9.0 Government Safety Net Programs

9.0 Government Safety Net Programs 9.1 Medicaid Managed Care, Child Health Plus and Family Health Plus Note: This section does not apply to Healthy New York, another government safety net program with different eligibility requirements. The Health Plan offers HMO programs sponsored by New York State that are intended to help ensure medical coverage for the uninsured. These programs are HMOBlue Option (Medicaid managed care), Child Health Plus and Family Health Plus. This section is intended for providers who participate in one or more of these programs. Note: When servicing a member whose PCP participates with the Monroe Plan for Medical Care (MPMC), MPMC participating providers may find additional information specific to that plan in the provider office manual supplied by MPMC. In addition to the other provisions of this Participating Provider Manual, the following provisions apply with regard to the following government-sponsored safety net programs: HMOBlue Option, Child Health Plus and Family Health Plus. Applicants for each of the programs must meet certain income guidelines. Income guidelines vary by program and may change from year to year. Enrollment in these HMO safety net programs is through a facilitated enroller. The agencies with facilitated enrollers vary by county. Prospective members may visit the New York State Department of Health (NYSDOH) Web site (www.health.state.ny.us) or contact the local Department of Social Services office or the Health Plan. The Health Plan has facilitated enrollers in some counties. Members of these HMO safety net programs must follow all the rules and guidelines of a typical HMO. This includes selecting a primary care physician (PCP) who coordinates all their care, including obtaining referrals to specialists and obtaining prior authorization for specified services. Referral and prior authorization requirements are listed in Section 4, Benefits Management. These requirements may vary from the requirements of our commercial HMO and point-of-service products. Members may change their PCPs by calling the customer service numbers on their ID cards, or by registering on the Health Plan s Web site (www.excellusbcbs.com). January 2005 9 1

9.0 Government Safety Net Programs Excellus BlueCross BlueShield Covered benefits vary by program. See the benefit comparison chart in Section 11, Product Overviews. For services to be covered, members must use providers who participate in the Health Plan s safety net provider network, including the Monroe Plan for Medical Care. Not all providers participate in all programs. (In other words, some providers who participate in Child Health Plus may not participate in Family Health Plus.) 9.1.1 HMOBlue Option (Medicaid Managed Care) HMOBlue Option is an HMO for Health Plan area residents who are covered by New York State s Medicaid program. Note: The product in the Health Plan s Rochester Region is called Blue Choice Option. Participating providers in the other regions may also see Blue Choice Option members. The program maintains the benefit structure of Medicaid, but requires members to follow all of the HMO rules and guidelines. (Medical management requirements may vary slightly from Health Plan commercial HMO programs.) Some services, such as prescription drugs, are covered under the regular Medicaid program. In a very limited number of counties, transportation to and from medical appointments is also provided. (This may consist of providing bus tokens, or paying cab fare in limited circumstances.) This service is NOT available in the majority of counties. There is no cost to members who participate in HMOBlue Option. There are no premiums, deductibles, copays or coinsurance. (Limited copays apply to the prescription drug benefit that is covered under regular Medicaid.) A member s eligibility in HMOBlue Option is always month to month, from the first day of the month through the last day of the month. Newborns are effective as of the date of birth. At the time of this writing, HMOBlue Option is not available in all counties, although members may see providers in any county as long as the providers participate in the Health Plan s Medicaid managed care provider network, including the Monroe Plan for Medical Care. 9 2 January 2005

Participating Provider Manual 9.0 Government Safety Net Programs 9.1.2 Family Health Plus Family Health Plus is a New York State program for adults between the ages of 19 and 64 who do not have health insurance either on their own or through their employers but have incomes too high to qualify for Medicaid. Family Health Plus is available to single adults, couples without children, and parents with limited income. Members must be residents of New York State and either United States citizens or qualified under one of a number of immigration categories. At the time of this writing, there is no cost to members who participate in Family Health Plus. There are no premiums, deductibles, copayments or coinsurance. Eligibility is always as of the first day of the month following enrollment. Members must recertify their eligibility annually. More information is available on the New York State Department of Health Web site at www.health.state.ny.us/fhplus. At the time of this writing, Family Health Plus is not available in all counties, although members may see providers in any county as long as the providers participate in the Health Plan s Family Health Plus provider network, including the Monroe Plan for Medical Care. 9.1.3 Child Health Plus Child Health Plus is a New York State program designed to cover children and adolescents (under age 19) who are residents of New York (regardless of immigration status), whose families have no comparable insurance coverage, and who are ineligible for Medicaid. There is no monthly premium for families whose income is less than 1.6 times the federal poverty level. Families with somewhat higher incomes pay a monthly premium per child. The amount of the premium is based on income and family size. There are no deductibles, copayments or coinsurance. Information is available by calling 1-800-698-4KID (1-800-698-4543) and asking about Child Health Plus. There is also information on the New York State Department of Health Web site (www.health.state.ny.us/nysdoh/chplus). Prospective enrollees may also contact their local county Department of Social Services. The Health Plan makes Child Health Plus available (as Child Health Plan) in all counties in the Health Plan s service area. Members may see providers in any county as long as the providers participate in the Health Plan s Child Health Plus provider network, including the Monroe Plan for Medical Care. January 2005 9 3

