LDSS Responsibilities. i) The LDSS has the primary responsibility for processing Medicaid Advantage enrollments. ii) Each LDSS determines Medicaid eligibility. To the extent practicable, the LDSS will follow up with Enrollees when the Contractor provides documentation of any change in status which may affect the Enrollee's Medicaid and/or Medicaid Advantage eligibility. iii) LDSS is responsible for providing pre-enrollment information on Medicaid Advantage to Dually Eligible beneficiaries, consistent with Social Services Law, Section 364-j(4)(e)(iv) and train persons providing enrollment counseling to Eligible Persons. iv) The LDSS is responsible for informing Eligible Persons of the availability of Medicaid Advantage Products, the scope of services covered by each, and that enrollment is voluntary. v) The LDSS is responsible for informing Eligible Persons of the right to confidential face-to-face enrollment counseling and will make confidential face-to-face sessions available upon request. vi) The LDSS is responsible for instructing Eligible Persons, to verify with the medical services providers they prefer, or have an existing relationship with, that such medical services providers are Participating Providers of the selected MCO and are available to serve the Enrollee. The LDSS includes such written instructions to Eligible Persons in its written materials related to Enrollment. vii) For Enrollments made during face-to-face counseling, if the Prospective Enrollee has a preference for particular medical services providers, Enrollment counselors shall verify with the medical services providers that such medical services providers whom the prospective Enrollee prefers are Participating Providers of the selected MCO and are available to serve the Prospective Enrollee. viii) The LDSS is responsible for the timely processing of Medicaid Advantage Enrollment applications received from participating health plans. ix) The LDSS is responsible for processing Enrollments in Medicaid Advantage without edits for Medicare coverage in the Welfare Management System (WMS); however the LDSS is responsible for ensuring that WMS is updated with Medicare A and B coverage status for new Enrollees upon review of documentation provided by the Contractor or the Enrollee. x) The LDSS is responsible for determining the eligibility status of Medicaid Advantage enrollment applications. Applications will be enrolled, pended or denied. xi) The LDSS is responsible for processing Medicaid Advantage enrollment applications until the last day of the month preceding the Effective Date of Enrollment, to the extent possible. xii) The LDSS is responsible for notifying the Contractor of plan-assisted enrollment applications that are accepted, pended or denied. xiii) The LDSS is responsible for entering individual enrollment form data and transmitting that data to the State's Prepaid Capitation Plan (PCP) Subsystem. The transfer of enrollment information may be accomplished by any of the following: A) LDSS directly enters data into PCP Subsystem; or B) LDSS or Contractor submits a tape to the State, to be edited and entered into PCP Subsystem; or C) LDSS electronically transfers data via a dedicated line, from eMedNY to the PCP Subsystem. xiv) Extensive use of the secondary roster will be utilized to coordinate the Effective Dates of Enrollment for Medicaid and Medicare Advantage. xv) The LDSS is responsible for prospectively re-enrolling an Enrollee who is disenrolled from the Contractor's Medicaid Advantage Product due to loss of Medicaid eligibility, who regains eligibility within three months, in the Contractor's Medicaid Advantage Product, provided that the individual remains enrolled in the Contractor's Medicare Advantage Product. xvi) The LDSS is responsible for processing new Enrollment applications to transfer a member of the Contractor's Medicaid managed care product to the Contractor's Medicaid Advantage Product if the Enrollee, upon gaining Medicare eligibility, wishes to enroll in the Contractor's Medicaid Advantage Product. To the extent possible, such Enrollments shall be made effective the first day of the month that the Enrollee's Medicare Advantage Coverage is effective. xvii) The LDSS is responsible for sending the following notices to Eligible Persons: A) Enrollment Confirmation Notice: This notice indicates the Effective Date of Enrollment, the name of the Medicaid Advantage Product and the individual who is being enrolled. This notice must also include a statement advising the individual that if his/her Medicare Advantage enrollment is denied by CMS, the individual's Medicaid Advantage Enrollment will be voided retroactively back to the Effective Date of Enrollment. In such instances, the individual may be responsible for the cost of any Medicaid Advantage Benefit rendered during the retroactive period if the benefit was provided by a non-Medicaid participating provider.
