OHCA MyCare Ohio Bulletin

November 21, 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).

MyCare Enrollment Statistics
As of November 13, 2014, the Department of Medicaid reports that there were 95,488 individuals enrolled in MyCare Ohio. Of that number, only 15,817 (16.6%) were enrolled for both Medicare and Medicaid. CareSource has the most total enrollees at 23,933, followed by Aetna (20,708), United (18,737), Molina (17,023), and Buckeye (15,087). CareSource also far and away led with the highest percentage of dual enrollees (28.8%), while the other plans had percentages in the 11-13% range. Not surprisingly, the three CareSource regions have the highest percentages of dual enrollees (18-23%), while the other four regions range between 11% and 14%. Anecdotally, because the state does not track enrollment by setting, we hear that dual enrollment in facility settings is one third of the total percentage.

Medicare Coinsurance Claims - Time Sensitive
It is very important that members quickly submit Medicare coinsurance claims for Medicaid only MyCare beneficiaries to the plans. For MyCare members, the Department of Medicaid no longer provides "zero pay remits" needed for Medicare bad debt as the result of an automatic claims crossover process. Instead, coinsurance must be billed separately to the MyCare plan that provides the person's Medicaid benefits. To qualify for the 2014 Medicare cost report - which determines bad debt payments for 2014 and interim payments for 2015 - a zero pay remit must be issued by December 31, 2014, about 40 days from now. Accordingly, billing these claims now is critical. OHCA is engaged with all five MyCare plans to ensure that each plan issues appropriate remittance advices for bad debt purposes. We also submit specific examples of remits from the plans to CGS for approval.

At this time, the MyCare plans are in different places. Molina Healthcare is generating remits with the necessary wording in response to coinsurance claims billed according to standard billing practices. Laura Wheeler of Buckeye Health Plan informed us that as of November 12, 2014, Buckeye corrected an error in their system and now is doing the same. (Previously, providers had to remove RUG codes from the coinsurance claims to get zero pay remits instead of denials from Buckeye.) Aetna also seems to be providing acceptable zero pay remits, although we need to verify that with CGS. United Healthcare and CareSource, however, often pay the coinsurance or a different amount instead of issuing a zero pay remit. Both plans said they would quickly look into this problem and provide an update to us. We also emphasized to all five plans that providers need rapid turnaround on coinsurance claims to meet the December 31 deadline. If you have submitted coinsurance claims to one or more of the plans and have not received a response, please feel free to send a spreadsheet of those claims to Pete Van Runkle or Diane Dietz, and we will follow up with plan key contacts for coinsurance issues.

Skilled Claim Examples Needed
In preparation for the anticipated January 2015 influx of MyCare Ohio Medicare enrollees, OHCA is working with the health plans to make sure they are ready to process and pay claims for Medicare skilled services. While the numbers will be greater starting in January, there already are some dual enrollees, and OHCA members are filing a few skilled claims with MyCare plans. To aid in our discussions with the plans, we very much would appreciate examples from you showing how the plans currently are handling skilled claims. Specifically, we need copies of UB04 claims and remittance advices for skilled claims submitted to each of the plans - either paid or not paid. In the case of claims that have been pending for a period of time, a copy of the plan's portal showing the pending claims, along with the UBs, would be helpful. Please email examples to Pete Van Runkle or Diane Dietz by Monday, November 25, 2014.

Medicare MyCare Participation
All MyCare Ohio beneficiaries and new enrollees have the right to have their Medicare benefits covered by their MyCare health plan or to opt out of the Medicare portion of MyCare - the portion that allows "integration" of all of the beneficiary's services. Please be aware of some key facts about opting out:

• Providers are not permitted to encourage beneficiaries or their families to opt out or to choose a particular health plan. Providers can, however, give factual information (including such things as whether or not specified providers are in a plan's network, that beneficiaries have the right to opt out, and that if they do so, they can keep their existing coverage).
• The MyCare plans are extremely interested in beneficiaries not opting out. Situations - albeit rare - in which a provider is alleged to have overstepped their bounds are referred to the long term care ombudsman for investigation. The plans also point out that certain business advantages may accrue to providers whose patients are dual enrollees.
• There are three prescribed ways for a person to opt out. Doing anything else is not effective. The three ways are calling the Medicaid hotline (800-324-8680), filing an online request on the hotline website (enter the relevant county), or filling out and mailing or faxing a paper form that can be downloaded from the hotline website.
• A provider that is the authorized representative for a Medicaid beneficiary is permitted to make MyCare decisions for them, consistent with the beneficiary's best interests. A representative payee for Social Security is NOT an authorized representative. An authorized representative is appointed by the beneficiary using the ODM 6723 form.
• Per Elbony McIntyre of the Department of Medicaid, the following results apply based on when a beneficiary opts out of MyCare;

If a beneficiary opts-out before January 1, their passive enrollment will never take effect and they are automatically reinstated into their [Medicare Advantage] and/or Part D plan.

