1. © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Medicaid Eligibility for 2013 HP - Fiscal Agent for the Arkansas Division of Medical Services

2. © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Agenda  HP Enterprise Services Contact  Primary Care Physicians  Verify Eligibility  Aid Categories/Plan Benefits  Questions

3. © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. HP Enterprise Services

4. 4 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. HP Enterprise Services Provider Assistance Center (PAC) Your first point of contact for billing, claim status, eligibility and all other questions is the Provider Assistance Center: Monday through Friday (8 a.m. - 5 p.m.) Toll-free in Arkansas (800) 457-4454 Local or out-of-state (501) 376-2211

5. © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Primary Care Physicians

6. 6 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Primary Care Physician (PCP) Arkansas Medicaid operates as a Primary Care Case Management Program. Most beneficiaries are required to have a PCP, and most services require PCP referral. Beneficiaries that are not required to enroll with a PCP include:  Beneficiaries with Medicare coverage  Residents of an Intermediate Care Facility for the Mentally Retarded  Residents of Long Term Care facilities  Beneficiaries on spend down aid categories  Retroactive eligible beneficiaries

7. 7 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Main responsibilities Primary Care Physician (PCP)  Provide health education  Assess medical conditions, initiating and recommending treatment or therapy  Refer to specialty physicians, hospital care, and other medically necessary services  Locate needed medical services  Coordinate prescribed medical and rehabilitation services with other professionals  Monitor the enrollees’ prescribed medical and rehabilitation services

8. 8 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Beneficiaries  Select a PCP (most beneficiaries)  Report changes in income or circumstances  Report TPL Main responsibilities

9. © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Eligibility

10. 10 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Verify Eligibility Using the Portal (DDE)

11. 11 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Enter NPI. Eligibility Verification Inquiry

12. 12 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Eligibility Verification Inquiry

13. 13 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Note: Eligibility is date specific and can only be honored if it was checked on the day of service. Eligibility Verification Inquiry

14. 14 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Service Type Code – One of a group of codes defined by the X12 270/271 standards describing a Health Plan Benefit. Generic Inquiry – A request for eligibility information that only specifies a request for information on Service Type Code ‘30’ for ‘Health Benefit Plan Coverage’. The Core Rules require special handling for a generic inquiry. Explicit Inquiry – A request for eligibility for a Service Type Code other than ‘30’. Definitions for ACA

15. 15 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Eligibility Verification Response

16. 16 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Eligibility Verification will give a generic response that will include 13 service types. 1 – Medical Care 30 – Health Benefit Plan Coverage 33 – Chiropractic 35 – Dental 47 – Hospital 48 – Hospital-Inpatient 50 – Hospital-Outpatient 86 – Emergency Services 88 – Pharmacy 98 – Professional (Physician) Visit- Office AL – Vision (Optometry) MH – Mental Health UC – Urgent Care Eligibility Verification Response

17. 17 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Eligibility Verification Response Extended Eligibility or Benefit Information includes: Primary Care Physician (PCP) information Third Party Liability (TPL) Benefit Limits Wavier Service Eligibility Information

18. 18 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Verifying Eligibility Provider's Responsibility Although you may search eligibility for past dates, AR Medicaid will only accept proof of verifying eligibility if it was checked on the date of service. Scenario: Recipient comes in office at 8:00 a.m. Your office verifies eligibility at time of visit, and eligibility shows active At 3:00 p.m., DHS terminates the coverage If you file your claim after 3:00 p.m., it will deny for no coverage AR Medicaid will process your claim only if you can provide proof of checking eligibility on the date of service. If you checked eligibility the day before or after, it will not be accepted as proof of verifying eligibility

19. 19 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Voice Response Providers can verify a beneficiary’s eligibility by calling the automated Voice Response System (VRS). By dialing the Provider Assistance Center line and selecting option 3, the VRS will retrieve recipient Medicaid eligibility, PCP and other information based on the beneficiary ID or date of birth and SSN and dates of service requested. Toll-free in Arkansas: (800) 457-4454 Local or out of state: (501) 376-2211

20. © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Plan Descriptions / Aid Categories / Benefit Limits

21. 21 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. All Medicaid beneficiaries are assigned to a plan description with corresponding levels of coverage. These are listed in Section I of the Arkansas Medicaid provider manuals. Plan Descriptions Overview

22. 22 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. FR – Full benefits MNLB – Medically needy, limited benefits AC – Additional cost sharing LB – Limited benefits Plan Descriptions General Classifications

23. 23 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Beneficiaries must be age 18 and under Beneficiaries may have limited services Beneficiaries may have co-payment requirements ARKids First-B beneficiaries have a co-pay cap. Co-pay cap is 5%, based on the family’s total gross income Plan Description 01 ARKids First-B

24. 24 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Children’s Medical Services (CMS) Plan Description 03 Services must be prior-authorized This is a non-Medicaid category

25. 25 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. This is a non-Medicaid category DDS non-Medicaid beneficiary ID numbers begin with 8888 DDS non-Medicaid provider ID numbers end with 86 Only DDS non-Medicaid providers may bill for DDS non-Medicaid beneficiaries Developmental Disability Services (DDS) Plan Description 04

26. 26 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Medically Needy Exceptional Plan Description *6 These beneficiaries are eligible for the full range of Medicaid services except: Nursing Facility Personal Care

27. 27 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Spend Down Plan Description *7 Beneficiaries must pay toward medical expenses when income and resources exceed the Medicaid financial guidelines. Plan Description 07 BCC (Breast and Cervical Cancer) has full benefits.

