Welcome To DMAS

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Welcome To DMAS
Case Managers Meeting
May 27 and 28, 2009
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Agenda

• WebEx CourtesyPamela Lewis
• Managed Care 101Paige Jones
• DMAS Web PageTammy Driscoll
• Private Duty Nursing (PDN)Tammy Driscoll
• DMAS UpdatesKathleen Dickerson

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Just a little WebEx Courtesy

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• Thank you

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Remember

• Mute your phone when
  joining the session.
• Do not place your phone
  on HOLD we may
• hear background music.

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Virginias Medicaid MCO Program
The Department of Medical Assistance
Services Health Care Services Division Managed
Care Operations Unit
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Presentation Outline

• 1. Overview of Managed Care
• 2. Eligibility and Enrollment
• 3. Acute and Long Term Care (ALTC)

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Overview of Managed Care
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MCO Program

• Virginias Mandatory Medicaid Managed Care
  Enrollment Program, called Medallion II
• Virginias Child Health Insurance Program (CHIP)
  known as FAMIS
• Medicaid and FAMIS clients are enrolled in
  contracted Managed Care Organizations (MCOs)

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Regulatory Authority
Medicaid

• Title XIX Social Security Act
• CMS 1915(b) Waiver
• 42 CFR Part 438
• 12VAC30-120-360 thru 420

FAMIS

• Title XXI Social Security Act
• 42 CFR Part 457
• FAMIS State Plan

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Managed Care

• Currently operating in 114 localities
• Statewide Medicaid/FAMIS Enrollment
• as of May, 2009
• Fee-for-Service 255,951
• MEDALLION 53,470
• Medallion II 457,210
• FAMIS FFS 7,184
• FAMIS MCO 50,636
• FAMIS PCP 1,203

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Virginia Medicaid Managed Care Program Coverage
Map
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Our MCO Partners

• Anthem HealthKeepers Plus
• HealthKeepers Plus by Priority
• HealthKeepers Plus by Peninsula
• AmeriGroup Community Care
• CareNet Southern Health
• Optima Family Care
• Virginia Premier Health Plan
• NOTE Not all MCOs are available in every area.
  Refer to the Managed Care Resource Guide. The
  Guide is available on-line at http//www.dmas.virg
  inia.gov/mc-home.htm.

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Member Services

• FFS
• Medicaid ID Card
• Recipient helpline (not toll-free)

• MCO
• MCO member ID card, handbook, and provider
  directory
• Toll-free member helpline
• Access to translation services/language telephone
  line free of charge
• 24-hour nurse advice line
• Access to medical case management
• Member outreach and health education materials
• Access to credentialed providers

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Billing Recipients

• Section 1128B(d) of the Social Security Act
  prohibits providers from balance billing any
  Medicaid recipient.
• Providers are prohibited from
• (1) charging, for any service provided to a
  patient under a State plan approved under title
  XIX, money or other consideration at a rate in
  excess of the rates established by the State,
  (or, in the case of services provided to an
  individual enrolled with a Medicaid managed care
  organization under title XIX under a contract
  under section 1903(m) or under a contractual,
  referral, or other arrangement under such
  contract, at a rate in excess of the rate
  permitted under such contract), or
• (2) charging, soliciting, accepting, or
  receiving, in addition to any amount otherwise
  required to be paid under a State plan approved
  under title XIX, any gift, money, donation, or
  other consideration.

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Billing recipients for Emergency Services

• The Virginia Administrative Code at
  12VAC30-120-395, and Section 1932(b)(2)(D) of the
  Social Security Act requires all emergency
  service providers, including those not enrolled
  with Medicaid, to accept established Medicaid
  reimbursement as payment in full.

