Dual Demonstration FAQs

Transcription

1 Dual Demnstratin FAQs Benefits What benefits are available under the Dual Demnstratin? Individuals have access t a cmprehensive netwrk f acute and lng term care services prviders, and access t the same medically necessary Medicare and Medicaid benefits as they d tday crdinated under ne entity with additinal value added services that vary by Medicare Medicaid Plan (MMP). Under the Dual Demnstratin, care crdinatin services will be available t all enrllees. MMPs will ffer a service crdinatin team t ensure the integratin f services t meet the enrllee s medical, behaviral health, lng term services and supprts, and scial needs. The team's apprach will be persn centered and built n the enrllee s specific preferences and gals. What are the advantages f participating in the Dual Demnstratin fr prviders? A single managed care entity called a Medicare Medicaid Plan (MMP) is respnsible fr cntracting and credentialing prviders f Medicare and Medicaid services. Additinally, the MMP is respnsible fr all Medicare and Medicaid claims prcessing, prvider payment, and appeals. Prviders will receive payment fr cvered Medicare and Medicaid services frm the MMP, and payment will reflect bth Medicare and Medicaid payment amunts withut submitting a secnd bill. In additin, authrizatin requirements are set by MMP with a timeframe f 3 days instead f 14 days. Fr nursing facility prviders, residents can be admitted under skilled criteria withut requiring a 3 day hspital stay, and may als be able t stay within the facility withut hspitalizatin by btaining authrizatin frm the MMP. Netwrks What are the netwrk adequacy standards fr the Dual Demnstratin? MMP s are respnsible fr managing their wn netwrks. Their netwrk adequacy requirement standards were jintly reviewed by bth HHSC and CMS fr adequacy. CMS reviewed the netwrks fr Medicare cvered services, and HHSC reviewed them fr Medicaid cvered services. In instances where Medicare and Medicaid bth cver a service, the mre stringent netwrk adequacy standards applied. Hw des a prvider cntract with an MMP? The MMPs in the Dual Demnstratin cunties have and cntinue t utreach t current Medicaid and Medicare prviders t ffer cntracts. Prviders may als cntact the MMPs directly. If prviders reach ut t an MMP t inquire abut a cntract, it is imprtant that the prvider ask the MMP specifically abut cntracting t prvide services in the Dual Demnstratin since the MMPs perate ther prducts. Accuntable Care Organizatins (ACOs) Can individuals receiving care frm a Medicare ACO enrll in the Dual Demnstratin? Dual eligible beneficiaries attributed t a Medicare ACO may als be eligible fr enrllment in the Dual Demnstratin.

2 T preserve the infrastructure f existing ACOs in the cunties in which the Dual Demnstratin perates (Bexar, Dallas, El Pas, Harris, Hidalg r Tarrant), beneficiaries in an ACO established by March 1, 2015 with fewer than 9,000 members will receive ntificatin abut the ptin t enrll in the Dual Demnstratin, but will nt be passively enrlled. Dual eligible beneficiaries attributed t an ACO with mre than 9,000 members will be eligible fr passive enrllment. The MMPs are required t develp shared savings arrangements with cntracted prviders. These arrangements allw prviders and MMPs t develp shared savings mdels that mirrr the frmat and requirements f current ACOs, r the flexibility t develp ther innvative arrangements. Eligibility Hw d prviders verify a member's Medicaid eligibility? Prviders shuld verify Medicaid eligibility and managed care enrllment using TexMedCnnect n the TMHP website at TexMedCnnect/Medicaid Eligibility and Service Authrizatin Verificatin (MESAV) will shw Medicaid eligibility and the managed care segments fr Medicaid r MMP managed care members. Hw will Dual Demnstratin members be identified in TIERS? MMPs have their wn plan cdes which are visible n the managed care screen. What are the plan cdes fr the Dual Demnstratin? Dual Demnstratin STAR+PLUS (Eff. 3/1/15) 4F Amerigrup Texas, Inc. Bexar 3G Amerigrup Texas, Inc. El Pas 7Z Amerigrup Texas, Inc. Harris 6F Amerigrup Texas, Inc. Tarrant 4G Mlina Healthcare f Texas Bexar 9J Mlina Healthcare f Texas Dallas 3H Mlina Healthcare f Texas El Pas 7V Mlina Healthcare f Texas Harris H9 Mlina Healthcare f Texas Hidalg 4H Superir Health Plan Bexar 9K Superir Health Plan Dallas HA Superir Health Plan Hidalg 7Q United Healthcare Texas Harris H8 HealthSpring Hidalg 6G HealthSpring Tarrant When a patient presents t a prvider's ffice r facility withut an ID card, hw will the prvider be able t identify an MMP enrllee? The infrmatin will appear as it des tday fr STAR+PLUS members n TMHP.cm, with the additin f an identifying MMP Plan Cde. What address is used t determine if a member is residing in a cunty participating in the Dual Demnstratin?