Appears in 1 contract
Samples: Medicaid Advantage Model Contract (Wellcare Health Plans, Inc.)
LDSS Responsibilities. i) The LDSS has the primary responsibility for processing Medicaid Advantage enrollments.
ii) Each LDSS determines Medicaid eligibility. To the extent practicable, the LDSS will follow up with Enrollees when the Contractor provides documentation of any change in status which may affect the Enrollee's Medicaid and/or Medicaid Advantage eligibility.
iii) LDSS is responsible for providing pre-enrollment information on Medicaid Advantage to Dually Eligible beneficiaries, consistent with Social Services Law, Section 364-j(4)(e)(ivj (4)(e)(iv) and train persons providing enrollment counseling to Eligible Persons.. APPENDIX H State January 1, 2008 H-2
iv) The LDSS is responsible for informing Eligible Persons of the availability of Medicaid Advantage Products, the scope of services covered by each, and that enrollment is voluntary.
v) The LDSS is responsible for informing Eligible Persons of the right to confidential face-to-face enrollment counseling and will make confidential face-to-face sessions available upon request.
vi) The LDSS is responsible for instructing Eligible Persons, to verify with the medical services providers they prefer, or have an existing relationship with, that such medical services providers are Participating Providers of the selected MCO and are available to serve the Enrollee. The LDSS includes such written instructions to Eligible Persons in its written materials related to Enrollment.
vii) For Enrollments made during face-to-face counseling, if the Prospective Enrollee has a preference for particular medical services providers, Enrollment counselors shall verify with the medical services providers that such medical services providers whom the prospective Enrollee prefers are Participating Providers of the selected MCO and are available to serve the Prospective Enrollee.
viii) The LDSS is responsible for the timely processing of Medicaid Advantage Enrollment applications received from participating health plans.
ix) The LDSS is responsible for processing Enrollments in Medicaid Advantage without edits for Medicare coverage in the Welfare Management System (WMS); however the LDSS is responsible for ensuring that WMS is updated with Medicare A and B coverage status for new Enrollees upon review of documentation provided by the Contractor or the Enrollee.
x) The LDSS is responsible for determining the eligibility status of Medicaid Advantage enrollment applications. Applications will be enrolled, pended or denied.
xi) The LDSS is responsible for processing Medicaid Advantage enrollment applications until the last day of the month preceding the Effective Date of Enrollment, to the extent possible.
xii) The LDSS is responsible for notifying the Contractor of plan-assisted enrollment applications that are accepted, pended or denied.
xiii) The LDSS is responsible for entering individual enrollment form data and transmitting that data to the State's Prepaid Capitation Plan (PCP) Subsystem. The transfer of enrollment information may be accomplished by any of the following:
A) LDSS directly enters data into PCP Subsystem; or
B) LDSS or Contractor submits a tape to the State, to be edited and entered into PCP Subsystem; or
C) LDSS electronically transfers data via a dedicated line, from eMedNY to the PCP Subsystem.
xiv) Extensive use of the secondary roster will be utilized to coordinate the Effective Dates of Enrollment for Medicaid and Medicare Advantage.
xv) The LDSS is responsible for prospectively re-enrolling an Enrollee who is disenrolled from the Contractor's Medicaid Advantage Product due to loss of Medicaid eligibility, who regains eligibility within three months, in the Contractor's Medicaid Advantage Product, provided that the individual remains enrolled in the Contractor's Medicare Advantage Product.
xvi) The LDSS is responsible for processing new Enrollment applications to transfer a member of the Contractor's Medicaid managed care product to the Contractor's Medicaid Advantage Product if the Enrollee, upon gaining Medicare eligibility, wishes to enroll in the Contractor's Medicaid Advantage Product. To the extent possible, such Enrollments shall be made effective the first day of the month that the Enrollee's Medicare Advantage Coverage is effective.