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Eligibility and Enrollment
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MCO Enrollment

• Mandatory enrollment of Medicaid and FAMIS
  clients into a MCO
• The majority of Medicaid clients are eligible for
  MCO enrollment

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Exclusions

• Medicaid Clients who are excluded from MCO
  enrollment will receive services through
  fee-for-service (regular) Medicaid
• Medicare
• Other Primary Insurance
• Foster care/subsidized adoptions
• Hospitalized at the time of enrollment
• Individuals in nursing facilities
• Individuals participating in the Technology
  Assisted Waiver
• Individuals institutionalized in a state facility
• Individuals authorized by DMAS (KePRO) into
  Treatment Foster Care Case Management or
  Psychiatric Residential Treatment Programs
• Refer to the Managed Care Resource Guide for the
  complete list of exclusions.

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MCO Carved Out Services

• Community Mental Health Rehabilitative Services
• Intensive In-Home Services for Children and
  Adolescents
• Therapeutic Day Treatment for Children and
  Adolescents
• Day Treatment/Partial Hospitalization
• Psychosocial Rehabilitation
• Crisis Intervention
• Intensive Community Treatment
• Crisis Stabilization Services
• Mental Health Support Services
• Case Management
• Mental Retardation Community Services
• Case Management Services
• Carved-out services are reimbursed through the
  Fee-For-Service Program however, the MCO is
  responsible for transportation.

• Certain Substance Abuse Treatment Services
• Substance Abuse Crisis Intervention
• Substance Abuse Intensive Outpatient
• Substance Abuse Day Treatment
• Opioid Treatment
• Substance Abuse Case Management
• Dental (Smiles For Children)
• School Health Services
• Abortions
• Specialized Infant Formula for Children Under Age
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• Health Department Lead Investigations

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Medicaid Enrollment in Managed Care

• Determined to be eligible for Medicaid DSS
  enters into system
• 15-45 days after eligibility entered into system,
  pre-assignment takes place

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Pre-assignment
Notified by letter
http//www.dmas.virginia.gov/downloads/pdfs/mc-mdl
nII_mco_preasnmnt.pdf
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Pre-assignment

• All clients are pre-assigned to a MCO
• Must call the Managed Care Helpline to make
  selection by deadline
• No call enrollment into pre-assigned MCO
• Obtain services through fee-for-service (regular
  Medicaid) until MCO is effective
• FAMIS does not have pre-assignment. FAMIS
  enrollees are assigned a plan immediately but
  have 90 days to make a change.

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Medicaid - Changing MCOs

• 90 days after effective date to change MCOs for
  any reason
• Before 18th of month, effective 1st of following
  month
• After 18th of month, enrollment delayed another
  month
• After 90 days change allowed with approval from
  DMAS for good cause
• Annual Open Enrollment change MCOs for any
  reason (refer to Managed Care Resource Guide for
  Open Enrollment info)
• FAMIS enrollees do not have Open Enrollment.
  They may change plans on their annual renewal
  date.

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60-day Re-enrollment

• Member loses Medicaid eligibility -- MCO
  enrollment ends
• Re-gains Medicaid eligibility within 60 days
• Automatically re-enrolled in previous MCO
• Notified by letter

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Newborn Enrollment

• Born to MCO-enrolled mom, baby covered by moms
  MCO for birth month plus 2 more months
• Mom can change babys MCO if ID on file
• Mom should report birth to DSS ASAP
• No Medicaid ID for baby at end of 3rd month
  loss of coverage
• Babies born to mothers enrolled in the FAMIS MOMS
  program are not guaranteed coverage

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Foster Care

• Children eligible for Medicaid under a foster
  care aid category will automatically be exempt
  from managed care
• Eligibility processed in ADAPT and foster care or
  adoption assistance screens are completed, ADAPT
  will send an FC or AA special indicator code with
  the MMIS enrollment.  ADAPT will enroll the child
  in appropriate MI AC (090, 091, 092, or 094)
  and the FC or AA indicator code will appear on
  the MMIS enrollee demographic screen
• Managed care exemption or disenrollment will only
  occur if the special indicator code is present on
  the 18th of the month (managed care cutoff).  If
  added after the 18th of the month, the exemption
  or disenrollment will be delayed another month

