HFS Issues Clarification on MMAI Program

by Polsinelli
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On August 8, 2014, the Illinois Department of Healthcare and Family Services (HFS) issued a three-page memo to long term care nursing home providers clarifying several issues regarding participation in the Medicare/Medicaid Alignment Initiative (MMAI). Key points of the memo include:

  • Rates: MCOs participating in MMAI have committed to paying providers at least the Medicaid reimbursement rate that a facility would receive under the fee-for-service system for Medicaid covered services. The MMAI will use the Resource Utilization Group (RUGS) methodology that the state implemented on January 1, 2014 for rate determination.
  • Timeline for Enrollment: On March 1, 2014, residents began voluntarily enrolling in MMAI in the Chicago-area and in Central Illinois. Based on an agreement with the nursing home industry, HFS placed nursing home residents in the later portion of the MMAI mailing to prevent automatic assignments of nursing home residents occurring before September 1, 2014. However, there may be circumstances that result in a nursing home resident being enrolled in MMAI earlier than August. For instance, a resident may call to request to be enrolled any time after January 1, 2014. Additionally, the HFS eligibility system may not yet reflect a nursing home admission, so an individual may receive the mailing earlier.
  • Opt-Out Process: Dual-eligibles may opt-out of MMAI at any time, moving the beneficiary back to regular Medicare Fee-for-Service (FFS).
  • Bed Certification: Conforming to the MMAI's goal to unify coverage, an MMAI enrollee may be placed into either a Medicaid or Medicare-certified bed.
  • Access to Prescription Drugs: To address provider concerns regarding situations in which an MCO's prior approval department is not available, HFS clarified that state law requires that Medicaid agencies and MCOs must pay for a 72-hour supply of a medicine distributed in an emergency situation regardless of whether a prior approval was issued.
  • Opportunity for Nursing Homes to Participate in MMAI/ Managed Long Term Services and Supports (MLTSS) Networks: MCOs must offer contracts to all nursing homes in their service areas. Either party may choose to limit the contract to existing residents. Additionally, nursing homes are required to have the option to terminate a contract with an MCO on 60-days' notice.
  • Moving Residents when a Facility is not in Network: HFS stated that it does not wish to cause any widespread moving of residents as a result of their transfer to managed care. Further, an enrollee may choose to maintain an existing provider relationship through a 180-day transition period. MCOs must pay for enrollees' services with pre-existing providers even if they are out of network during this transition period.
  • Continuity of Care and Care Plan Adherence: When a resident begins the transition to managed care or is between two different managed care MCOs, MCOs must pay for services in the existing care plan and any necessary changes to that plan to the extent the services are covered under the MCOs contract, until the MCO develops its own care plan. MCOs must also have a mechanism in place to receive requests for prior approval 24 hours a day, 365 days a year.
  • Nursing Home Liaison at HFS: HFS has created an inbox dedicated to Long Term Care issues and nursing home issues involving the MMAI. Questions and comments can be sent to HFS.LTC@illinois.gov.
  • Medicare Bad Debt: HFS acknowledged that under standard fee-for-service Medicare, providers were entitled to claim unpaid copays as bed debt, but that these amounts cannot be submitted to Medicare as bad debt under MMAI. HFS clarified that CMS included additional money in the MMAI capitation payments to MCOs to cover the copay amount. CMS and HFS are currently working with the MCOS to ensure that they understand that copays were part of the capitated payment. The MCOs and facilities will be responsible for negotiating how the facilities will be compensated for what they previously received under the bad debt policy.

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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