xvii) The LDSS is responsible for sending the following notices to Eligible Persons:
A) Enrollment Confirmation Notice: This notice indicates the Effective Date of Enrollment, the name of the Medicaid Advantage Product and the individual who is being enrolled. This notice must also include a statement advising the individual that if his/her Medicare Advantage enrollment is denied by CMS, the individual's Medicaid Advantage Enrollment will be voided retroactively back to the Effective Date of Enrollment. In such instances, the individual may be responsible for the cost of any Medicaid Advantage Benefit rendered during the retroactive period if the benefit was provided by a non-Medicaid participating provider.)
Appears in 1 contract
Samples: Contract Modification (Wellcare Health Plans, Inc.)
LDSS Responsibilities. i) The LDSS has the primary responsibility for processing Medicaid Advantage enrollmentsthe Enrollment process.
ii) Each LDSS determines Medicaid and FHPlus eligibility. To the extent practicable, the LDSS will follow up with Enrollees when the Contractor provides documentation of any change in status which may affect the Enrollee's Medicaid and/or Medicaid Advantage Medicaid, FHPlus, or MMC eligibility.
iii) The LDSS is responsible for coordinating the Medicaid and FHPlus application and Enrollment processes.
iv) The LDSS is responsible for providing pre-enrollment information on Medicaid Advantage to Dually Eligible beneficiariesPersons, consistent with Social Services Law, Section Sections 364-j(4)(e)(iv) and train 369-ee of the SSL, and the training of persons providing enrollment Enrollment counseling to Eligible Persons.
ivv) The LDSS is responsible for informing Eligible Persons of the availability of Medicaid Advantage Products, MCOs and HIV SNPs offering MMC and/or FHPlus products and the scope of services covered by each, and that enrollment is voluntary.
vvi) The LDSS is responsible for informing Eligible Persons of the right to confidential face-to-face enrollment Enrollment counseling and will make confidential face-to-face sessions available upon request.. APPENDIX H October 1, 2005 H-2
vivii) The LDSS is responsible for instructing Eligible Persons, Persons to verify with the medical services providers they prefer, or have an existing relationship with, that such medical services providers are Participating Providers of the selected MCO and are available to serve the Enrollee. The LDSS includes such written instructions to Eligible Persons in its written materials related to Enrollment.
viiviii) For Enrollments made during face-to-face counseling, if the Prospective Enrollee has a preference for particular medical services providers, Enrollment counselors shall verify with the medical services providers that such medical services providers whom the prospective Prospective Enrollee prefers are Participating Providers of the selected MCO and are available to serve the Prospective Enrollee.
viiiix) The LDSS is responsible for the timely processing of Medicaid Advantage managed care Enrollment applications received from participating health plans.
ix) The LDSS is responsible for processing Enrollments in Medicaid Advantage without edits for Medicare coverage in the Welfare Management System (WMS); however the LDSS is responsible for ensuring that WMS is updated with Medicare A applications, Exemptions, and B coverage status for new Enrollees upon review of documentation provided by the Contractor or the EnrolleeExclusions.
x) The LDSS is responsible for determining the eligibility status of Medicaid Advantage enrollment Enrollment applications. Applications will be enrolled, pended or denied. The LDSS will notify the Contractor of the denial of any Enrollment applications that the Contractor assisted in completing and submitting to the LDSS under the circumstances described in 2(c)(i) of this Appendix.
xi) The LDSS is responsible for processing determining the Exemption and Exclusion status of individuals determined to be eligible for Medicaid Advantage enrollment applications until the last day under Title 11 of the month preceding the Effective Date of Enrollment, to the extent possibleSSL.
xii) The LDSS is responsible for notifying the Contractor of plan-assisted enrollment applications that are accepted, pended or denied.
xiii) The LDSS is responsible for entering individual enrollment form data and transmitting that data to the State's Prepaid Capitation Plan (PCP) Subsystem. The transfer of enrollment information may be accomplished by any of the following:
A) LDSS directly enters data into PCP Subsystem; or
B) LDSS or Contractor submits a tape to the State, to be edited and entered into PCP Subsystem; or
C) LDSS electronically transfers data via a dedicated line, from eMedNY to the PCP Subsystem.