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Acute and Long-Term Care (ALTC)
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ALTC Integration

• Applies only to individuals enrolled in the
  managed care program as of September 1, 2007, or
  after
• Individuals first enrolled in a MCO who become
  eligible for a HCBS waiver (except for the Tech
  waiver) continue to receive primary and acute
  care services through their MCO

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ALTC Integration

• Waiver services are provided through FFS and
  carved out of the MCO
• For example Waiver services are treated the
  same way as dental and community mental health
  services
• There was no impact on waiver participants prior
  to September 1, 2007

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ALTC Coverage Logistics

• Participants will have two ID cards. Both cards
  display the Medicaid ID number
• Medicaid (DMAS) FFS card for waiver services.
• MCO card for primary and acute care.
• When a participant receives a waiver service it
  is covered by DMAS FFS.
• When a participant receives a primary or acute
  care service (e.g., physician visit) it is
  covered by their MCO.

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ALTC Coverage Logistics

• Transportation
• For transportation to a primary/acute care
  service
• Participants call the MCO
• For transportation to a waiver service
  Participants call LogistiCare (1-866-386-8331)
• ID Cards
• For primary and acute care services
  Participants use their MCO card
• For waiver services
  Participants use their FFS Medicaid (DMAS)
  card

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Questions about ALTC?

• Waiver services provided through FFS and carved
  out of the MCO
• Contact Yvonne Goodman, R.N.
• Yvonne.Goodman_at_dmas.virginia.gov
• Primary or acute care service (e.g., physician
  visit) covered by the MCO
• Contact Kathleen Dickerson, R.N.
• Kathleen.dickerson_at_dmas.virginia.gov

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Managed Care HelpLine

• Medicaid MCO Clients can receive assistance by
  calling the
• Managed Care HelpLine at
• 1-800-643-2273
• TDD 1-800-817-6608
• 830 am 600 pm
• Monday through Friday

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FAMIS CPU

• FAMIS Clients can receive assistance
• by calling the
• Central Processing Unit at
• 1-866-87FAMIS(1-866-873-2647)
• TDD1-888-221-15908 a.m. to 7 p.m. Monday -
  Friday9 a.m. to 12 noon Saturday

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Visit Us On The Web

• http//www.dmas.virginia.gov/mc-home.htm
• www.virginiamanagedcare.com
• Access the Managed Care Resource Guide at
  http//www.dmas.virginia.gov/mc-home.htm
• Questions?
• ManagedCareHelp_at_dmas.virginia.gov

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Managed Care Websitehttp//www.dmas.virginia.gov

• Department of Medical Assistance Services

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Click on Staying Healthy
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Click here to navigate the Staying Healthy pages
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Special links are featured in the copy of each
page
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Order from www.famis.org Staying Healthy posters
for waiting and exam rooms in English and Spanish
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Private Duty Nursing (PDN)

• Clarification of Coverage

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Private Duty Nursing (PDN)
PDN Coverage for Medicaid and FAMIS Children

• . . . and how this differs from skilled nursing
  coverage available under Home Health and Home and
  Community Based Care Waivers

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Private Duty Nursing (PDN)

• Medically necessary PDN is covered for Medicaid
  children under EPSDT and FAMIS children under the
  FAMIS benefit
• PDN offers continuous nursing care. This differs
  from short-term, intermittent nursing care
  available under Home Health and through some of
  the home and community based care waivers (also
  referred to as skilled nursing)

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PDN Eligibility

• Covered groups
• Medicaid/FAMIS Plus enrollees under 21
• FAMIS enrollees under age of 19
• Coverage for PDN for Medicaid and FAMIS MCO
  enrollees is covered under the MCO.

