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1 Department of Medical Assistance Services Department of Medical Assistance Services – Eligibility and Enrollment Unit.

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Presentation on theme: "1 Department of Medical Assistance Services Department of Medical Assistance Services – Eligibility and Enrollment Unit."— Presentation transcript:

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2 1 Department of Medical Assistance Services Department of Medical Assistance Services – Eligibility and Enrollment Unit March Department of Medical Assistance Services MMIS WebEx Training

3 2 Department of Medical Assistance Services Agenda Deemed Newborn Report FAMIS Moms The Governor’s Access Plan for the Seriously Mentally Ill (GAP) Commonwealth Coordinated Care (CCC) Health and Acute Care Project (HAP) Dual Aid Categories (AC’s) – Reminder AC 058 – Open Ended Spenddowns Social Security Number (SSN) Verification Citizenship and Identity (C&I) Verification RS-O-485A Report Social Security Cards Pseudo SSN’s First Name Unknown (FNU) Enrollments

4 3 Department of Medical Assistance Services Deemed Newborn Enrollment Broadcast 8970 –DMAS will no longer enroll deemed newborns as reported by the Medicaid MCO. A weekly report will be ed to local agency contacts. –Report serves as notification of birth. Enroll members as soon as possible; all eligibility criteria has been met.

5 4 Department of Medical Assistance Services FAMIS MOMS Reintroduced 12/1/2014 Income limit = 200% of the FPL; the 5% FPL disregard is allowed. Eligibility continues through the last day of month in which the 60 th postpartum day falls. AC = 005 No retroactive coverage Members born to FAMIS MOMS mother enrolled in AC 010 or AC 014.

6 5 Department of Medical Assistance Services GAP What is GAP? Demonstration program offering a targeted benefit package for up to 20,000 Virginians who: –Have income less than 100% of the federal poverty level –Are suffering from serious mental illness (SMI). –Are 21 through 64 years old –Have no health insurance, including Medicaid, FAMIS, Medicare or Tricare –Are not residing in long-term care, mental health or penal institution In Virginia the Governor’s Access Plan for the Seriously Mentally Ill (GAP) will run from January 2015 to January GAP AC = 087

7 6 Department of Medical Assistance Services GAP (continued) Referrals will come from: –self-referral; –family members; –community mental health providers; –local departments of social services; –health care providers; –community organizations; –jails/prisons (upon release); –hospitals; and –other community resources providing assistance to individuals.

8 7 Department of Medical Assistance Services GAP (continued) Cover Virginia will: Receive online and telephonic applications for the GAP Program; Provide a toll free customer service line; Determine eligibility; Send out member handbook; and Handle individuals' appeal of actions which have denied, reduced, or terminated covered benefits.

9 8 Department of Medical Assistance Services GAP (continued) Applications for GAP can be completed: –Telephonically through by calling or TDD at –Through the provider assisted web portal at https://www.virginiamedicaid.dmas.virginia.gov/wps/portal. https://www.virginiamedicaid.dmas.virginia.gov/wps/portal Applicants beginning the process through Cover Virginia will be referred to their local CSB for a GAP Seriously Mentally Ill (SMI) Screening.

10 9 Department of Medical Assistance Services GAP (continued) Cover Virginia will: –Process completed applications –Send letter with GAP ID #’s and handbooks Magellan will: –Send member ID cards GAP coverage is effective on the first day of the month in which the completed application was received.

11 10 Department of Medical Assistance Services GAP (continued) Front Back Sample GAP Member ID Card

12 11 Department of Medical Assistance Services GAP (continued) No retroactive eligibility Individuals meeting the eligibility requirements are enrolled for a period of 12 continuous months except in the following cases; the individual: –reaches his/her 65 th birthday –moves out of the Commonwealth of VA –is deceased, or –becomes enrolled in Medicare or full-coverage Medicaid. After 12 months the financial/non-financial eligibility will be reviewed by Cover VA.

13 12 Department of Medical Assistance Services GAP (continued) Contact Info for Members: Magellan of Virginia offers a 24 hour, 7 day per week toll free line for individuals receiving GAP benefits to obtain information. –Members may contact a care manager by calling or GAP9. –Members may also access the Peer Support Line by calling *Please note that these are member only lines*

14 13 Department of Medical Assistance Services GAP (continued) Additional information on the GAP Demonstration Waiver: Questions pertaining to GAP may be ed to:

15 14 Department of Medical Assistance Services GAP (continued) GAP Enrollments = AC 087 GAP Recipient Questions received by LDSS should be directed to Cover VA. Applications for MA received by LDSS – contact Cover VA.

16 15 Department of Medical Assistance Services CCC Three year financial demonstration program operated under a three year contract between: –DMAS –CMS –The three contracted health plans; Anthem Healthkeepers, Virginia Premier Complete Care and Humana Gold Plus Integrated.

