Eastpointe Medicaid 1915 b/c Waiver Questions/Concerns/Comments Please note that this is an ongoing document and updated approximately every two weeks. Newly added questions and answers will be in red. Clinical Questions Question 1: As a provider that has a MOA with SRMHC LME and Eastpointe LME we provide both TCM IDD and MH/SA TCM services. My question is when will TCM be transferred to the MCO-Eastpointe? What role will the provider agency have in the case management or managed care process for these services? Will the provider agencies have a transition/transfer period and process? Answer: On January 1, 2013 TCM for MH, SA and IDD will no longer be available as a standalone service with no transition period after January 1, 2013. The transition will begin prior to January 1, 2013. Eastpointe will be hiring licensed care coordination staff for MH/SA and Qualified IDD professionals well before our January 1, 2013. There will be many care coordination activities that will occur in the months leading up to January 1, 2013, and Eastpointe will be working closely with TCM agencies, consumers and guardians, and community agencies to ensure that everyone understands and is comfortable with the transition from Targeted Case Management to Care Coordination. Our mutual goal is to engage in a process that informs, educates and respects the consumer and community stakeholders as we move forward to full implementation of the Waiver on January 1, 2013. Eastpointe will keep consumers, providers and the community informed as we move forward. We will be scheduling meetings with TCM agencies. Question 2. Can you provide me with information regarding respite services under the new innovations directive. Specifically - what are the maximum number of hours that a recipient can receive? Are the hours allocated on an annual basis allotment or are there time frames (weekly, monthly etc.). In which the hours must be utilized? What assessment tool is utilized to determine the hours that a recipient is eligible for? In what ways does the other services that one receives impact the number of respite hours that is allocated? Answer: Eastpointe will defer answering service specific questions until we have attended the additional Innovations Waiver specific training for MCOs that DMA is planning over the next few months to ensure our answers reflect the most current and accurate information available to us.
Question 3. Since the MCO will be providing the Care Coordination for adults, if the client is being seen by an agency for Basic Benefits, who will provide the possible needs for more of a direct care need? Will the Care Coordinators be giving direction to the Basic Benefits staff to meet the unmet needs? Answer: Although care coordination will follow up referrals to providers to find out if the referred person kept their appointments, the primary focus of MH/SA Care will be consumers who are at high risk of inpatient admissions or readmissions, consumers who are in the top percentage of service costs, consumers with special health care needs as defined by the MCO contract, consumers who first enter the behavioral healthcare system through crisis/emergency services, consumers for whom there is a need for behavioral health and medical care coordination and other populations for which it is determined that care coordination is essential to their successful engagement in treatment. Question 4. Is the CAP MR-DD waiver extension planned to implement on 4/1/12, the same thing as the 1915 b/c waiver. If not, when will the Innovations waiver implement? Answer: CAP MR-DD Waivers are for specified time periods. The current CAP MR DD waiver was a 3 year Waiver. The current CAP MR-DD Waiver expires and the CAP MR-DD waiver planned for 4/1/12 is the new CAP MR-DD waiver that replaces the current CAP MR DD waiver. It is NOT the 1915b/c waiver. The 1915 b/c Innovations Waiver for Eastpointe (Eastpointe, Beacon and Southeastern Regional LMEs) is scheduled to begin January 1, 2013. Question 5: So my question is if the proposed and implemented date for the 1915 waiver is indeed 1/2013 why are case managers and providers telling the families that home supports is stopping on 4/1/2012? If the waiver is to change from home supports to the alternative home and community supports 1915 waiver on 1/2013, how could it be implemented on 4/1/2012? And how can home supports stop before the 1915 waiver is implemented? Answer: Please refer to the information in Question #4. Quality Management Questions Policy & Contract Compliance Questions External Operations Questions Question 1: Will existing providers with Memorandum of Agreements (MOA s) in both areas remain as providers or will there be an application process. If so, what does that process look like? Answer: When Eastpointe, Southeastern Regional and The Beacon Center LME s merge to become Eastpointe LME effective July 1, 2012 all providers that currently have an In Catchment
and Out of Catchment Memorandum of Agreement (MOA) will continue to be a provider in the Eastpointe LME. We are waiting on clarification from the Division as to whether new MOA s will need to be signed. In order to become a provider in the Managed Care Organization (MCO) providers will have to submit an application which will be posted on the LME s website. The release date for the application is approximately April 1, 2012. This will include a Credentialing process in which documentation from the provider will need to be submitted. Current providers who do not submit an application will not be able to provide or bill for behavioral health Medicaid services after December 31, 2012. Question 2: When will the application process begin? Also with Beacon becoming Eastpointe when will the consumers be transitioned or will business as usual continue through the site in Rocky Mount? Answer: Please see Question #1 that explains the application process to be a provider in the MCO. Consumers will continue to receive services through their current providers as The Beacon Center, Southeastern Regional and Eastpointe merge unless they choose another provider. Effective July 1, 2012 Eastpointe LME will have primary sites in Goldsboro, Lumberton, Rocky Mount and Beulaville. Question 3: I am currently a Medicaid Provider of Psych services at the masters LPA level. Will I have to re-do forms for any reason, such as verifying my status or re-applying as a provider to the new entity, for you or the government? Answer: You will need to follow the application process that is referred to in Question #1. Question 4: With the merger of The Beacon Center and Eastpointe just around the corner, would The Beacon Center consider holding off on the Alternative Family Living (AFL) insurance requirements until Eastpointe takes charge? Answer: Article III, Section 3.10 of the Memorandum of Agreement (MAO) and IPRS State Funded Contract states that a provider shall not subcontract or assign any of the services contemplated under this agreement without obtaining prior written approval from the Local Management Entity (LME). Any approved subcontracts or assignments for program delivery shall be subject to all conditions of this agreement which includes the insurance requirements. Providers who subcontract with AFL providers must show evidence of insurance as indicated in the MOA.
Question 5: Every MCO will have foster children living in their catchment area who have Medicaid in a different catchment area. If I am a provider in the Eastpointe/Beacon/SER catchment area, and I am providing therapy for a foster care child who lives in Lenoir County, but has Medicaid in Surry County: What is the process to gain authorization for the provision of services for this child? Answer: With the example that you have given you would need to be a provider in the MCO that covers Surry County. Lenoir County is where the consumer is receiving treatment but not their legal residence from which they receive Medicaid. Providers will need to be in the Provider Network for each MCO from which their consumers Medicaid originates. Independent Practitioners will have to complete an application to be part of the Provider Network for each MCO that they are willing to accept consumers from. The authorization process will be detailed in the MCO s Provider Manual. Question 6: It is my understanding that under the Waiver, adult day health care will become a day support. Will the Center have to become qualified under the new LME to provide day supports in order to continue serving our current participants? If so, when should we begin the process to switch from adult day health care to day supports? Will we have to change anything at all? Answer: Under the Innovations Waiver, Adult Day Health Care will become Day Supports. Question 7: When will providers begin submitting their applications to Eastpointe if they are Beacon Center area providers? Answer: You will need to follow the process referred to in question #1. Question 8: What is the deadline for credentialing and is the application available yet? Answer: Please refer to the information in question #1. Question 9: My question is regarding the transition process. If I am already endorsed through The Beacon Center located in Wilson, NC; what do I need to do to transition over? Will my agency automatically transition over, or do I need to do a new application? Answer: Please refer to the information in question #1. Business Operations Questions Question 1: Has the procedure for file transfers been determined at this point to get the information from the private provider to the LME? If so please post the procedure.
Answer: The IT department is currently working to establish a secure portal that providers will utilize to upload their claim files. Once the portal is in place there will be instructions and/or manuals placed on our Medicaid Waiver website for providers to utilize. We will also have trainings for providers prior to go live on the new processes. Question 2: Another MCO began implementation of the waiver on January 3rd. Their billing system is not working properly and it is hard to reach key people. What steps are you taking to avoid this kind of problem? Answer: As with any new process there are going to be stumbling blocks, however Eastpointe is taking every precaution possible to make sure that we learn from the MCO s that are going before us. We have regularly scheduled meetings with the other MCO s and we talk about the problems that they are having and how we can best avoid those issues. We are also working with Managed Care experts that are giving us lots of advice on how to manage processes so that we can make sure our billing system is implemented appropriately. Question 3: Will Eastpointe be using a third party billing service; such as a clearing house to submit claims and received electronic EOBs thru? Answer: Eastpointe will be using our own electronic system to receive 837 s from providers and to create and re-submit 835 s back to them. We will not use an external clearing house to handle our processes. However, Eastpointe will work with any providers who have their own clearinghouses to ensure that we can receive and transmit data back and forth. Question 4: I need to find out who will be the clearing house that Eastpointe will be using and what will your payer id number be. Answer: Providers use of clearinghouses (private vendors) to oversee their claims submission and processing is a business decision by the provider to be paid by the provider. While it is the prerogative of the provider to use a vendor, the MCO will not pay the vendor an additional fee as administration is already part of the rate paid to the provider. Question 5: When will the reimbursement rates designated to each service (under the waiver) be released? Answer: At this time rates have not been developed as we are still early in the financial development process. Specific rates will be released as we move along in the waiver process and reach consensus with DMA regarding Eastpointe's PMPM.