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Nursing and Waiver Enrollees

• Approximately 37 of the 113 FFS individuals
  receiving PDN are enrolled in a Medicaid Waiver
• Not all waivers offer nursing services
• EPSDT can provide PDN to help manage the childs
  chronic nursing care needs
• For Example The EDCD waiver does not include
  PDN coverage therefore, the child may need PDN
  (covered thru EPSDT)

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Nursing and Waiver Enrollees
FYI - Waiver enrollees must use waiver services
each month to maintain their waiver eligibility

• If in the EDCD waiver, the child should use a
  waiver service on a regular basis
• If waiver enrollees lose their waiver eligibility
  they may lose their Medicaid coverage

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DMAS Updates

• Smiles For Children
• Plan First
• Childrens Mental Health Program
• Community Mental Health Rehabilitative Services
  (CMHRS)
• Long Term Care

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• Spread the News!
• Access to Dental Care is Available in Virginia
  through
• Smiles For Children

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Smiles For Children

• The Medicaid/FAMIS Dental Program is called
  Smiles For Children.
• Program enrollment is dependent on Medicaid/FAMIS
  eligibility.
• All dental benefits for program enrollees are
  administered by Doral Dental, USA.
• Doral uses the 12-digit Medicaid ID number as the
  enrollee ID Number

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Smiles For Children

• Smiles For Children provides comprehensive dental
  benefits, including braces, for eligible
  enrollees under the age of 21.
• Limited medically necessary oral surgery,
  including extractions, and associated diagnostic
  services are available for enrollees age 21 and
  older.

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Smiles For Children

• Questions - dental benefits, eligibility,
  locating participating providers and scheduling
  dental appointments call Doral at
• 1-888-912-3456
• Provider search feature - at Doral and DMAS
  websites
• www.doralusa.com
• www.dmas.virginia.gov/dental-home.htm
• Member outreach materials are available upon
  request.
• The MCOs cover transportation for their Medicaid
  enrollees
• FFS clients can access transportation thru
  Logisticare

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Plan FirstVirginiasFamily Planning Program
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Purpose

• To improve birth outcomes
• To help in birth spacing
• To reduce Medicaid expenditures for pregnancy and
  child birth by preventing unplanned pregnancies.

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Plan First Eligibility

• Requesting expansion to include both uninsured
  men and women who have countable income within
  200 FPL and have not had a sterilization
  procedure.
• Awaiting Centers for Medicare and Medicaid
  Services (CMS) approval anticipate implementing
  this summer.

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Effective Contraception

• All contraceptive methods shown to be
  cost-effective due to preventing unplanned
  pregnancies
• Long term contraception found to produce higher
  savings - such as Implanon, Mirena, Paragard,
  Depo-Provera
• (AJPH, 3/2009)

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Effective Contraception cont.

• DMAS and MCOs vary between coverage through
  Pharmacy benefit and Physician benefit
  confusing to providers
• DMAS developing coverage Fact Sheet with MCO
  input for providers to promote more effective
  delivery

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Plan First

• For more information about Plan First
• Go to www.dmas.virginia.gov
• On the left - click on
• Maternal and Child Health
• Outreach, providers, billing, application, etc.

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Eligibility
Children adolescents under the age of 21, who

• Have been in a Psychiatric Residential Treatment
  Facility (PRTF) at least 90 days
• Have a psychiatric diagnosis
• Remain eligible for Medicaid after they leave the
  PRTF (based upon family income)
• Have a family (foster or biological) willing to
  take the child home
• Have community services available immediately
  upon discharge from the PRTF
• Continue to need the level of services of the PRTF

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Services

• Transition Coordination
• Environmental Modifications
• Companion Services (agency and consumer directed)
• Respite Services (agency and consumer directed)
• Service Facilitation for consumer-directed
  services
• Therapeutic Consultation
• Family Caregiver Training
• In-Home Residential Supports

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Status

• 14 kids enrolled
• 7 males 7 Females

Age Range 12 Under 2 13-18 11 19-21 1
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For More Information

• Mendy Meeks
• Childrens Mental Health Program Coordinator
• [phone]
• childmhprog_at_dmas.virginia.gov
• Or visit
• www.dmas.virginia.gov
• click on Maternal and Child Health/Childrens
  Mental Health Program

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COMMUNITY MENTAL HEALTH REHABILATATIVE
SERVICES (CMHRS) Update
Changes Effective 8/1/2009
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CHMRS UpdatePrior Authorization (PA) will be
required for

• Therapeutic Day Treatment for Children and
  Adolescents
• Intensive Community Treatment
• Psychosocial Rehabilitation
• Mental Health Support
• Mental Health Case Management
• Day Treatment/Partial Hospitalization for Adults
• PA Not Required For Up To 6 Months For Existing
  Clients
• iEXCHANGE Required For Submission of PA to KePRO
• Good Cause Exception Allowed

CMHRS Services are Carved Out of MCO Contracts
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CHMRS Billing Changes

• New Codes Required To Bill Assessment Without PA
• Service Limits Based Upon Fiscal Year (July 1 to
  June 30) Versus Treatment Year
• The Medicaid Management Information System (MMIS)
  Claims Payment System Will Stop Payment When
  Claims Exceed The Service Limit Effective July
  1, 2009

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CHMRS UpdateDMAS working closely with the VACSB
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CMHRS Training and Reference Information

• DMAS and KePRO are conducting trainings on these
  changes (March 2009 - June 2009)
• The CMHRS Training Schedule Is Available at
  http//www.dmas.virginia.gov/downloads/pdfs/ln-cmh
  tletter.pdf
• Community Mental Health Rehabilitative Services
  Provider Manual www.dmas.virginia.gov, is being
  updated and will be available on the DMAS website
  soon
• CMHRS Training Presentation will be posted to the
  DMAS website soon

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• Email CMHRS questions to

• cmhrs_at_dmas.virginia.gov

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Long Term Care .including Home Community
Based Waiver (HCBW) Programs Updates
http//www.dmas.virginia.gov/ltc-home.htm
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LTC Budget Items

• 3 rate increase for consumers and agency
  directed personal care under HCBWs
• 400 New MR Waiver slots added
• Added in phases
• 200 July 1, 2009
• 200 January 2010

as of 07/01/2009 MR Waiver is changing to the
intellectual disabilities (ID) Waiver
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LTC Update

• Virginia Gold - a new grant program that offers
  funding for quality improvement programs in
  nursing facilities to enhance quality and
  increase staff retention.

For more information visit
http//www.dmas.virginia.gov/ltc-home.htm
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Contact Information Long-Term Care Division
FYI

• Terry Smith, Division Director
  
• 804-371-8490
• Program Managers
• Steve Ankiel Helen Leonard
  William Butler
• (804-371-8894)
  (804-768-2149)
  (804-371-8886)
• Supervisors
• Yvonne Goodman- DD/Tech Deborah Pegram- PACE
  Melissa Fritzman-QMR
• (804-786-0503) (804-371-2912)
  (804-225-4206)
• Tracy Harris, Lead Analyst for DD
• (804-225-4791)

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Early and Periodic, Screening, Diagnosis, and
Treatment (EPSDT) Program Updates
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EPSDT Contacts

• Anne Young, EPSDT Preauthorization Coordinator
• [phone]
• anne.young_at_dmas.virginia.gov
• EPSDT Fax
• [phone]
• Brian Campbell, EPSDT Coordinator
• [phone]
• brian.campbell_at_dmas.virginia.gov
• www.dmas.virginia.gov/ch-home.htm

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Questions

• Send any questions or comments to
  managedcarehelp_at_dmas.virginia.gov
• Spring 2009 Case Manager Presentation and
  Materials (including Q As) will be available at
  http//www.dmas.virginia.gov/mc-home.htm

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Thank You for Attending
Spring 2009 Case Managers Meeting