28. 28 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Tuberculosis (TB) Plan Description 08 Beneficiary coverage includes drugs, physician services, outpatient services, rural health clinic encounters, Federally Qualified Health Center (FQHC), and clinic visits for TB-related services only.

29. 29 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Qualified Medicare Beneficiary Plan Description *8 For QMB beneficiaries, Medicaid pays Medicare premiums, coinsurance, and deductible If the service provided is not a Medicare-covered service, then Medicaid will not pay for the service under the QMB policy 18S – ARSeniors has full benefits

30. 30 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Working Disabled Plan Description 10 Beneficiaries in aid category 10 are part of an employment initiative designed to enable people with disabilities to gain employment without losing medical benefits Beneficiaries must be ages 16 through 64 and disabled as defined by Supplemental Security Income (SSI) There are two levels of cost sharing in this aid category, depending on the individual’s income:

31. 31 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Working Disabled Plan Description 10 10 R WD RegCo (Regular Medicaid Cost Sharing): Beneficiaries with gross income below 100% of the Federal Poverty Level (FPL) are responsible for the regular Medicaid cost sharing (pharmacy, inpatient hospital and prescription services for eyeglasses) 10 N WD NewCo (New Cost Sharing): Beneficiaries with gross income equal to or greater than 100% FPL have cost sharing for more services The cost sharing amounts for the “WD NewCo” eligible's are listed in a chart that can be found in Section I of the provider manual

32. 32 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Pregnant Woman, Infants and Children Poverty Level (PW-PL) Plan Description 61 Includes both pregnant women and children. Providers must use the last three (3) digits of the Medicaid ID number to determine benefits. When the last three digits are: 100 series (101, 102, etc.) – the beneficiary is eligible as an adult for pregnancy- related services only 200 series (201, 202, etc.) – the beneficiary is eligible as a child and receives a full range of Medicaid services A pregnant teen may be eligible either as a child or as an adult. The last three digits of her ID number determine the services for which she is eligible. If the plan description is “PW Unborn Child”-no Ster cov, then there is no sterilization or family planning benefit.

33. 33 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Pregnant Woman Presumptive Eligibility (PW-PE) Plan Description 62 This is a temporary plan description that pays ambulatory, prenatal care services only. Delivery and hospitalization are not covered in this category.

34. 34 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Family Planning Waiver (FPW) Plan Description 69 Women in aid category 69 (FP-W) are eligible for most family planning services, subject to the benefit limits listed in the appropriate provider manual.

35. 35 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Specified Low Income Medicare Beneficiary (SLIMB, SMB) Plan Description 58, 78, 88 Beneficiaries are not eligible for the full range of Medicaid services Beneficiaries are eligible only for Medicaid payment of their Medicare part B premium

36. 36 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Overview Benefits Arkansas Medicaid administers over 50 programs. Here are just a few of the many benefits available to eligible beneficiaries. Physician services Inpatient hospital Outpatient hospital Lab/X-ray Prescription Therapy (OT/PT/Speech) Mental health Emergency room Long Term Care Hospice Dentistry (under age 21 and for qualifying aid categories for ages 21 +) Medical equipment

37. 37 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Physician Visits Benefit Limits Beneficiary age 21 and over – 12 visits per state fiscal year (SFY) Under age 21 – not subject to benefit limit Consults – beneficiary can receive two consults per SFY regardless of age (Note: Beneficiaries under age 21 in the Child Health Services (EPSDT) Program are eligible for extensions of the physician consultation benefit if the extension is medically necessary) See Section II of the Physician manual

38. 38 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Physician Visits Benefit Limits The following are included: Physician services in the office, patient’s home or nursing facility Rural Health Clinic (RHC) encounters Medical services provided by a dentist Medical services furnished by an optometrist Certified nurse-midwife services Advanced nurse practitioner services

39. 39 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Prescription Coverage Benefit Limits Beneficiary age 21 and over – three per month (without extension of benefits) Under age 21 – are not subject to prescription drug limit See Section II of the Physician manual

40. 40 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Lab and X-Ray Services Benefit Limits Outpatient laboratory and radiology services and machine tests: Beneficiary age 21 and over – $500 per SFY Under age 21 – no benefit limit See Section II of the Physician manual

41. 41 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Lab and X-Ray Services Benefit Limits The following are not included: Family planning Emergency services MRIs Cardiac catheterization

42. 42 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Inpatient Hospital Benefit Limits Beneficiary age 21 and over – 24 days per SFY Under age 21 – no benefit limit Rehabilitative hospital inpatient services See Section II of the Hospital manual

43. 43 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Outpatient Hospital Benefit Limits Beneficiary age 21 and over – 12 non-emergency outpatient hospital visits per SFY Under age 21 – No benefit limit Outpatient hospital and rehabilitative hospital services therapy/ treatments services are included in the non-emergency outpatient hospital services Excludes ER services See Section II of the Hospital manual

44. 44 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Pregnancy Benefit Limits Two ultrasounds per pregnancy Two fetal non-stress tests per pregnancy See Section II of the Physician manual

45. 45 © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice. Beneficiary age 21 and over – one exam and one pair of glasses every 12 months excluding replacement or repairs Beneficiary under age 21 – one exam and one pair of glasses every 12 months (not including replacement or repairs) One visual prosthetic device every 24 months from the last date of service Vision Benefit Limits See Section II of the Visual Care manual

46. Questions? © Copyright 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice.

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