9.0 Government Safety Net Programs Excellus BlueCross BlueShield 9.2 General Requirements 9.2.1 Identifying Members Members of HMOBlue Option, Family Health Plus or Child Health Plus have identification cards that include the BlueCross BlueShield cross and shield logos as well as the name of the health benefit program. (See Section 11, Product Overviews, for sample ID cards.) Monroe Plan for Medical Care members also have the MPMC logo on either the front or back of their ID cards. The member ID prefix for Child Health Plus members is ZFB. HMOBlue Option and Family Health Plus members do not have a standard Health Plan ID number, but rather the Medicaid client identification number (CIN). It consists of two letters followed by five numerals and another letter (example: AB12345C). 9.2.2 Checking Eligibility Providers may check eligibility for HMOBlue Option and Family Health Plus members by calling the appropriate provider line. (See Contact List in Section 2.) In addition, eligibility information for HMOBlue Option and Family Health Plus members is available via the Electronic Medicaid Eligibility Verification System (EMEVS). The code for HMOBlue Option membership is MR. Family Health Plus membership will read Family Health Plus. Other options for checking eligibility are the Medicaid telephone system, or the PC Medicaid eligibility software. Providers should have the member s name, date of birth and CIN number available before calling. 9.2.3 Speaking with Members The Health Plan expects participating providers to maintain certain standards when speaking with members. Participating Health Plan providers must: Provide complete and current information concerning diagnosis, treatment and prognosis in terms a member can understand. Prior to initiating a service, inform a member if the service is not covered and specify the cost of the service. Prior to initiating a procedure or treatment, provide the information a member needs to give informed consent. Tell the member to contact Customer Service for information about accessing services not covered by the Health Plan. (For Health Plan addresses and phone numbers, see Contact List in Section 2.) 9 4 January 2005

Participating Provider Manual 9.0 Government Safety Net Programs 9.2.4 Minimum Office Hours In keeping with requirements established by the New York State Department of Health (DOH), primary care physicians (PCPs) who serve HMOBlue Option, Child Health Plus, and Family Health Plus members must practice a minimum of 16 hours at each office location. The DOH will waive this requirement under certain circumstances: The Health Plan must submit a waiver regarding a specific physician to the Medical Director of the DOH Office of Managed Care. The physician must be able to fulfill the responsibilities of a PCP, as defined in Section 4 of this manual. The physician must be available at least eight hours a week. The physician must be practicing in a Health Provider Shortage Area (HPSA) or in a similarly determined shortage area. The waiver request must demonstrate that there are systems in place to guarantee continuity of care and fulfillment of the appointment availability and 24-hour access standards defined in Section 2. The DOH notifies the Health Plan when a waiver has been granted. 9.3 Prenatal, Postpartum and Newborn Care 9.3.1 Clinical Guideline The Health Plan has established a clinical guideline for prenatal and postpartum care, to serve as a reference point for physicians and consulting health professionals who provide services to pregnant members of the Health Plan s managed care programs. See the Quality Management information in Section 2 for instructions on how to access this guideline. The Health Plan s prenatal and postpartum guideline includes standards that address: prenatal diagnostic treatment services and postpartum services, including recommendations for HIV testing and counseling and post-hiv-test counseling risk assessment, and the management and coordination of care for high risk pregnancies nutrition assessment and referral coordination of care between providers of prenatal care and the primary care physician, pediatrician, and other related providers after-hours emergency consultations January 2005 9 5

