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OHCA MyCare Ohio Bulletin

August 4, 2014

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).

Reprieve on August Bed Tax Payment
OHCA requested relief for members relative to the bed tax (franchise permit fee) installment due August 14 because of the difficulties providers are experiencing receiving payment under MyCare Ohio. Julie Evers of the Ohio Department of Medicaid provided the following response:

As you are aware, the next quarterly payment of the Nursing Facility Franchise Permit Fee is due to the Ohio Department of Medicaid on August 14, 2014. ODM has decided not to place vendor holds for non-payment of the franchise fee until after September 14, 2014. Additionally, any penalties authorized for non-payment of the franchise fee will not be assessed – as long as payment is received by the Department on or before September 14, 2014.

Please note that the subsequent payment, due on December 14, 2014, is not impacted.

Reporting Patient Liability on MyCare Claims
Where to report patient liability on Medicaid claims to MyCare Ohio health plans remains in flux because of questions about lump sum amounts and about whether the Department of Medicaid (ODM) will weigh in on the subject. Bottom line today for SNFs is that with the exception of Buckeye Community Health Plan, where on the claim patient liability is reported is a secondary issue because the plans take patient liability from the ODM 834 report and not from the claim. Buckeye is the exception and is using the amount reported on the claim. Buckeye's current instructions are to report patient liability using Value Code 30, 31, FC, or D3. Buckeye has not advised how lump sum payments should be differentiated. According to Buckeye representatives, reporting patient liability in Box 54 will result in it not being deducted, although the claim will pay. For the other plans, we recommend reporting patient liability in Box 54 for consistency with fee for service Medicaid. The plans' use of the 834 for patient liability will result in incorrect payments because the data ODM reports are not always accurate, but SNF claims will be processed and paid regardless where the patient liability is placed on the claim.

In claims for partial months (when a SNF decides to bill early for the first half of the month, for instance), patient liability should be included on the first claim and not the second claim, unless the amount is not used up on the first claim. Again, how liability is handled on partial month claims does not have any impact on how they are paid except for Buckeye, but it is important for Buckeye.

July 1, 2014, SNF Rates
We furnished the July 1, 2014, rates for all Ohio SNFs to the MyCare health plans, and they are loading the new rates into their payment systems. We believe claims billed in August for July dates of service will be paid using the new rates, but claims billed in July for July services may not. At least one plan - Molina Healthcare - will adjust those claims automatically without any further action by the provider.

Electronic Funds Transfer
Many providers are receiving payments from MyCare Ohio plans by paper check. All plans can pay by electronic funds transfer (EFT), but you must sign up for it. We encourage members to do so to expedite receipt of payment and to reduce administration. Click the links below for EFT enrollment for each plan:

Aetna

Buckeye

CareSource

Molina

United Healthcare

Prior Authorization Notes

• Buckeye Community Health Plan requires authorization numbers on claims for July services billed in August for the Northeast and Northwest Regions. July services billed (and received by Buckeye) in July are not covered by this requirement. It also does not apply to the West Central Region, which will be included in a month or two. You should have received a list of authorization numbers from Buckeye. If you did not, please contact their Provider Services section.
• Most MyCare Ohio beneficiaries are Medicaid only, which means if they are admitted to a SNF for a skilled stay, their MyCare plan does not cover the stay and prior authorization for the admission is not required. If the MyCare member stays in the center after their skilled benefit is exhausted, however, the MyCare plan is responsible for Medicaid payment for the continued stay. In this situation, the plans require prior authorization because they view the “admission” as taking place when the patient “flips” from Medicare to Medicaid. To avoid a gap in payment, OHCA strongly suggests beginning the authorization process as soon as the patient is admitted for the skilled stay unless you are sure that they will not be staying longer. At a recent meeting, all of the MyCare plans confirmed that this is a best practice.
• 
  The MyCare health plans are required by contract with the Department of Medicaid to complete levels of care on existing MyCare members who are seeking admission to a SNF. This requirement does not apply to members requesting waiver services or individuals who have not enrolled in MyCare yet (e.g., Medicaid pending). The plans are to approve the level of care either before or concurrently with prior authorization for the SNF admission. The prior authorization, however, remains the critical element to ensure payment.
• 
  None of the MyCare plans, except for United Healthcare (UHC), requires prior authorization for a claim for coinsurance for a Medicaid only MyCare member because the plan is not responsible for the primary claim to Medicare. UHC, however, does mandate authorization currently, but is considering eliminating this requirement. Molina Healthcare requires notification of the skilled admission to process the coinsurance claim, but it does not include any kind of review.
• 
  To admit a MyCare member to a SNF for a short term stay while their family is out of town or otherwise unable to care for them, there are two scenarios. If the member receives waiver services, the stay could be "waiver respite" and should be included in the member's care plan from the Area Agency on Aging. If the member is not on a waiver or does not have waiver respite as part of their plan, the admission would be under the normal prior authorization and level of care processes through the plan. The family should contact the member's care manager to initiate the authorization as early as possible before the planned short term admission.

Transportation: "Thirty Mile" Requirement
OHCA members report that people answering the phone for MyCare Ohio plans and transportation brokers at times say that transportation is not authorized unless the trip is longer than 30 miles. For medically necessary transportation for SNF patients, there is no such limitation. The confusion occurs because their contract with the state mandates that MyCare plans cover transportation outside 30 miles for MyCare members living in the community to get access to needed medical care. The extra benefit is above and beyond the "state plan" benefit of medical transportation. When calling to arrange transportation for a patient, it may be helpful to explain that the person is a SNF patient and you are requesting medically necessary transportation (e.g., to a physician's office). Please let OHCA know if you continue to have problems in this area.

New United Healthcare Transportation Request Form
United Healthcare’s transportation broker, MTM, issued a new form to be used for requesting transportation for United’s MyCare Ohio members. You may download the form from OHCA’s Managed Care web page under “United Healthcare Transportation Request Form.” Please use this form in place of the previous version. The form applies only to United, not any of the other plans.

Buckeye Requests Admission Information
OHCA SNF members report receiving a notice (“100 day letter”) from Buckeye Community Health Plan informing them that the plain will email a form to document the admission dates of all Buckeye members in their centers. The purpose of the form is to validate on a monthly basis which members have been in the center for 100 or more days. As explained in the 100 day letter, MyCare Ohio health plans receive significantly higher capitation payments from Ohio Medicaid for members who are in SNFs for that long, and we have heard many times from plan representatives about the importance of that information. Unfortunately, the Department of Medicaid does not have data on when individual Medicaid beneficiaries were admitted to a SNF, so the department requires the plans to collect the admission dates and report them periodically. We recommend members assist Buckeye by providing this information. The other MyCare health plans tell us that they are attempting to derive the admission data from other sources, but may need to issue a 100 day letter in the future.