e

10 Credentialing & Quality Assurance If patient refuses to leave, will HMO assist or pay? If not, make sure you can bill privately. Should be reasonable processes for both. (Time to return to compliance) Are Peer review requirements reasonable? Audit requirements? Don t lose legal protections for documents or violate HIPAA! Documentation requirements should reference and not exceed State statue/rules. Don t agree to unlimited free document production. Is Appeals process fair and reasonable? 8 P a g e