9.0 Government Safety Net Programs Excellus BlueCross BlueShield 9.3.2 Newborn Coverage The newborn child of a Child Health Plus member does not automatically receive health coverage. For information about insurance options for the newborn, the mother or guardian may call Customer Service. (For Health Plan addresses and phone numbers, see the Contact List in Section 2.) The newborn child of an HMOBlue Option or Family Health Plus member may be enrolled in Child Health Plus or HMOBlue Option, depending on the situation. When the child is younger than six months and weighs less than 1200 grams (2 lbs., 10 oz.) or is determined to be eligible for an SSI category; or when the mother is enrolled in certain special needs or partial capitation plans; the child will be enrolled in an appropriate special program. 9.3.3 Vaccines for Children All providers administering vaccines to children covered by HMOBlue Option must participate in the New York Vaccine for Children (NYVFC) program. NYVFC provides the vaccines free of charge. However, the HMOBlue Option provider agreement allows reimbursement for the administration of the vaccine. Providers should call NYVFC for additional information. (See Contact List in Section 2.) 9.3.4 Incentives for Preventive Care The Health Plan sends parents of newborns and children in these safety net programs reminders about the importance of preventive care. On occasion, there may be a form for the provider office to stamp as verification that a well child exam or postpartum visit took place. When the member returns the completed form (in a previously provided stamped envelope addressed to the Health Plan), he or she is eligible for a gift. 9.4 Sterilization Procedures Important: Sterilization procedures, whether incidental to maternity or not, require completion of a patient consent form in accordance with Medicaid guidelines covering informed consent procedures for hysterectomy and sterilization specified in 42 CFR, Part 441, sub-part (F), and 18NYCRR Section 505.13 and with applicable EPSDT requirements specified in 42 CFR, Part 441, sub-part (B), 18NYCRR, Part 508. Bilateral tubal ligation or vasectomy: Patients must be at least 21 years of age and must complete and sign LDSS-3134, Sterilization Consent Form, at least 30 days but not more than 180 days prior to the procedure. The Provider must send a copy of the completed form to the Health Plan with the claim. Hysterectomy: Hysterectomy is covered only in cases of medical necessity and not solely for the purpose of sterilization. Patients must be informed that the procedure will render them permanently incapable of reproducing, and have completed LDSS-3113, Acknowledgement of Receipt of Hysterectomy Information, at least 30 days prior to the procedure. Prior acknowledgment may be 9 6 January 2005

Participating Provider Manual 9.0 Government Safety Net Programs waived when a woman is sterile prior to the hysterectomy or in life-threatening emergencies where prior consent is impossible. This form also must be submitted to the Health Plan for verification. As a Medicaid managed care plan delivery system, the Health Plan is obligated to deny payment for sterilization procedures when the consent has not been completed. The completed consent form must be submitted to the Health Plan, to assure payment. Providers may request a supply of these forms by writing, faxing, or calling the NYSDOH. (See Contact List in Section 2.) A copy of each form is included at the end of this section for reference. 9.5 HIV Care The Health Plan recommends that providers follow the HIV guidelines established by the NYSDOH AIDS Institute. These guidelines pertain to prevention and medical management of adults, children, and adolescents with HIV infection. These guidelines are available at the NYSDOH Aids Institute Web site, www.hivguidelines.org. Individuals may obtain HIV information and referrals by calling the DOH s Anonymous HIV Counseling and Testing Program at 1 (800) 541-AIDS. 9.6 Claim Submission to the Health Plan Claims may be submitted to the Health Plan electronically or on paper. This includes claims for MPMC members. Providers should submit electronic claims to the clearinghouse. The Health Plan maintains a separate post office box for paper claims for HMOBlue Option and Family Health Plus. Paper claims for Child Health Plus members do NOT go to the separate PO box. Instead, they go to the Health Plan s regular address for claims. (See Contact List in Section 2.) 9.7 Member Payments Medicaid The following sections are a direct reprint from the July 2003 DOH Medicaid Update. The update is a reminder to all hospitals, free-standing clinics and individual practitioners about requirements of the Medicaid program related to requesting compensation from Medicaid recipients, including Medicaid recipients who are enrolled in managed care health benefit programs such as HMOBlue Option and Family Health Plus. 9.7.1 Acceptance and Agreement When a provider accepts a Medicaid recipient as a patient, the provider agrees to bill Medicaid for services provided or, in the case of Medicaid managed care enrollee, agrees to bill the recipient s managed care plan for services covered by the member contract. The provider is prohibited from requesting any monetary compensation from the recipient, or his/her responsible relative, except for any applicable Medicaid copayments. January 2005 9 7

9.0 Government Safety Net Programs Excellus BlueCross BlueShield A provider may charge a Medicaid recipient, including a Medicaid recipient enrolled in a managed care plan, ONLY when both parties have agreed PRIOR to the rendering of the service that the recipient is being seen as a private pay patient. This must be a mutual and voluntary agreement. It is suggested that the provider maintain the patient s signed consent to be treated as private pay in the patient record. A provider who participates in Medicaid fee-for-service but does not participate in the recipient s Medicaid managed care plan may not bill Medicaid fee-for-service for any services included in the managed care plan, with the exception of family planning services. Neither may such a provider bill the recipient for services that are covered by the recipient s Medicaid managed care member contract unless there is prior agreement with the recipient that he/she is being seen as a private patient as described above. The provider must inform the recipient that the services may be obtained at no cost to the recipient from a provider that participates in the recipient s managed care plan. 9.7.2 Claim Submission The prohibition on charging a Medicaid recipient applies when a participating Medicaid provider fails to submit a claim to Computer Sciences Corporation (CSC) or the recipient s managed care plan within the required timeframe. It also applies when a claim is submitted to CSC or the recipient s managed care plan and the claim is denied for reasons other than that the patient was not Medicaid eligible on the date of service. 9.7.3 Collections A Medicaid recipient, including a Medicaid managed care enrollee, must not be referred to a collection agency for collection of unpaid medical bills or otherwise billed, except for applicable Medicaid copayments, when the provider has accepted the recipient as a Medicaid patient. Providers may, however, use any legal means to collect applicable unpaid Medicaid copayments. 9.7.4 Emergency Medical Care A hospital that accepts a Medicaid recipient as a patient, including a Medicaid recipient enrolled in a managed care plan, accepts the responsibility of making sure that the patient receives all medically necessary care and services. Other than for legally established copayments, a Medicaid recipient should never be required to bear any out-of-pocket expenses for medically necessary inpatient services or medically necessary services provided in a hospital based emergency room (ER). This policy applies regardless of whether the individual practitioner treating the recipient in the facility is enrolled in the Medicaid program. When reimbursing for ER services provided to Medicaid recipients in managed care, health plans must apply the Prudent Layperson Standard, provisions of the Medicaid Managed Care Model Contract and Department of Health directives. 9 8 January 2005

Participating Provider Manual 9.0 Government Safety Net Programs 9.7.5 Claim Problems If a problem arises with a claim submission, the provider must first contact CSC or, if the claim is for a service included in the Medicaid managed care benefit package, the enrollee s Medicaid managed care plan. If CSC or the managed care plan is unable to resolve an issue because some action must be taken by the recipient s local department of social services (e.g., investigation of recipient eligibility issues), the provider must contact the local department of social services for resolution. For questions regarding Medicaid managed care, please call the Office of Managed Care at (518) 473-0122. For questions regarding Medicaid fee-for-service, please call the Office of Medicaid Management at (518) 473-2160. 9.8 Fair Hearing In addition to the grievance and appeal guidelines outlined in Section 4, a member of HMOBlue Option, Family Health Plus or Child Health Plus may request a fair hearing regarding adverse determinations concerning enrollment, disenrollment and eligibility; and regarding the denial, termination, suspension or reduction of a clinical treatment or other benefit package service. This hearing allows the member to present his/her case in person and ask the attendees questions regarding the member s case. Fair hearing rights and the related form are included with member notices of final adverse determinations. If the member believes that an action taken by the Health Plan is wrong, he/she can ask for a fair hearing by telephone or in writing. (See Contact List in Section 2.) The member must ask for a fair hearing within 60 days from the date noted on the Denial of Benefits Under Managed Care Notice. Once the fair hearing is requested, the State will send the member a notice with the time and place of the hearing. The member has the right to bring a person to help, such as a lawyer, a friend, a relative, or someone else. At the hearing, this person can give the hearing office something in writing or just orally state why the action should not be taken. This person can also ask questions of any other people at the hearing. The member also has the right to bring people to speak in his/her favor. If the member has any papers that will help his/her case (pay stubs, receipts, medical bills, heating bills, medical verification, letters, etc.), he/she should bring them. The member has the right to see his/her case file to help get ready for the hearing. The member may call or write to the NYS Office of Temporary and Disability Assistance, Fair Hearing Section (as listed under FAIR HEARINGS on the Contact List, Section 2). The Office of Temporary and Disability Assistance will give the member and the hearing officer free copies of the documents from the member s file. The member should ask for these documents before the date of the hearing. The documents will be provided to the member within a reasonable time before the date of the hearing. Documents will be mailed only if the member specifically requests that they be mailed. January 2005 9 9

9.0 Government Safety Net Programs Excellus BlueCross BlueShield 9.9 Sample Forms Form: LDSS-3134, Sterilization Consent Form Form: LDSS-3113, Acknowledgement of Receipt of Hysterectomy Information 9 10 January 2005