3 A member's residential address is used t determine if they reside in a Dual Demnstratin cunty. HHSC eligibility btains this infrmatin frm the Scial Security Administratin (SSA). Enrllment Is the enrllment int a MMP mandatry? N, enrllment is ptinal. Hw d members pt in? Members shuld call the Medicaid enrllment brker, MAXIMUS, t pt in at If a member pts ut, d they have t enrll in a Medicare Advantage plan (Part C) r can they get Original Medicare with a Prescriptin Drug Plan (Part D)? The member can chse either ne. If an individual pts in r pts ut f the prgram, when is the change effective? Requests t pt in, r disenrll frm ne MMP and enrll in anther MMP will be accepted thrugh the 12th f the mnth fr an effective date f cverage the 1st calendar day f the next mnth. Requests fr pt ins r MMP plan changes received after the 12th f the mnth will be prcessed fr an effective date f the 1st f the secnd mnth fllwing the request. It is imprtant t nte that since enrllment is dne by mnth, a member can't be enrlled r disenrlled mid mnth. An individual can pt ut f the Dual Demnstratin at any time f the mnth and the change wuld be effective the first day f the fllwing mnth. A member can call n the very last day f the mnth, and be disenrlled frm the Demnstratin the next day. Are dual eligible individuals in an emplyer spnsred Medicare retirement plan excluded frm the Duals Demnstratin? Dual eligible individuals with emplyer spnsred Medicare retirement plans are nt excluded frm the Dual Demnstratin, but will nt be passively enrlled. These members wuld have t pt in. Will the varius enrllment letter mailings be available nline in advance? Enrllment letters are available n the HHSC website: care/dual eligible/ Billing, Claims & Payments Wh d I bill fr services prvided prir t the Dual Demnstratin? If the patient was nt enrlled in an MMP at the time f service, prviders shuld bill the apprpriate payer (either Medicare r Medicaid) based n dates f service fr which they are billing. Prviders shuld bill the prgram the individual was enrlled in at the time the service was prvided. As part f the Dual Demnstratin cntinuity f care prvisins, medically necessary cvered services must be prvided r arranged fr during the applicable transitin perid. Current lng term services and supprts (LTSS) services will be authrized fr up t six mnths after initial enrllment int an MMP. Current acute care services will be authrized fr up t 90 days. Will claims autmatically crssver frm Medicare t the patient s new MCO like they crssver nw t TMHP?

4 All claims will be paid by the MMP, s there is nthing t crss ver. Medicare prviders can use HETS t lk up which MMP a member is in. Medicaid prviders can use the same systems they use tday, such as THMHP TexMedCnnect Prtal/MESAV. Will the MMP s use Electrnic Funds Transfer (EFT) t pay prviders? EFT varies by MMP. Prviders shuld seek infrmatin abut specific billing practices frm the MMP(s) with which they are cntracted. What are the claims payment requirements fr MMPs? The current requirement in Medicare Advantage is t pay 95% f clean claims within 30 days (42 CFR ). The Texas Dual Demnstratin imprves upn this standard in several ways: In line with current STAR+PLUS requirements fr nursing facility services, the MMPs shall prcess 98% f clean claims within 10 days and 99% within 90 days (TX Cntract, sectin ). Fr Medicare Part D claims, the MMPs shall prcess electrnic claims within 14 days r within 21 days fr nn electrnic claims (TX Cntract, Appendix D, Article II, N.2). In line with current STAR+PLUS requirements fr nn NF, nn Part D services, the MMPs shall prcess 98% f clean claims within 30 days and 99% within 90 days (TX Cntract, sectin ). Will the Medicare reimbursement schedule be negtiated with each MMP by the prvider r will it cincide with the RUG Schedule with Medicare? Payment levels fr in netwrk prviders are dictated by the terms f the cntracts that prviders establish with the MMPs. Nn cntracted prviders shuld bill the MMP during the cntinuity f care perid. After that, if the prvider has nt entered a cntract with the MMP, the MMP may transitin the member (with their cnsent) t an in netwrk prvider. Are prviders required t submit ne bill r separate bills fr bth acute and lng term care services? If prviders are required t submit ne bill, what frm wuld prviders need t use? What ther types f frms wuld prviders use fr the Dual Dem? If the services are cvered by Medicare (such as hspitals, ancillaries/cmprehensive Out Patient Rehabilitatin Facilities (CORFs), Outpatient Rehabilitatin Facilities (ORFs) and prfessinal services), prviders shuld fllw CMS guidelines and bill n a UB 04. Prfessinal services, including thse delivered by nn skilled Medicaid prviders, wuld be billed n a CMS 1500 frmat. Behaviral health services are a mixture case management and psychscial rehab are usually billed n a UB04 Rev Cde 100 r 900. Prfessinal services wuld bill in CMS 1500 frmat. Hspital wuld be billed n a UB 04. Hme health can bill either n a UB 04 r CMS Fr prviders participating in the Dual Demnstratin, is timely filing based n the Medicare time frame f up t 1 year r is it dependent n the individual MMP? In netwrk prviders shuld refer t the cnditins f their cntracts with each MMP fr timely filing requirements. Cmplaints/Grievances, Appeals & Fair Hearings What is the member cmplaint/grievance, appeals and fair hearings prcess? The cmplaint, r grievance, is filed either rally r in writing, and acted upn at the MMP level.