If a beneficiary opts-out after January 1, once their enrollment has become effective they will automatically be returned to original Medicare and temporarily enrolled in the Limited Income Newly Eligible Transition program (LI Net) for their Part D benefits. If the beneficiary does not select a Part D plan within 60 days, one will be selected for them. [This is a correction to information we received previously and reported to members.]

• Any MyCare beneficiary or enrollee who signs up for a Medicare Advantage plan or changes their Part D plan during the open enrollment period in November and early December is considered to have opted out of MyCare for Medicare and does not need to opt out by any of the methods listed above. This does not include a beneficiary who already has Medicare Advantage and does not change. They will be passively enrolled for MyCare Medicare.

As a reminder, any dual eligible individual who has a Medicare supplement (Medigap) policy or other creditable third party coverage (generally not including Medicare Advantage) cannot participate in MyCare Ohio for either Medicare or Medicaid. Use the ODM 6614 form to notify the department of third party coverage.

Molina Authorization Renewal
MMolina Healthcare only authorizes custodial SNF care in 6 month increments, which means that new authorizations will be needed soon. A spreadsheet for requesting renewal of the authorizations is posted on the OHCA website on the Managed Care page. Please use the spreadsheet to fax in your list of Molina patients, or you may call Molina at 855-322-4079. A reminder from Molina's Ami Cole: the plan does not require an authorization number on the claim form. Additional information is available in the Molina SNF frequently asked question document.

Patient Liability Reconciliation Spreadsheet
We encourage members to use the MyCare Ohio patient liability reconciliation spreadsheet, available with instructions on the OHCA Managed Care web page. This form is designed to allow skilled centers to correct erroneous patient liability data that MyCare plans use to pay claims. It is essential that you submit, with the spreadsheet, 9401 forms supporting the patient liability amounts you enter on the spreadsheet. The plan will not be able to reconcile the claims without the documentation. The plans in general still appear to be paying a large percentage of claims incorrectly, often because of patient liability errors. Please note that assisted living providers should not use the reconciliation spreadsheet. The health plans and the Area Agencies on Aging (AAAs) are working on a separate process whereby the AAAs will update the plans on client liability changes for Medicaid assisted living consumers.

Other Patient Liability Notes
Relative to SNF claims, Buckeye Health Plan tells us they are reconciling erroneous payments themselves and taking back the overpayments without the provider having to use the spreadsheet. Molina Healthcare sent to their providers a detailed communication explaining that they implemented a system fix on November 13, 2014, that allows them to start deducting patient liability. Like Buckeye, Molina will reconcile past, incorrectly paid claims themselves, as described more fully in their bulletin. We believe for both plans, a portion of the adjusted claims still will have wrong patient liability because of inaccurate data provided by the Department of Medicaid. In those cases, use the reconciliation spreadsheet to report the errors. Both Buckeye and Molina say they will complete the recoupments by the end of the year. CareSource already began recouping payments that reflect inaccurate patient liability. They are sending special notice letters to affected providers. Please contact Mark Grippi at CareSource if you have concerns about the amount of the recoupment or about how CareSource calculated it.

Level of Care
Resolving a long standing question about MyCare Ohio, the Department of Medicaid's Christi Pepe affirmed that a level of care is not necessary to admit a MyCare beneficiary. The level of care criteria are subsumed into the health plan's decision to give prior authorization for the admission, so all a center needs is the prior authorization. In fact, Ms. Pepe observed that a plan could authorize admission of a beneficiary who does not meet level of care. She said when auditing the plans, the department will not look behind a center's claims for a level of care determination, as would be the case in fee for service Medicaid. Please note that level of care (through the Area Agency on Aging) still is required for a person who is Medicaid pending - that is, not yet enrolled in MyCare - and for waiver recipients. The prior authorization requirement applies to beneficiaries who already are in MyCare. Also, PASRR still applies to MyCare members being admitted to a skilled care center in the same manner as it applies to all other patients.

CareSource Transportation Quick Reference Guide
We have posted the final version of the CareSource transportation quick reference guide to the OHCA website. The key point is that facility staff can schedule transportation directly with the transportation provider instead of having to go through a broker or get authorization from the plan.

Final Version of Care Management Tables

We apologize for the multiple versions of these tables, but we believe that after another review by the MyCare plans, we have the final, shown below.

 

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