xiv) Extensive use of the secondary roster will be utilized to coordinate the Effective Dates of Enrollment for Medicaid and Medicare Advantage.
xv) The LDSS is responsible for prospectively re-enrolling an Enrollee who is disenrolled from the Contractor's Medicaid Advantage Product due to loss of Medicaid eligibility, who regains eligibility within three months, in the Contractor's Medicaid Advantage Product, provided that the individual remains enrolled in the Contractor's Medicare Advantage Product.
xvi) The LDSS is responsible for processing new Enrollment applications to transfer a member of the Contractor's Medicaid managed care product to the Contractor's Medicaid Advantage Product if the Enrollee, upon gaining Medicare eligibility, wishes to enroll in the Contractor's Medicaid Advantage Product. To the extent possible, such Enrollments shall be made effective the first day of the month that the Enrollee's Medicare Advantage Coverage is effective.
xvii) The LDSS is responsible for sending the following notices to Eligible Persons:
A) Enrollment Confirmation Notice: This notice indicates the Effective Date of Enrollment, the name of the Medicaid Advantage Product and the individual who is being enrolled. This notice must also include a statement advising the individual that if his/her Medicare Advantage enrollment is denied by CMS, the individual's Medicaid Advantage Enrollment will be voided retroactively back to the Effective Date of Enrollment. In such instances, the individual may be responsible for the cost of any Medicaid Advantage Benefit rendered during the retroactive period if the benefit was provided by a non-Medicaid participating provider.
Appears in 1 contract
LDSS Responsibilities. i) The LDSS has the primary responsibility for processing Medicaid Advantage enrollmentsthe Enrollment process.
ii) Each LDSS determines Medicaid and FHPlus eligibility. To the extent practicable, the LDSS will follow up with Enrollees when the Contractor provides documentation of any change in status which may affect the Enrollee's Medicaid and/or Medicaid Advantage Medicaid, FHPlus, or MMC eligibility.
iii) The LDSS is responsible for coordinating the Medicaid and FHPlus application and Enrollment processes.
iv) The LDSS is responsible for providing pre-enrollment information on Medicaid Advantage to Dually Eligible beneficiariesPersons, consistent with Social Services Law, Section Sections 364-j(4)(e)(iv) and train 369-ee of the SSL, and the training of persons providing enrollment Enrollment counseling to Eligible Persons.
ivv) The LDSS is responsible for informing Eligible Persons of the availability of Medicaid Advantage Products, MCOs and HIV SNPs offering MMC and/or FHPlus products and the scope of services covered by each, and that enrollment is voluntary.
vvi) The LDSS is responsible for informing Eligible Persons of the right to confidential face-to-face enrollment Enrollment counseling and will make confidential face-to-face sessions available upon request.
vivii) The LDSS is responsible for instructing Eligible Persons, Persons to verify with the medical services providers they prefer, or have an existing relationship with, that such medical services providers are Participating Providers of the selected MCO and are available to serve the Enrollee. The LDSS includes such written instructions to Eligible Persons in its written materials related to Enrollment.
viiviii) For Enrollments made during face-to-face counseling, if the Prospective Enrollee has a preference for particular medical services providers, Enrollment counselors shall verify with the medical services providers that such medical services providers whom the prospective Prospective Enrollee prefers are Participating Providers of the selected MCO and are available to serve the Prospective Enrollee.
viiiix) The LDSS is responsible for the timely processing of Medicaid Advantage managed care Enrollment applications received from participating health plans.
ix) The LDSS is responsible for processing Enrollments in Medicaid Advantage without edits for Medicare coverage in the Welfare Management System (WMS); however the LDSS is responsible for ensuring that WMS is updated with Medicare A applications, Exemptions, and B coverage status for new Enrollees upon review of documentation provided by the Contractor or the EnrolleeExclusions.
x) The LDSS is responsible for determining the eligibility status of Medicaid Advantage enrollment Enrollment applications. Applications will be enrolled, pended or denied. The LDSS will notify the Contractor of the denial of any Enrollment applications that the Contractor assisted in completing and submitting to the LDSS under the circumstances described in 2(c)(i) of this Appendix.
xi) The LDSS is responsible for processing determining the Exemption and Exclusion status of individuals determined to be eligible for Medicaid Advantage enrollment applications until the last day under Title 11 of the month preceding SSL.
