The latest in our
series of member updates on MyCare Ohio. If you have questions or comments,
please
contact Pete Van Runkle (pvanrunkle@ohca.org) or Diane Dietz (ddietz@ohca.org).
MyCare Ohio
Enrollment
Update
As MyCare Ohio
completes its second full week of implementation in the Northeast Region, the
other participating regions move toward implementation. According to the
Department of Medicaid's (ODM's) timetable, everyone in the next three regions
(Northwest, Southwest, Northeast Central) who did not choose a MyCare plan
affirmatively should have their auto-assignment letters. The effective date of
coverage is June 1. According to ODM, 28,357 of 33,657 enrollees (84%) in the
three regions were auto-enrolled, although they have until later this month to
enroll voluntarily in a different plan. Of 4,794 individuals who enrolled
voluntarily in the three regions, 53% chose dual enrollment. Bottom line,
though, the vast majority of MyCare enrollees are in the program for Medicaid
only and are keeping their current Medicare benefits, at least for the time
being. Please remember that everyone enrolled in MyCare for Medicaid only will
be notified by mail in October 2014 that they will be enrolled passively into
their current MyCare plan for Medicare benefits effective January 1, 2015. If
they do not want to be enrolled for Medicare, the beneficiary will need to
affirmatively opt out for Medicare by contacting the hotline through one of the
three allowable means (web, paper, phone). As for the final tier of MyCare
regions, the initial notice went out in late April. Next week, ODM will send the
auto-assignment letters, heading toward a July 1 effective
date.
Enrollment
Reminders
Thousands more dual
eligible Ohioans are enrolling or being enrolled into MyCare Ohio over the next
month and a half. At the same time, there inevitably are mistakes regarding
beneficiaries' eligibility for the program. The two most common errors are
individuals in ICFs/IID and individuals with Medicare supplements. People in
ICFs/IID and on Department of Developmental Disabilities waivers are
categorically ineligible for MyCare. If you operate an ICF or provide waiver
services and have any consumers who receive MyCare notifications or enrollment
packets, please contact OHCA and we will help you get them off the rolls. Act as
quickly as possible to avoid any potential negative consequences. People who
have Medicare supplemental policies (not Medicare Advantage) also are ineligible
for MyCare because of the exclusion for creditable third party coverage. Notify
the Department of Medicaid using the ODJFS 6614
form if you have any patients who have Medicare supplements but receive
MyCare enrollment materials.
More MyCare
Enrollment Statistics
Jim Poremba of the
Department of Medicaid shared MyCare Ohio enrollment statistics from the Consumer
Hotline Monthly Report for April. While this report covers all aspects of
managed care enrollment through Ohio's centralized managed care hotline,
beginning on page 30 you will find statistics about MyCare enrollment through
May 1, 2014. Of particular note is the number of enrollments for Medicaid only
that occurred both voluntarily and through automatic assignment in the Northeast
Region. Of the 26,860 beneficiaries enrolled, 15,910 were auto-enrolled for
Medicaid only and another 5,731 voluntarily enrolled for Medicaid only. Also of
interest is the number of voluntary enrollments and auto-assignments by MyCare
plan within the Northeast Region. It appears at the launch of the program,
CareSource leads the way with approximately 45% of enrollments, followed by
United with approximately 36%, and Buckeye with approximately 20%.
Training
OHCA strongly
encourages all members in MyCare Ohio regions to participate in the training
programs offered by the health plans operating in their region. Here is the
latest information OHCA has about training:
Additional
Dayton Area Community Forum
A second MyCare
Ohio West Central Regional Community Forum has been scheduled for June 4,
2014 from 1:00-4:00 p.m. at the Top of the Market in Dayton.
MyCare
Provider Manuals
The MyCare Ohio
plans have begun to post their provider manuals on their websites. So far,
United Healthcare and CareSource have posted manuals, and Buckeye Community
Health Plan posted a quick reference guide. The manuals are a great resource for
providers on all aspects of their interaction with the plan, including such
matters as billing and prior authorization of services. As a convenience to
members, OHCA collected the manuals published so far and posted them to the
Managed Care web page: United;
CareSource;
Buckeye.