17 16 Department of Medical Assistance Services CCC (continued) Persons who may be eligible for CCC include those who: –Are over 21 years of age –Have full Medicare coverage (Parts A, B, D) –Have full Medicaid coverage –Live in one of the 5 designated regions –Have no other comprehensive coverage

18 17 Department of Medical Assistance Services CCC (continued) Enrollment in CCC is voluntary Four “passive” phases of enrollment have occurred since the opt-in phase began March 1, Passive enrollment occurs when: –Individual is found eligible for CCC and is sent notification that they will be enrolled in a specific health plan at 60 and 30 day intervals prior to enrollment.

19 18 Department of Medical Assistance Services CCC (continued) To opt-out of CCC or change health plan assignment the member should call the enrollment broker at The member will remain enrolled in the health plan for the remainder of the month in which they opt-out if action is not taken prior to enrollment.

20 19 Department of Medical Assistance Services CCC (continued) CCC Members Receive: –All current Medicare-covered services –All current Medicaid-covered services –Most importantly an individual care manager assigned to assist the person in the procurement and coordination of their care needs.

21 20 Department of Medical Assistance Services CCC (continued) CCC Care Managers must have regular contact; including face-to-face contact with nursing facility and waiver enrollees because of this requirement: –The MMIS Member Demographic screen must reflect the member’s current physical location and correct FIPS code. –Authorized representative or POA information should be entered on the Comment Screen. –If the enrollee cannot be located from the information in the MMIS the case managers may call LDSS workers for assistance in reaching the members.

22 21 Department of Medical Assistance Services CCC (continued) Access to care issues often occur when members experience a break in eligibility due to AC changes or closures due to failure to complete renewals. Contact the CCC division with any suggestions for preventing coverage breaks.

23 22 Department of Medical Assistance Services CCC (continued) Prior to requesting patient pay adjustments for facility and waiver enrolled individuals the provider should: –First contact the assigned care manager to see if needed items or services are covered by the plan as a covered benefit or supplemental service. –If not covered, then request a patient pay adjustment through the normal process.

24 23 Department of Medical Assistance Services HAP Launched 12/1/2014 EDCD Members transitioned to managed care for acute care services. Affected approximately 2,700 EDCD members. New EDCD enrollees who do not have managed care exclusions will be enrolled.

25 24 Department of Medical Assistance Services HAP (continued) Primary and acute care services received through managed care delivery model. Home and community based services provided through Medicaid fee-for-service. Managed care plans coordinate acute care services. Service authorization requirements and limitations are unchanged.

26 25 Department of Medical Assistance Services HAP (continued) Inquiries and health plan enrollments handled by Maximus. Individuals choose health plan per current policies. Questions about HAP can be sent to:

27 26 Department of Medical Assistance Services Dual AC’s – Reminder Use of dual-eligible AC’s allows for federal funds to pay 100% of Part B premium costs. Enroll QMB or SLMB members who meet a spenddown or become eligible for long-term care in the appropriate dual- eligible AC: DUAL QMB AC’SSLMB PLUS AC’S 028 MN Aged & QMB024 MN Aged SLMB Plus 048 MN Blind & QMB 044 MN Blind/Disabled SLMB Plus 068 MN Disabled & QMB % SSI aged SLMB Plus % SSI Aged & QMB % SSI blind/disabled SLMB Plus % SSI Blind & QMB % SSI Disabled & QMB

28 27 Department of Medical Assistance Services Dual AC’s (continued) Disabled Example A disabled member is found eligible for and enrolled in SLMB AC 053 effective 1/1/15. The member has two six month spenddowns established. The member then submits medical bills which meet the spenddown liability on 3/5/15. The member meets all other MN financial requirements. The member will now be enrolled in SLMB Plus AC 044 (MN Blind/Disabled) from 3/5-6/30/15.

29 28 Department of Medical Assistance Services Dual AC’s (continued) – LTC Example An aged member is found eligible for and enrolled in SLMB AC 053 effective 1/1/15. The member enters a nursing facility on 3/1/15. The member meets all LTC financial and nonfinancial requirements. The member will now be enrolled in SLMB Plus AC 025 (300% SSI Aged).

30 29 Department of Medical Assistance Services AC 058 – Open Ended Spenddowns February 2015 report – only 113 open ended enrollments for the entire state! Leaving spenddowns open ended can cause: –Erroneous enrollment in CCC –Technical Errors

31 30 Department of Medical Assistance Services SSN Verification The USCIS or Alien # should not be used for SSN.