5 All current Medicare and Medicaid prtectins remain in place fr members, with certain enhancements: Beneficiaries will have the added prtectin f cntinued services while an appeal is pending. Fr Medicaid appeals, members will cntinue t have an ptin t appeal directly thrugh the MMP, but will have additinal time t d s. Beneficiaries will have 60 instead f 30 days. Fr Medicaid services, the member may appeal t the MMP, but als may request a fair hearing thrugh HHSC within 90s days, cnsistent with current Medicaid plicy. Cnsistent with existing rules, Part D Appeals will be autmatically frwarded t the CMS Medicare Independent Review Entity (IRE) if the MMP misses the applicable adjudicatin timeframe. The IRE fr Medicare is MAXIMUS. Mre infrmatin is available at: Fr verlapping (Medicare and Medicaid) services, the appeal may 1) start at the MMP and then 2a) will be aut frwarded t the IRE and 2b) the member may als request an HHSC fair hearing at the same time if they chse. What is the prvider cmplaint/grievance and appeals prcess? Prvider appeals, grievances, and/r dispute reslutin is the respnsibility f the MMP. Please nte that under managed care, prviders shuld first exhaust the cmplaints r grievance prcess with their MMP befre filing a cmplaint with HHSC. If after cmpleting the MMP prcess, the prvider believes they did nt receive full due prcess frm the MMP, they may file a Medicaid cmplaint r inquiry thrugh HHSC's Health Plan Management (HPM) cmplaints bx at: HPM_cmplaints@hhsc.state.tx.us. Transprtatin Services Wh is respnsible fr prviding nn emergency transprtatin? MMPs are respnsible fr cntracting with prviders t prvide nn emergency ambulance transprtatin. Prviders shuld cntact the apprpriate MMP t request an authrizatin prir t prviding nn emergency ambulance transprtatin. The Medical Transprtatin Prgram is respnsible fr prviding transprtatin t and frm cvered Medicaid healthcare services. The tll free phne number yu call t schedule a trip depends n where yu live: Live in the Hustn / Beaumnt area? Call Live in the Dallas area? Call Everyne else can call (1 877 MED TRIP). What is the bligatin f the MMP fr transprtatin in the nursing facility (NF)? Nursing facilities are respnsible fr prviding nn emergency transprtatin (e.g., transprtatin t dctr appintments, etc.) as ccurs currently. This is because nnemergency transprtatin is included as part f the daily rate. Prir authrizatins are nt required fr emergency services, including emergency transprtatin. T schedule Medicaid nn emergency ambulance transprtatin, the NF prvider must request authrizatin frm the MMP. MMP prir authrizatin request frms can be fund n the MMP website, r in the MMP prvider manual. The MCOs are required t prvide authrizatins based n medical necessity criteria and respnd t authrizatin requests within 3 business days.

6 Dental Prviders Des the Dual Demnstratin impact dental prviders? What abut dental prviders wh prvide care in a nursing facility? Like in the STAR+PLUS prgram, nly members eligible fr STAR+PLUS hme and cmmunity based waiver services are eligible fr dental services in the Dual Demnstratin. Hwever, sme f the MMPs ffer dental services as a value added service. Dental prviders may cntinue t prvide rutine dental services t adult nursing hme residents and be reimbursed thrugh an adjustment in their Applied Incme in the calculatin f Incurred Medical Expense prcess. Pharmacy Will MMP use the STAR+PLUS frmulary r the Medicare frmulary? Bth, it is an integrated prgram and the MMP cvers bth Part D and Texas Medicaid drugs. CMS Prvider FAQ: Medicaid Crdinatin/Medicare and Medicaid Crdinatin/Medicare Medicaid Crdinatin Office/FinancialAlignmentInitiative/Dwnlads/TXPrviderFAQ.pdf CMS Hme Health FAQ: Medicaid Crdinatin/Medicare and Medicaid Crdinatin/Medicare Medicaid Crdinatin Office/FinancialAlignmentInitiative/Dwnlads/TXHmeHealthPrviderFAQ.pdf Fr mre infrmatin abut the Texas Financial Alignment Demnstratin, please visit: Medicaid Crdinatin/Medicare and Medicaid Crdinatin/Medicare Medicaid Crdinatin Office/FinancialAlignmentInitiative/Texas.html