MyCare Ohio
Member Identification Cards
Some confusion has
resulted from MyCare Ohio member identification cards. The MyCare Ohio logo that
commonly appears on the cards lists both Medicare and Medicaid, even though many
MyCare beneficiaries are enrolled for Medicaid only. Please note that if the
member is enrolled for both Medicare and Medicaid, there will be a special note
of "Medicare Rx" on the face of the card, in addition to the MyCare logo. Molina
altered the MyCare logo on the Medicaid only card to remove the Medicare
reference.
Level of Care
for MyCare Beneficiaries
As a general rule,
MyCare Ohio does not affect the level of care (LOC) process for Medicaid long
term services and supports eligibility, either for skilled nursing facility care
or waiver services. There is one important exception to this rule. If a person
already is enrolled in MyCare, has not had a LOC done, and seeks admission into
a SNF, their MyCare health plan performs the LOC review instead of the area
agency on aging (AAA). The plan is required to use the same LOC criteria as
currently used for Medicaid, but may or may not use the 3697 form. This
exception to the normal rule applies only to SNF admissions, not to waiver
services, for which the AAAs will continue to do the LOCs.
Prior
Authorization Notes
The MyCare Ohio
health plans typically have prior authorization hours that are similar to normal
business hours, but SNF admissions may come at any time. In theory, the care
manager for a MyCare beneficiary who is hospitalized or living in the community
should be aware of and working with the beneficiary and the hospital or other
care provider to determine the need for SNF care and authorize the admission in
advance. In the event, however, authorization has not been obtained, or you
don't know if has been obtained, all the MyCare plans have systems for providing
authorization during non-business hours, typically via the prior authorization
phone line rolling to the 24/7 nurse line. In any case, it is risky to accept a
MyCare admission without an authorization in place, so if there is any doubt,
call the plan's prior authorization line. Please also note that prior
authorization is needed to readmit a Medicaid MyCare beneficiary whose Medicare
days are exhausted or for a continued stay under Medicaid or for waiver services
after Medicare days are exhausted.
Specific to Buckeye
Community Health Plan, Mike Ceballos shared the following regarding SNF
authorizations in the Northeast Region:
- Each NF will
receive the authorization associated with each of their residents via Excel
sometime the last week of May – shooting for 5/28.
- Our process
necessitated that we first validate a member’s residence in the facility. From
there we must manually create each of the authorizations.
- It is a one-year
authorization.
- While this process
will be replicated in Northwest Ohio, we hope to complete the validation census
earlier in the month and get the authorizations out earlier in the
month.
Assessment
Tips
The MyCare Ohio
plan care managers are required to assess all of their members in skilled
nursing and assisted living centers. They will do these comprehensive
assessments on site at the center, but the timing may differ for individual
members because of how the plan evaluates them under the risk stratification
guidelines. Individuals judged at higher risk because of their past health care
utilization will be assessed sooner. Please be aware that not everyone will be
assessed at the same time. The plans informed OHCA that it is not necessary for
facility personnel to sit in on the entire assessment, and they do not want to
receive the MDS for each member in advance of the assessment. We suggested that
in advance of the visit, the plan give the center a list of members they need to
assess and a list of the information they want the facility to
provide.
Provider Relations
Representatives
Molina provided a
listing of their provider relations representatives:
Karen Argabrite
Butler, Clermont, Clinton, Hamilton, Warren 740-972-0999
Karen.Argabrite@MolinaHealthcare.com
Crossover
Billing for Medicaid Only MyCare Members
Most MyCare Ohio
members are in the program for Medicaid only. As a result, their Medicare
services will continue to be billed to traditional Medicare or to a Medicare
Advantage plan. For patients with traditional Medicare, providers will bill CGS
as they did previously. For coinsurance days, however, the crossover claims no
longer should go to Ohio Medicaid because the individual's Medicaid benefits now
are the responsibility of their MyCare plan. For Part A coinsurance, there
usually is no Medicaid payment, but the claim must be submitted to and processed
by Medicaid (and in the case of MyCare, by the health plan) to support claiming
the amount as bad debt on the Medicare cost report. Unfortunately, the
Department of Medicaid informed us that for now, coinsurance claims for Medicaid
only MyCare members still will cross over to Ohio Medicaid. They will be denied,
but the denials will not support bad debt treatment, so SNFs will need to bill
the MyCare plan, showing the prior payment amount from Medicare, to get a proper
no pay remittance advice. This process is similar to direct billing for Medicare
supplemental payments. There is no need, however, to wait for the remittance
advice from Ohio Medicaid.