32 31 Department of Medical Assistance Services SSN Verification Name entered in VaCMS/MMIS must match applicant name on Social Security card or SSA records. Exact spelling must be used. Any name changes must be completed with SSA prior to changes in VaCMS/MMIS. –This includes Adoption Assistance children and individuals who have a name change due to marriage or divorce. M D

33 32 Department of Medical Assistance Services SSN Verification (continued) To verify SSN’s: –Use the Federal Hub, SOLQ-I or SVES If SSN is not verified or proof of application for a SSN is not provided enrollment in the VaCMS/MMIS should not occur until the correct information is provided. M

34 33 Department of Medical Assistance Services C & I Verification MMIS exchanges data with SSA for the documentation of C&I. If matched, the MMIS is updated to reflect the verification. If not matched, a monthly discrepancy report is generated. M

35 34 Department of Medical Assistance Services RS-O-485A Report SSN & identifying information is transmitted to SSA for verification on the 21 st of the month. Non-matches are listed on the RS-O-485A Report on SPARK. Eligibility staff reviews discrepancies and attempts to resolve. M

36 35 Department of Medical Assistance Services RS-O-485A (continued) Discrepancy is a data entry error: –Correct so new data match occurs in the next month. If not data entry error: –Member should be given 10 days to resolve or provide verification from SSA. Written notice should advise member of Medicaid cancellation if verification is not received. M

37 36 Department of Medical Assistance Services RS-O-485A (continued) Individual provides verification: –Update member’s data to allow for a match in the following month’s process. SSN verification not provided: –Send advanced notice of proposed cancellation and cancel the coverage. M

38 37 Department of Medical Assistance Services Social Security Cards Three types of cards issued by the SSA All three cards show a name and SSN Card Type #1: – On Card: Name SSN –Issued to: U.S. Citizens; and People lawfully admitted to the United states on a permanent basis.

39 38 Department of Medical Assistance Services Social Security Cards (continued) Card Type #2: On Card: “Valid for Work Only with DHS Authorization” Name SSN Issued to: People who are lawfully admitted to the U.S. on a temporary basis who have Department of Homeland Security Authorization to work.

40 39 Department of Medical Assistance Services Social Security Cards (continued) Card Type #3: On Card: “Not Valid for Employment” Name SSN Issued to: People who are lawfully admitted to the U.S. without Department of Homeland Security Authorization to work., but who have a non-working reason for needing a SSN.

41 40 Department of Medical Assistance Services Psuedo SSN’s Members who do not have a SSN must have a pseudo SSN entered Only one format is acceptable for entry of pseudo numbers: 2 digit day of birth & 2 digit year of birth 999-MM-DDYY All pseudos must begin with “999”2 digit month of birth M

42 41 Department of Medical Assistance Services FNU Enrollments FNU = First Name Unknown May appear on immigration documents Social Security card could have: –FNU and a last name, or –Only one name listed System searches required to determine if MMIS first name field should contain: –FNU or –Unknown

43 42 Department of Medical Assistance Services F.N.U. (continued)

44 43 Department of Medical Assistance Services F.N.U. (Continued)

45 44 Department of Medical Assistance Services F.N.U. (continued)

46 45 Department of Medical Assistance Services F.N.U. (continued)

47 46 Department of Medical Assistance Services MMIS Coverage Correction Form The DMAS Eligibility and Enrollment Unit would like to advise LDSS staff of an updated MMIS Coverage Correction form (form number: dmas eng) that is now available in the Forms section of the SPARK page that will help streamline submissions. The new version of the form includes a section for requesting duplicate member ID linking as well as requests for resetting a member’s ID indicator. This eliminates the need to use the MMIS Duplicate Member ID Link Request form ( eng ) and the MMIS Reset ID Card Indicator Request form (form number eng ). As a result, both of these forms will be removed from the SPARK page.

48 47 Department of Medical Assistance Services Help is an away… BUY IN UNIT Assistance with state Buy-In: (804) (804) HIPP UNIT Assistance for LDSS with HIPP issues: (800) LTC UNIT Assistance with level of care issues & related PP reports, admit dates: (804) TPL UNIT Assistance with TPL issues including carrier codes (804) MANAGED CARE HELPLINE Assistance for members (800) MEMBER HELPLINE: Assistance for members (804)

49 48 Department of Medical Assistance Services Continued… Lois Brengel, Program Manager Eligibility & Enrollment Unit (804) Sarah Samick, Enrollment Supervisor Eligibility & Enrollment Unit (804) Cindy Olson, Eligibility Policy Manager Eligibility Policy Unit (804) Tiaa Lewis, HIPP Buy-In Manager HIPP & Buy-in Unit (804)

50 49 Department of Medical Assistance Services Thank you… Thank you for viewing this presentation. Continue to send questions and comments about this training or ideas for future trainings to: Eligibility and Enrollment issues should be sent to the Enrollment Inbox at Patient Pay enrollment questions or issues should be sent to the Patient Pay Inbox at


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