Provision of Services While Financial Eligibility is Pending. The MCO will cooperate fully in executing a memorandum of understanding or other written agreement with each ADRC within its service area that describes the circumstances in which the MCO will provide services to an individual who is functionally eligible but whose financial eligibility is pending. This agreement can be to serve individuals whose financial eligibility is pending at the time of initial enrollment or during a period of disenrollment due to loss of financial eligibility. The MOU shall include a process for the resource center to inform the individual, or their legal decision maker, that if he/she is determined not to be eligible, he/she will be liable for the cost of services provided by the MCO. The MCO will not receive a capitation payment for an individual during the time financial eligibility is pending. If and when eligibility is established, the MCO will receive a capitation payment retroactively to the date indicated as the “effective date of enrollment” on the Enrollment Request form, up to a maximum of ninety (90) calendar days of serving the person while financial eligibility was pending. The effective date of enrollment entered on the Enrollment Request Form shall also be no earlier than the date on which an individual or their legal decision maker signs an explicit agreement (not just the enrollee’s signature on the enrollment form) to accept services during the period of pending financial eligibility. If the individual is determined not to be eligible, the MCO may bill that individual for the services the MCO has provided. The MCO shall pay providers for services which were provided and prior authorized by the MCO. MCO providers may not directly collect payment from the individual. The timelines for completion of the comprehensive assessment and member- centered plan shall be the same as those indicated in Article V, Care Management.