Buckeye Bad
Debt Policy
For MyCare Ohio
beneficiaries who are participating in the program for both Medicare and
Medicaid (dual members), the MyCare plan is responsible for paying not only for
Medicare covered services but also for bad debt resulting from unpaid
coinsurance. Each of the plans is developing its own coinsurance/bad debt
policy. OHCA recently received a detailed statement of Buckeye
Community Health Plan's policy.
Billing as
Own Trading Partner
Some SNFs bill fee
for service Medicaid as their own trading partner. In other words, they do not
use one of the commercial clearinghouses, but bill directly through the MITS
portal. The MyCare Ohio managed care plans are accustomed to receiving claims
from clearinghouses, primarily although not exclusively Emdeon. OHCA asked the
plans how providers who currently bill as their own trading partner will submit
claims to the plans. Here are the responses:
- Aetna --
WebConnect*
- Buckeye -- Has own
portal accepting batched claims
- CareSource -- Must
use clearinghouse, but accepts several
- Molina --
WebConnect*
- United -- Has own
portal accepting batched claims
* WebConnect is
a portal front end offered by Emdeon. The two plans using it are covering the
fees for the service.
Provider
Identification Number for Billing
We are in the
process of verifying whether a provider must have an identification number from
a MyCare Ohio plan in order to bill for services. The preliminary results are
that the plans do not require provider identification numbers on claims, and the
National Provider Identifier (NPI) is sufficient. We will continue to seek
clarification. On a related point, Melissa Brown of CareSource provided the
following information about provider identification numbers (ID #s) for waiver
providers: "The area agencies on aging have provided CareSource with a roster of
all their contracted providers. We have been diligently loading those providers
in our system which generates the CareSource provider ID #. With that
generation, a letter has been mailed to those individual providers identifying
that ID # and welcoming them to our panel of providers. That is the ID #
required for registering on the portal. The portal billing is an option to
submit claims for those specific providers, and if they have capability, they
are more than welcome to also submit claims via electronic data interchange
(through a partner clearinghouse) or paper."
Ancillary
Contracting
At the most recent
MyCare Ohio Long Term Care Collaborative meeting, the MyCare plans all seemed
amenable to working with ancillary providers that partner with SNFs and assisted
living residences even if the ancillary providers are not contracted with the
plan. As noted below, one plan actively is seeking to identify and reach out to
these facility partners for contracting, while other plan representatives
suggested the providers contact them. Prior authorization may not be required
for all ancillary services, depending on the plan, or the plans otherwise are
applying an informal transition of care period.
Ami Cole of Molina
informed us that although the MyCare Ohio transition of care (TOC) requirements
do not apply to most ancillary services that are billed directly to
Medicare/Medicaid, Molina intends to include services rendered to members in a
center as part of the TOC process and will load authorizations to pay for these
ancillary services, as well. They initiated a survey to the centers to better
understand which providers are being used in their regions in an effort to
secure contracts with key ancillary providers they may not have contracted
currently. This will take some time, but in the interim, they do intend to cover
these services.
Mike Ceballos of
Buckeye addressed the TOC issue for ancillaries as well. He suggested that a
good rule of thumb is if a provider is in doubt, have them call the Buckeye
Utilization Management (UM) line to get an authorization at 1-866-296-8731. Mike
added that "there are certainly lots of providers who operate in and around
nursing facilities who may or may not be in network that we need to make sure we
do get in network. Additionally, if/when those providers call our UM line, they
can work through those details."
MyCare
Medicaid Hospice Policy
Christi Pepe of the
Department of Medicaid provided a statement of the department's policy on
Medicaid room and board coverage for hospice patients under MyCare Ohio. As we
reported previously, the MyCare plans have different methods of paying for
hospice room and board. Some plans will pay the SNF, other plans will pay the
hospice program. Here is the policy: