Common use of Assisting Members to Maintain Medicaid Eligibility Clause in Contracts

Assisting Members to Maintain Medicaid Eligibility. The MCO is responsible for assisting members in their responsibility to maintain Medicaid eligibility. This may include: Reminding members of the required annual Medicaid recertification procedure and assisting them to get to any needed appointments; Assisting members to understand any applicable Medicaid income and asset limits and as appropriate and needed, supporting members to meet verification requirements; Assisting members to understand any deductible, cost share or patient liability obligation they may need to meet to maintain Medicaid eligibility; Assisting members to understand the implications of their functional level of care as it relates to the eligibility criteria for the program; If appropriate and needed, assisting members to obtain a representative payee or legal decision maker; and Referring members as needed to other available resources in the community that may assist members in obtaining or maintaining eligibility such as Elder and Disability Benefits Specialists and advocacy organizations. Coordinate with residential provider to assist member in completing Medicaid review. Providing Information that May Affect Eligibility Members have a responsibility to report certain changes in circumstances that may affect Medicaid eligibility to the income maintenance agency within ten (10) calendar days of the change. Notwithstanding the member’s reporting obligations, if the MCO has information about a change in member circumstances that may affect Medicaid eligibility, the MCO is to provide that information to the income maintenance agency as soon as possible but in no event more than ten (10) calendar days from the date of discovery (see Article IV.C.2.c.). Members who receive SSI benefits are required to report certain changes to the Social Security Administration rather than the local IM agency. MCOs should assist members in meeting these reporting requirements since loss of SSI has a direct impact on Medicaid eligibility. Reportable information includes: The member’s functional eligibility as determined by the LTCFS using procedures specified by the Department; The average monthly amount of medical/remedial expenses the member pays for out-of-pocket; The housing costs the member pays for out-of-pocket, either in the member’s own home or apartment or in a community-based residential care facility (see Section E of this article); Non-payment of any required cost share (post eligibility treatment of income); The member has died; The member has been incarcerated; The admission of a member who is age 21 or over and under age 65 to an Institute for Mental Disease; The member has moved out of the county or service area; Any known changes in the member’s income or assets; Changes in the member’s marital status.

Assisting Members to Maintain Medicaid Eligibility. The MCO is responsible for assisting members in their responsibility to maintain Medicaid eligibility. This may include: Reminding members of the required annual Medicaid recertification procedure and assisting them to get to any needed appointments; Assisting members to understand any applicable Medicaid income and asset limits and as appropriate and needed, supporting members to meet verification requirements; Assisting members to understand any deductible, cost share or patient liability obligation they may need to meet to maintain Medicaid eligibility; Assisting members to understand the implications of their functional level of care as it relates to the eligibility criteria for the program; If appropriate and needed, assisting members to obtain a representative payee or legal decision maker; and Referring members as needed to other available resources in the community that may assist members in obtaining or maintaining eligibility such as Elder and Disability Benefits Specialists and advocacy organizations. Coordinate with residential provider to assist member in completing Medicaid review. Providing Information that May Affect Eligibility Members have a responsibility to report certain changes in circumstances that may affect Medicaid eligibility to the income maintenance agency agency, as appropriate, within ten (10) calendar days of the change. Notwithstanding the member’s reporting obligations, if the MCO has information about a change in member circumstances that may affect Medicaid eligibility, the MCO is to provide that information to the income maintenance agency as soon as possible but in no event more than ten (10) calendar days from the date of discovery (see Article IV.C.2.c.IV.C.2.d. page 53). Members who receive SSI benefits are required to report certain changes to the Social Security Administration rather than the local IM agency. MCOs should assist members in meeting these reporting requirements since loss of SSI has a direct impact on Medicaid eligibility. Reportable information includes: The member’s functional eligibility as determined by the LTCFS Long-Term Care Functional Screen using procedures specified by the Department; The average monthly amount of medical/remedial expenses the member pays for out-of-pocket; The housing costs the member pays for out-of-pocket, either in the member’s own home or apartment or in a community-based residential care facility (see Section E F of this article); Non-payment of any required cost share (post eligibility treatment of income); The member has died; The member has been incarcerated; The admission of a member who is age 21 or over and under age 65 to an Institute for Mental Disease; The member has moved out of the county or service area; Any known changes in the member’s income or assets; Any disqualifying Medicare coverage elections (Partnership and PACE only); Changes in the member’s marital status.

Assisting Members to Maintain Medicaid Eligibility. The MCO PO is responsible for assisting members in their responsibility to maintain Medicaid eligibility. This may include: Reminding members of the required annual Medicaid recertification procedure and assisting them to get to any needed appointments; Assisting members to understand any applicable Medicaid income and asset limits and as appropriate and needed, supporting members to meet verification requirements; Assisting members to understand any deductible, cost share or patient liability obligation they may need to meet to maintain Medicaid eligibility; Assisting members to understand the implications of their functional level of care as it relates to the eligibility criteria for the program; If appropriate and needed, assisting members to obtain a representative payee or legal decision maker; and Referring members as needed to other available resources in the community that may assist members in obtaining or maintaining eligibility such as Elder and Disability Benefits Specialists and advocacy organizations. Coordinate with residential provider to assist member in completing Medicaid review. Providing Information that May Affect Eligibility Members have a responsibility to report certain changes in circumstances that may affect Medicaid eligibility to the income maintenance agency agency, within ten (10) calendar days of the change. Notwithstanding the member’s reporting obligations, if the MCO PO has information about a change in member circumstances that may affect Medicaid eligibility, the MCO PO is to provide that information to the income maintenance agency as soon as possible but in no event more than ten (10) calendar days from the date of discovery (see Article IV.C.2.c.)discovery. Members who receive SSI benefits are required to report certain changes to the Social Security Administration rather than the local IM agency. MCOs POs should assist members in meeting these reporting requirements since loss of SSI has a direct impact on Medicaid eligibility. Reportable information includes: The member’s functional eligibility as determined by the LTCFS using procedures specified by the Department; The average monthly amount of medical/remedial expenses the member pays for out-of-pocket; The housing costs the member pays for out-of-pocket, either in the member’s own home or apartment or in a community-based residential care facility (see Section E of Dof this article); Non-payment of any required cost share (post eligibility treatment of income); The member has died; The member has been incarcerated; The admission of a member who is age 21 or over and under age 65 to an Institute for Mental Disease; The member has moved out of the county or service area; Any known changes in the member’s income or assets; Any disqualifying Medicare coverage elections Changes in the member’s marital status. Medicare Coverage Elections The MCO is responsible to assist members to understand any Medicare coverage choices, including Medicare Advantage plan election periods, in order to avoid unintended disenrollment. Medicaid Deductibles or Cost Share Deductibles A member may attain full-benefit Medicaid financial eligibility through meeting a deductible (see Medicaid Eligibility Handbook Ch. 24.2, xxxx://xxx.xxxxxxxxxxx.xxxxxxxxx.xxx/meh-ebd/meh.htm). Such members are eligible in Group A without a cost share for the remainder of the deductible period. The PACE organization shall explain to the member the circumstances under which the member may have to pay a deducitble and assist the member with the financial eligibility re-determination by the income maintenance agency at the end of the deductible period.

Assisting Members to Maintain Medicaid Eligibility. The MCO is responsible for assisting members in their responsibility to maintain Medicaid eligibility. This may include: Reminding members of the required annual Medicaid recertification procedure and assisting them to get to any needed appointments; Assisting members to understand any applicable Medicaid income and asset limits and as appropriate and needed, supporting members to meet verification requirements; Assisting members to understand any deductible, cost share or patient liability obligation they may need to meet to maintain Medicaid eligibility; Assisting members to understand the implications of their functional level of care as it relates to the eligibility criteria for the program; If appropriate and needed, assisting members to obtain a representative payee or legal decision maker; and Referring members as needed to other available resources in the community that may assist members in obtaining or maintaining eligibility such as Elder and Disability Benefits Specialists and advocacy organizations. Coordinate with residential provider to assist member in completing Medicaid review. Providing Information that May Affect Eligibility Members have a responsibility to report certain changes in circumstances that may affect Medicaid eligibility to the income maintenance agency within ten (10) calendar days of the change. Notwithstanding the member’s reporting obligations, if the MCO has information about a change in member circumstances that may affect Medicaid eligibility, the MCO is to provide that information to the income maintenance agency as soon as possible but in no event more than ten (10) calendar days from the date of discovery (see Article IV.C.2.cIV.C.1.c.). Members who receive SSI benefits are required to report certain changes to the Social Security Administration rather than the local IM agency. MCOs should assist members in meeting these reporting requirements since loss of SSI has a direct impact on Medicaid eligibility. Reportable information includes: The member’s functional eligibility as determined by the LTCFS Long-Term Care Functional Screen using procedures specified by the Department; The average monthly amount of medical/remedial expenses the member pays for out-of-pocket; The housing costs the member pays for out-of-pocket, either in the member’s own home or apartment or in a community-based residential care facility (see Section E of this article); Non-payment of any required cost share (post eligibility treatment of income); The member has died; The member has been incarcerated; The admission of a member who is age 21 or over and under age 65 to an Institute for Mental Disease; The member has moved out of the county or service area; Any known changes in the member’s income or assets; Changes in the member’s marital status.

Assisting Members to Maintain Medicaid Eligibility. The MCO PO is responsible for assisting members in their responsibility to maintain Medicaid eligibility. This may include: Reminding members of the required annual Medicaid recertification procedure and assisting them to get to any needed appointments; Assisting members to understand any applicable Medicaid income and asset limits and as appropriate and needed, supporting members to meet verification requirements; Assisting members to understand any deductible, cost share or patient liability obligation they may need to meet to maintain Medicaid eligibility; Assisting members to understand the implications of their functional level of care as it relates to the eligibility criteria for the program; If appropriate and needed, assisting members to obtain a representative payee or legal decision maker; and Referring members as needed to other available resources in the community that may assist members in obtaining or maintaining eligibility such as Elder and Disability Benefits Specialists and advocacy organizations. Coordinate with residential provider to assist member in completing Medicaid review. Providing Information that May Affect Eligibility Members have a responsibility to report certain changes in circumstances that may affect Medicaid eligibility to the income maintenance agency agency, within ten (10) calendar days of the change. Notwithstanding the member’s reporting obligations, if the MCO PO has information about a change in member circumstances that may affect Medicaid eligibility, the MCO PO is to provide that information to the income maintenance agency as soon as possible but in no event more than ten (10) calendar days from the date of discovery (see Article IV.C.2.c.)discovery. Members who receive SSI benefits are required to report certain changes to the Social Security Administration rather than the local IM agency. MCOs POs should assist members in meeting these reporting requirements since loss of SSI has a direct impact on Medicaid eligibility. Reportable information includes: The member’s functional eligibility as determined by the LTCFS Long-Term Care Functional Screen using procedures specified by the Department; The average monthly amount of medical/remedial expenses the member pays for out-of-pocket; The housing costs the member pays for out-of-pocket, either in the member’s own home or apartment or in a community-based residential care facility (see Section E of Dof this article); Non-payment of any required cost share (post eligibility treatment of income); The member has died; The member has been incarcerated; The admission of a member who is age 21 or over and under age 65 to an Institute for Mental Disease; The member has moved out of the county or service area; Any known changes in the member’s income or assets; Any disqualifying Medicare coverage elections Changes in the member’s marital status. Medicare Coverage Elections The MCO is responsible to assist members to understand any Medicare coverage choices, including Medicare Advantage plan election periods, in order to avoid unintended disenrollment. Medicaid Deductibles or Cost Share Deductibles A member may attain full-benefit Medicaid financial eligibility through meeting a deductible (see Medicaid Eligibility Handbook Ch. 24.2, xxxx://xxx.xxxxxxxxxxx.xxxxxxxxx.xxx/meh-ebd/meh.htm). Such members are eligible in Group A without a cost share for the remainder of the deductible period. The PACE organization shall explain to the member the circumstances under which the member may have to pay a deducitble and assist the member with the financial eligibility re-determination by the income maintenance agency at the end of the deductible period.

Assisting Members to Maintain Medicaid Eligibility. The MCO is responsible for assisting members in their responsibility to maintain Medicaid eligibility. This may include: Reminding members of the required annual Medicaid recertification procedure and assisting them to get to any needed appointments; Assisting members to understand any applicable Medicaid income and asset limits and as appropriate and needed, supporting members to meet verification requirements; Assisting members to understand any deductible, cost share or patient liability obligation they may need to meet to maintain Medicaid eligibility; Assisting members to understand the implications of their functional level of care as it relates to the eligibility criteria for the program; If appropriate and needed, assisting members to obtain a representative payee or legal decision maker; and Referring members as needed to other available resources in the community that may assist members in obtaining or maintaining eligibility such as Elder and Disability Benefits Specialists and advocacy organizations. Coordinate with residential provider to assist member in completing Medicaid review. Providing Information that May Affect Eligibility Members have a responsibility to report certain changes in circumstances that may affect Medicaid eligibility to the income maintenance agency within ten (10) calendar days of the change. Notwithstanding the member’s reporting obligations, if the MCO has information about a change in member circumstances that may affect Medicaid eligibility, the MCO is to provide that information to the income maintenance agency as soon as possible but in no event more than ten (10) calendar days from the date of discovery (see Article IV.C.2.cIV.0.2.c.). Members who receive SSI benefits are required to report certain changes to the Social Security Administration rather than the local IM agency. MCOs should assist members in meeting these reporting requirements since loss of SSI has a direct impact on Medicaid eligibility. Reportable information includes: The member’s functional eligibility as determined by the LTCFS Long-Term Care Functional Screen using procedures specified by the Department; The average monthly amount of medical/remedial expenses the member pays for out-of-pocket; The housing costs the member pays for out-of-pocket, either in the member’s own home or apartment or in a community-based residential care facility (see Section E of this article); Non-payment of any required cost share (post eligibility treatment of income); The member has died; The member has been incarcerated; The admission of a member who is age 21 or over and under age 65 to an Institute for Mental Disease; The member has moved out of the county or service area; Any known changes in the member’s income or assets; Any disqualifying Medicare coverage elections (Partnership only); Changes in the member’s marital status. Medicare Coverage Elections - Partnership The MCO is responsible to assist members to understand any Medicare coverage choices, including Medicare Advantage plan election periods, in order to avoid unintended disenrollment from the Partnership program. Medicaid Deductibles or Cost Share Deductibles A member may attain full-benefit Medicaid financial eligibility through meeting a deductible (see Medicaid Eligibility Handbook Ch. 24.2, xxxx://xxx.xxxxxxxxxxx.xxxxxxxxx.xxx/meh-ebd/meh.htm). Such members are eligible in Group A without a cost share for the remainder of the deductible period. This will happen rarely in the Family Care Program, but can occur in the following situations: Members who meet a nursing home level of care and who are newly enrolling in a home and community-based waiver program may have met a Medicaid deductible prior to enrollment and thereby become financially eligible for the remainder of the six-month deductible period (see MEH Ch.24.3). Such persons have no cost share. At the end of the deductible period the income maintenance agency will re-determine the member’s financial eligibility, which in almost all cases will be under the special Home and Community-Based Services (HCBS) waiver eligibility group (Group B or B+). The member will then not have to meet a deductible but may have to pay a cost share depending on income and allowable deductions. The MCO shall explain these circumstances to the member and assist the member with the financial eligibility re-determination by the income maintenance agency at the end of the deductible period. Members who meet a non-nursing home level of care may have met a Medicaid deductible prior to enrollment and thereby become financially eligible for the remainder of the six-month deductible period. At the end of the deductible period, the income maintenance agency will re-determine the member’s Medicaid eligibility. Prior to the end of the deductible period, the MCO shall explain to the member that upon re-determination, unless the member will be eligible under a different Medicaid eligibility category or is able to prepay the deductible, the member will lose Medicaid eligibility and be disenrolled when the current deductible period ends until the member can meet the deductible in the next deductible period. The MCO shall review with the member how to meet the new deductible amount, including the option to prepay it in order to avoid a period of ineligibility. The income maintenance agency will determine if the person is eligible under a different category of full-benefit Medicaid. If not, the agency will determine the new deductible amount and monitor whether it’s met, including explaining the option to prepay the deductible. Cost Share or Patient Liability Members may be required to pay a monthly cost share or patient liability in order to be eligible for Family Care or Partnership. Cost share, also called post eligibility treatment of income, applies to members who live in their own home, an adult family home, a community-based residential facility or a residential care apartment complex. Patient liability applies to members who reside in a nursing home or Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF-IID) for 30 or more consecutive days or are likely to reside there for 30 or more consecutive days. The income maintenance agency is responsible for determining the member’s cost share or patient liability. Cost share is imposed on members in accordance with 42 C.F.R. § 435.726. Patient liability is imposed in accordance with 42 C.F.R. § 435.725. The Department will ensure that a member who has a cost share is not required to pay any amount in cost share which is in excess of the average capitation payment attributable to waiver services, as determined by the Department. The MCO is responsible for collecting the members’ monthly cost share or patient liability, subject to the following Department policies and procedures: The MCO will send a xxxx to any member who has a cost share or patient liability in advance of or as early as possible during the month in which the cost share or patient liability is due. Members who were enrolled in IRIS as of the first day of the month in which they transition to Family Care or Family Care Partnership, generally pay the cost share amount for that month to their IRIS fiscal employer agent. If the MCO capitation payment was offset by the cost share amount for that month, the MCO will attempt to verify whether the member paid his or her cost share to an IRIS fiscal employer agent. If the MCO has documentation to verify the member paid the cost share to the fiscal employer agent, the MCO may request a capitation payment adjustment on an enrollment discrepancy report (see Article IV.0.5.a.). Cost share and patient liability are not prorated for partial months. The system logic that determines a member’s patient liability amount can offset either a MCO capitation payment or a Nursing Home Fee-for-Service (NH FFS) claim, but not both. ForwardHealth automatically deducts the appropriate monthly patient liability amount from the first NH FFS claim or capitation payment received for the member. (See Forward-Health Online Handbook topic #3188: xxxxx://xxx.xxxxxxxxxxxxx.xx.xxx/WIPortal/Subsystem/KW/Displ ay.aspx ). Generally, when members residing in a NH are enrolled into a MCO and the enrollment includes past months, the NH FFS claim will be offset by the patient liability amount for the past month(s), and the subsequent capitation payment(s) for the past month(s) will not be offset by the patient liability amount. However, this depends on when the NH FFS claim is submitted and processed in the system, so MCOs should monitor the 820 transaction to determine whether or not the patient liability amount was used to offset the capitation payment. If the patient liability amount was used to offset the capitation payment, the MCO should collect the liability amount. The MCO will attempt to collect the patient liability amount from the nursing home when the 820 Report (see Article XV.E) indicates that the capitation payment was offset by the patient liability amount but the member already paid the patient liability to the nursing home. The MCO will attempt to collect the patient liability amount from the member when the 820 Report indicates the capitation payment was offset by the patient liability amount, the paid FFS NH claim was not offset by the patient liability amount, and the member did not pay the patient liability to the nursing home. The MCO will transfer the patient liability amount to the nursing home when the 820 Report indicates that the capitation payment was not offset by the patient liability amount but the member already paid the patient liability amount to the MCO. If a member fails to pay the cost share or patient liability as billed by the due date, the MCO will: Contact the member to determine the reason for non- payment. Determine whether the cost share or patient liability presents an undue hardship for which the MCO is willing to waive some or the entire obligation. Remind the member that non-payment may result in loss of eligibility and disenrollment. Attempt to convince the member to make payment or negotiate a payment plan. Offer the member assistance with financial management services or refer the member for establishment of a representative payee or legal decision maker if needed. If all efforts to assist the member to meet the financial obligation are unsuccessful, refer the situation to the income maintenance agency for ongoing eligibility determination and the ADRC for options counseling.