A) Exempt means an individual eligible for Medicaid under Title 11 of the Effective Date SSL determined by the LDSS or the SDOH to be in a category of Enrollmentpersons, as specified in Section 364-j of the SSL and/or New York State's Operational Protocol for the Partnership Plan, that are not required to participate in the extent possibleMMC Program; however, individuals designated as Exempt may elect to voluntarily enroll.
B) Excluded means an individual eligible for Medicaid under Title 11 of the SSL determined by the LDSS or the SDOH to be in a category of persons, as specified in Section 364-j of the SSL and/or New York State's Operational Protocol for the Partnership Plan, that are precluded from participating in the MMC Program.
xii) The LDSS is responsible Individuals eligible for notifying Medicaid under Title 11 of the Contractor SSL in the following categories will be eligible for Enrollment in the Contractor's MMC product at the LDSS's option, as indicated in Schedule 2 of plan-assisted enrollment applications that are accepted, pended or deniedAppendix M.
A) Xxxxxx care children in the direct care of LDSS;
B) Homeless persons living in shelters outside of New York City.
xiii) The LDSS is responsible for entering individual enrollment Enrollment form data and transmitting that data to the State's Prepaid Capitation Plan (PCP) Subsystem. The transfer of enrollment information may be accomplished by any of the following:
A) LDSS directly enters data into PCP Subsystem; or
B) LDSS or Contractor submits a tape to the State, to be edited and entered into PCP Subsystem; or
C) LDSS electronically transfers data via a dedicated line, from eMedNY to the PCP Subsystem.
xiv) Extensive use of the secondary roster will be utilized to coordinate the Effective Dates of Enrollment for Medicaid and Medicare Advantage.
xv) The LDSS is responsible for prospectively re-enrolling an Enrollee who is disenrolled from the Contractor's Medicaid Advantage Product due to loss of Medicaid eligibility, who regains eligibility within three months, in the Contractor's Medicaid Advantage Product, provided that the individual remains enrolled in the Contractor's Medicare Advantage Product.
xvi) The LDSS is responsible for processing new Enrollment applications to transfer a member of the Contractor's Medicaid managed care product to the Contractor's Medicaid Advantage Product if the Enrollee, upon gaining Medicare eligibility, wishes to enroll in the Contractor's Medicaid Advantage Product. To the extent possible, such Enrollments shall be made effective the first day of the month that the Enrollee's Medicare Advantage Coverage is effective.
xvii) The LDSS is responsible for sending the following notices to Eligible Persons:
A) Enrollment Confirmation Notice: This notice indicates the Effective Date of Enrollment, the name of the Medicaid Advantage Product and the individual who is being enrolled. This notice must also include a statement advising the individual that if his/her Medicare Advantage enrollment is denied by CMS, the individual's Medicaid Advantage Enrollment will be voided retroactively back to the Effective Date of Enrollment. In such instances, the individual may be responsible for the cost of any Medicaid Advantage Benefit rendered during the retroactive period if the benefit was provided by a non-Medicaid participating provider.)
Appears in 1 contract
Samples: Medicaid Managed Care Model Contract (Wellcare Health Plans, Inc.)
