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How do I fix this case?? Long-Term Managed Care Enrollment in iC and CARES. WSSA Conference 5/28/2009 Heidi Herziger & Linda Auchue. Topics Covered. iC Supplement for Partner Portal eligibility verification**
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WSSA Conference 5/28/2009
Heidi Herziger & Linda Auchue
**This supplemental documentation can be used in conjunction with the Resource Center PowerPoint presentation that was provided for the Centralized Enrollment Conference Calls
Clicking on “Member Search” will bring up the screen below. As you can see, this screen allows greater range of options for searching on member information – including a name search and a “sounds-like” search. Partners are encouraged to narrow their searches by as many fields as possible since search requests that produce too many results will return an error.
The Member Information screen includes the demographic information for the member, in the first two columns, as well as high level eligibility, enrollment, Medicare, TPL, and Patient Liability information. The following fields, all on the right hand side of the screen, should be noted for the LTC MCOs:
Family Care levels of care are: L04 – Non Nursing Home and L06 – Nursing Home
PACE and Partnership levels of care are: ICF/IC1, SNF/SN1 and ISN/IS1
The “Member Maintenance” Menu is shown at the bottom of the Member Information
screen. This allows the user access to more specific information for the member. By
clicking the categories on the left (Member, Managed Care, Medicare, etc…) the user will
be given sub-menu options to choose from.
In the above example, the category “Member” is selected, which reveals submenu
items of “Benefit Plan”, “Member ID Cards”, and “Member Review”.
County IM will have access to the following “Member Maintenance” Categories:
**Note: The Family Care Non-MA Benefit Plan does NOT mean that the member is a Family Care Non-MA member from 4/1/09 - 4/30/10. The Family Care Non-MA is not used for capitation payment purposes or claims editing purposes, it is just stored because of the Family Care information sent from CARES.
Where is Member Cost Share and Spenddown Information?Detailed Member cost share and spenddown information is not available at this time using the iC functionality tab. County staff can however use the Enrollment Tab (below) to verify this information.
Just below the Spenddown Information is the Cost Share
information in the Nursing Home Liability section of the
eligibility results page.
CARES send iC 1 managed care enrollment transaction a day which includes an enrollment date a disenrollment date and a level of care. So if Family Care is confirmed multiple times in 1 day as a Pass, only the last information confirmed is sent to iC.
** Remember that only 1 enrollment transaction is sent from CARES to iC each day, so if the disenrollment date and new, corrected enrollment date are both confirmed on the same date, iC will not get the disenrollment information from CARES.
Day 2 – enrollment into another managed care program
Day 2 – enrollment into the IRIS program
PACE and Partnership
Enrollment date is 2/2/09
Medicaid/NH MA budget for 01/01/09 - 02/28/09 is $1819.13
Family Care Budget in CARES
The earliest Family Care budget is effective 3/1/09 (there was another 03/09 budget that was no longer valid for this member).
Family Care – CARES confirmation dates
Family Care eligibility was never confirmed for 02/09, so the 02/09 Family Care Cost Share amount was never sent to iC.
Cost Share - iC Below is the iC Cost Share information for this member, note that there is no Waiver Cost Share, which is used for the Family Care capitation offset, for 02/09.
Systems issues specific to Family Care members:
****The exception to the solution to #2 is the 1st month of Waiver eligibility when the waiver begin date is not the 1st of the month. For the first month, the old Waiver Cost Share amount (the NH liability that was not zeroed out) will remain from the 1st of the month through the day before the Waiver MA Program Start Date. The waiver cost share amount will update with an effective date equal to the Waiver Program Start Date in CARES. A manual 3070 needs to be sent to EDS to change the Waiver Cost Share amount to the correct amount for that month. See slide 37.
This is an example of what iC looks like when a Family Care member moves from a NH to Waiver MA and the Waiver MA starts mid month, leaving a residual NH Liability Waiver Cost Share amount. Below is the NH page with the 1/13/09 NH discharge date.
Below is the first waiver page created for the member after the NH discharge date of 1/13/09 was entered and confirmed in CARES.
NH Closure in CARES – this closure also sends a $0 NH Liability (Medicaid Cost Share in interChange) to iC for 1/1/09 – 3/31/09.
Medicaid Cost Share = $0 which is the $0 NH Liability from CARES based on the NH discharge date of 1/31/09 and the NH AG closure date of 3/31/09
On 4/22/09 the ESS ran with dates for 03/09. The confirmation of this AG sent iC a Waiver cost share information for 3/6/09-3/31/09.
Family Care and Waiver budget in CARES for 3/6 – 3/31/09 match because ESS ran with dates for 03/09.
CARES and interChange Report - Temporary
* This is not a comprehensive listing of MCO reports. It is a subset of reports related to member eligibility and MCO enrollment.