HFS Issues Clarification on MMAI Program

by Polsinelli

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.

© Polsinelli | Attorney Advertising

Written by:


Polsinelli on:

Readers' Choice 2017
Reporters on Deadline

"My best business intelligence, in one easy email…"

Your first step to building a free, personalized, morning email brief covering pertinent authors and topics on JD Supra:
Sign up using*

Already signed up? Log in here

*By using the service, you signify your acceptance of JD Supra's Privacy Policy.
Custom Email Digest
Privacy Policy (Updated: October 8, 2015):

JD Supra provides users with access to its legal industry publishing services (the "Service") through its website (the "Website") as well as through other sources. Our policies with regard to data collection and use of personal information of users of the Service, regardless of the manner in which users access the Service, and visitors to the Website are set forth in this statement ("Policy"). By using the Service, you signify your acceptance of this Policy.

Information Collection and Use by JD Supra

JD Supra collects users' names, companies, titles, e-mail address and industry. JD Supra also tracks the pages that users visit, logs IP addresses and aggregates non-personally identifiable user data and browser type. This data is gathered using cookies and other technologies.

The information and data collected is used to authenticate users and to send notifications relating to the Service, including email alerts to which users have subscribed; to manage the Service and Website, to improve the Service and to customize the user's experience. This information is also provided to the authors of the content to give them insight into their readership and help them to improve their content, so that it is most useful for our users.

JD Supra does not sell, rent or otherwise provide your details to third parties, other than to the authors of the content on JD Supra.

If you prefer not to enable cookies, you may change your browser settings to disable cookies; however, please note that rejecting cookies while visiting the Website may result in certain parts of the Website not operating correctly or as efficiently as if cookies were allowed.

Email Choice/Opt-out

Users who opt in to receive emails may choose to no longer receive e-mail updates and newsletters by selecting the "opt-out of future email" option in the email they receive from JD Supra or in their JD Supra account management screen.


JD Supra takes reasonable precautions to insure that user information is kept private. We restrict access to user information to those individuals who reasonably need access to perform their job functions, such as our third party email service, customer service personnel and technical staff. However, please note that no method of transmitting or storing data is completely secure and we cannot guarantee the security of user information. Unauthorized entry or use, hardware or software failure, and other factors may compromise the security of user information at any time.

If you have reason to believe that your interaction with us is no longer secure, you must immediately notify us of the problem by contacting us at info@jdsupra.com. In the unlikely event that we believe that the security of your user information in our possession or control may have been compromised, we may seek to notify you of that development and, if so, will endeavor to do so as promptly as practicable under the circumstances.

Sharing and Disclosure of Information JD Supra Collects

Except as otherwise described in this privacy statement, JD Supra will not disclose personal information to any third party unless we believe that disclosure is necessary to: (1) comply with applicable laws; (2) respond to governmental inquiries or requests; (3) comply with valid legal process; (4) protect the rights, privacy, safety or property of JD Supra, users of the Service, Website visitors or the public; (5) permit us to pursue available remedies or limit the damages that we may sustain; and (6) enforce our Terms & Conditions of Use.

In the event there is a change in the corporate structure of JD Supra such as, but not limited to, merger, consolidation, sale, liquidation or transfer of substantial assets, JD Supra may, in its sole discretion, transfer, sell or assign information collected on and through the Service to one or more affiliated or unaffiliated third parties.

Links to Other Websites

This Website and the Service may contain links to other websites. The operator of such other websites may collect information about you, including through cookies or other technologies. If you are using the Service through the Website and link to another site, you will leave the Website and this Policy will not apply to your use of and activity on those other sites. We encourage you to read the legal notices posted on those sites, including their privacy policies. We shall have no responsibility or liability for your visitation to, and the data collection and use practices of, such other sites. This Policy applies solely to the information collected in connection with your use of this Website and does not apply to any practices conducted offline or in connection with any other websites.

Changes in Our Privacy Policy

We reserve the right to change this Policy at any time. Please refer to the date at the top of this page to determine when this Policy was last revised. Any changes to our privacy policy will become effective upon posting of the revised policy on the Website. By continuing to use the Service or Website following such changes, you will be deemed to have agreed to such changes. If you do not agree with the terms of this Policy, as it may be amended from time to time, in whole or part, please do not continue using the Service or the Website.

Contacting JD Supra

If you have any questions about this privacy statement, the practices of this site, your dealings with this Web site, or if you would like to change any of the information you have provided to us, please contact us at: info@jdsupra.com.

- hide
*With LinkedIn, you don't need to create a separate login to manage your free JD Supra account, and we can make suggestions based on your needs and interests. We will not post anything on LinkedIn in your name. Or, sign up using your email address.