LDSS Responsibilities. i) The LDSS has the primary responsibility for processing Medicaid Advantage enrollments.
ii) Each LDSS determines Medicaid eligibility. To the extent practicable, the LDSS will follow up with Enrollees when the Contractor provides documentation of any change in status which may affect the Enrollee's Medicaid and/or Medicaid Advantage eligibility.
iii) LDSS is responsible for providing pre-enrollment information on Medicaid Advantage to Dually Eligible beneficiaries, consistent with Social Services Law, Section 364-j(4)(e)(iv) and train persons providing enrollment counseling to Eligible Persons.
iv) The LDSS is responsible for informing Eligible Persons of the availability of Medicaid Advantage Products, the scope of services covered by each, and that enrollment is voluntary.
v) The LDSS is responsible for informing Eligible Persons of the right to confidential face-to-face enrollment counseling and will make confidential face-to-face sessions available upon request.
vi) The LDSS is responsible for instructing Eligible Persons, to verify with the medical services providers they prefer, or have an existing relationship with, that such medical services providers are Participating Providers of the selected MCO and are available to serve the Enrollee. The LDSS includes such written instructions to Eligible Persons in its written materials related to Enrollment.
vii) For Enrollments made during face-to-face counseling, if the Prospective Enrollee has a preference for particular medical services providers, Enrollment counselors shall verify with the medical services providers that such medical services providers whom the prospective Enrollee prefers are Participating Providers of the selected MCO and are available to serve the Prospective Enrollee.
viii) The LDSS is responsible for the timely processing of Medicaid Advantage Enrollment applications received from participating health plans.
ix) The LDSS is responsible for processing Enrollments in Medicaid Advantage without edits for Medicare coverage in the Welfare Management System (WMS); however the LDSS is responsible for ensuring that WMS is updated with Medicare A and B coverage status for new Enrollees upon review of documentation provided by the Contractor or the Enrollee.
x) The LDSS is responsible for determining the eligibility status of Medicaid Advantage enrollment applications. Applications will be enrolled, pended or denied.
xi) The LDSS is responsible for processing Medicaid Advantage enrollment applications until the last day of the month preceding the Effective Date of Enrollment, to the extent possible.
xii) The LDSS is responsible for notifying the Contractor of plan-assisted enrollment applications that are accepted, pended or denied.
xiii) The LDSS is responsible for entering individual enrollment form data and transmitting that data to the State's Prepaid Capitation Plan (PCP) Subsystem. The transfer of enrollment information may be accomplished by any of the following:
A) LDSS directly enters data into PCP Subsystem; or
B) LDSS or Contractor submits a tape to the State, to be edited and entered into PCP Subsystem; or
C) LDSS electronically transfers data via a dedicated line, from eMedNY to the PCP Subsystem.
xiv) Extensive use of the secondary roster will be utilized to coordinate the Effective Dates of Enrollment for Medicaid and Medicare Advantage.
xv) The LDSS is responsible for prospectively re-enrolling an Enrollee who is disenrolled from the Contractor's Medicaid Advantage Product due to loss of Medicaid eligibility, who regains eligibility within three months, in the Contractor's Medicaid Advantage Product, provided that the individual remains enrolled in the Contractor's Medicare Advantage Product.
xvi) The LDSS is responsible for processing new Enrollment applications to transfer a member of the Contractor's Medicaid managed care product to the Contractor's Medicaid Advantage Product if the Enrollee, upon gaining Medicare eligibility, wishes to enroll in the Contractor's Medicaid Advantage Product. To the extent possible, such Enrollments shall be made effective the first day of the month that the Enrollee's Medicare Advantage Coverage is effective.
xvii) The LDSS is responsible for sending the following notices to Eligible Persons:
A) Enrollment Confirmation Notice: This notice indicates the Effective Date of Enrollment, the name of the Medicaid Advantage Product and the individual who is being enrolled. This notice must also include a statement advising the individual that if his/her Medicare Advantage enrollment is denied by CMS, the individual's Medicaid Advantage Enrollment will be voided retroactively back to the Effective Date of Enrollment. In such instances, the individual may be responsible for the cost of any Medicaid Advantage Benefit rendered during the retroactive period if the benefit was provided by a non-Medicaid participating provider.)
Appears in 1 contract
Samples: Medicaid Advantage Contract Attestation (Wellcare Health Plans, Inc.)
