Information in CIS eligibility records is used to select individuals who must/may enroll in either the Health Choices mandatory MCOs . If an individual is not kept out of a plan because of one of the conditions listed in Section 386.12 Fee-For-Service. CIS will display which plan option the individual has. CAO staff cannot enter or change the medical assistance plan option.
CAO staff must do the following:
Let individuals know about the plans.
Answer questions about how the plans work.
Give out brochures and other information about the plans.
Tell individuals to call the contractors at their toll-free numbers for PCP selection and more information on how the program operates.
After an individual has been enrolled in a plan, the contractor running the plan has thirty days to link the individual with a PCP. If the individual does not contact the contractor at the toll-free number to select a PCP, the contractor must try to contact the individual by telephone or mail to explain the plan and help the individual select a PCP. If the contractor cannot reach the individual, the contractor must select a PCP for the individual from the area where the individual lives.
If the contractor needs to select a PCP for the individual, the contractor must use the MA paid claims history file to find a PCP the individual has already been to. Travel time from the individual’s home to the PCP’s office must be thirty minutes or less for individuals living in urban areas and sixty minutes or less for those living in rural areas.
The contractor must send all of the following to the individual :
A notice of enrollment.
An ID card with the PCP’s name, address, and phone number.
A handbook explaining how to get services from or through the PCP.
The individual may change his or her PCP for any reason. Requests for changes must be handled by the contractors. CAOs must refer individuals to the contractor at their toll-free numbers. A change becomes effective on the first day of the calendar month after the month in which the individual asked for the change, as long as the request was received by the fifteenth day of the month. If the request is received after the fifteenth day, the change becomes effective on the first day of the second month after the individual asked for the change.
The PCP may ask for an individual to be switched to another PCP , but only for good cause. For example, the PCP may ask for a change if an individual does not follow a treatment plan or if the PCP believes the individual’s medical condition could be managed better by another PCP . The PCP must send a written request for the change to the contractor who is running the plan. The PCP must keep serving the individual until the change is in effect.
An individual must be dropped from a managed care plan by the contractor or the system if the individual moves from a county covered by the plan to one not covered by the plan. An individual must also be dropped if he or she meets one of the conditions listed in Section 386.12, Fee-For-Service.
MCOs are responsible to provide payment for up to 30 days of Long Term Care (LTC) facility services (including hospital reserve days and therapeutic bed hold days) for its enrolled members. Non-timely disenrollment results in the LTC facility having problems billing for admissions greater than 30 days. When the CAO is notified of an active MA recipient’s admission to an LTC facility via an Admission and Discharge Transmittal (MA 103), a Medical Evaluation (MA 51) form, an e-mail from DMSSC Tech Support, by another CAO, or by the recipient, the following procedures should be followed:
The CAO should verify the recipient is enrolled in an MCO.
The CAO should enter a “35” or “36” facility code in CIS, if the recipient is enrolled in an MCO. This will end the MCO enrollment and allow for billing through fee-for-service procedures if the recipient is otherwise eligible for payment of LTC services.
Reminder: The Office of Long Term Living reviews all MA cases in facilities to assure that correct billing has been completed.
Updated March 11, 2013, Replacing February 14, 2012