Verifying Medicaid Recipient Eligibility - The Family Network on ...

<strong>Verifying</strong> <strong>Medicaid</strong>
<strong>Recipient</strong> <strong>Eligibility</strong>
Bureau of <strong>Medicaid</strong> Services &
Area <strong>Medicaid</strong> Program Offices
September 2011

How Do I Ask Questions
During this Teleconference?
• Any questions that arise during the
teleconference may be emailed to Mr. Harold
Walker at: Harold.Walker@ahca.myflorida.com.
• We will answer as many questions as possible
during the teleconference, in addition,
responses to all questions will be posted at:
http://ahca.myflorida.com/<strong>Medicaid</strong>/elibrary/index.shtml.
1

Objectives
• Present a general overview about how to verify
<strong>Medicaid</strong> recipient eligibility.
• Increase understanding of the different
<strong>Medicaid</strong> benefit categories.
• Increase understanding of the importance to
verify <strong>Medicaid</strong> recipient eligibility each time
you render services.
2

Section 1
Presentation Outline
• Determination of <strong>Eligibility</strong>
Section 2
• <strong>Medicaid</strong> Reimbursement
Section 3
• Ways to Access <strong>Recipient</strong> Information
3

Section 4
Presentation Outline
• Benefit Plans and Program Codes
• Programs with full <strong>Medicaid</strong> benefits
• Programs with limited <strong>Medicaid</strong> benefits
Section 5
• Steps to Verify <strong>Eligibility</strong>
Section 6
• Summary and Resources
4

Section 1
Determination of
<strong>Eligibility</strong>
5

Determination of <strong>Eligibility</strong>
<strong>The</strong> Agency for Health Care Administration (AHCA)
does not determine eligibility for <strong>Medicaid</strong>.
<strong>Eligibility</strong> is determined by the following state and
federal agencies:
• <strong>The</strong> Social Security Administration determines
eligibility for Supplemental Security Income (SSI).
<strong>Recipient</strong>s of SSI are automatically eligible for
<strong>Medicaid</strong>.
6

Determination of <strong>Eligibility</strong>, cont’d
• <strong>The</strong> Florida Department of Children and Families
determines eligibility for:
• low-income children and families
• low-income individuals who are age 65 and older
• disabled persons, and
• persons seeking institutional care.
• Florida Department of Health determines eligibility
for the <strong>Family</strong> Planning Waiver.
7

Determination of <strong>Eligibility</strong>, cont’d
• Presumptive <strong>Eligibility</strong> for Pregnant Women (PEPW) is
determined by qualified provider agencies designated by the
Department of Children and Families, including:
• County Health Departments (CHD)
• Regional Perinatal Intensive Care Centers (RPICC), and
• Other agencies that have been approved, upon request by
DCF.
8

Determination of <strong>Eligibility</strong>, cont’d
Florida Healthy Kids Corporation determines eligibility for
the Title XXI programs:
• MediKids,
• Healthy Kids, and
• Title XXI Children’s Medical Services <strong>Network</strong>.
• MediKids is a <strong>Medicaid</strong> look-alike program administered by
AHCA, for children 1 through 4 who are not eligible for
<strong>Medicaid</strong>. MediKids children receive <strong>Medicaid</strong> services and
access services through <strong>Medicaid</strong> managed care plans.
• Individuals can apply on-line at: www.floridakidcare.org
9

<strong>Eligibility</strong> Determination Process
Persons applying for assistance at DCF
• Can apply on-line at:
http://www.myflorida.com/accessflorida or by
submitting a paper application.
• DCF determines eligibility, notifies
individual/family.
• If <strong>Medicaid</strong> eligible, DCF transmits data to
Florida <strong>Medicaid</strong> Management Information
System (FMMIS).
10

<strong>Eligibility</strong> Determination Process,
cont’d
Persons applying at Social Security for SSI
• SSA determines eligibility.
• SSA notifies individual/family.
• Transmits data to FMMIS via the State Data
Exchange.
11

Medicare Verification
Just having a Medicare number does not mean the person has
Medicare. To confirm if an individual has Medicare check for
Medicare Part “A”, Part “B”, or “A & B” coverage.
Medicare
AB
Medicare #99999999A
This example shows that the individual has both a Medicare
number and coverage for Parts A and B.
12
12

For more information about who may qualify for Medicare go to:
www.medicare.gov
13
13

Section 2
<strong>Medicaid</strong>
Reimbursement
14

FMMIS
<strong>The</strong> Florida <strong>Medicaid</strong> Management Information
System (FMMIS) is the system that:
• contains information about the recipient’s
<strong>Medicaid</strong> eligibility,
• maintains Florida <strong>Medicaid</strong> provider
information,
• processes claims, and
• makes payments to <strong>Medicaid</strong> providers.
15

<strong>Medicaid</strong> reimburses <strong>Medicaid</strong>
providers for services rendered
to <strong>Medicaid</strong> eligible recipients.
Not all recipients are eligible for
all services.
16

<strong>Medicaid</strong> will not
reimburse a provider for
a service unless FMMIS
shows that a recipient is
eligible for <strong>Medicaid</strong> on
the date of service.
17

It is the provider’s
responsibility to verify a
patient’s <strong>Medicaid</strong>
eligibility prior to
providing any <strong>Medicaid</strong>
reimbursable services.
18

Card Not Proof of <strong>Eligibility</strong>
• Possession of a <strong>Medicaid</strong> ID card does not
mean a recipient is eligible for <strong>Medicaid</strong>
services.
• A provider should verify a recipient’s eligibility
each time the recipient receives services.
• <strong>Medicaid</strong> will not reimburse a provider for any
service rendered on a day on which the recipient
of that service was ineligible.
19

Section 3
Ways to Access
<strong>Recipient</strong>
Information
20

Ways to Access
<strong>Recipient</strong> Information
<strong>Eligibility</strong> and benefit information is available to
providers via the following:
• Point of Sale (POS) devices;
• Computer software that can be added to a
personal computer;
• Automated voice response that generates a
report with all the eligibility information for a
particular recipient, which can be faxed to the
provider’s fax machine;
21

Ways to Access
<strong>Recipient</strong> Information , cont’d
• Automated voice response that provides eligibility
information using a touch-tone telephone;
• PDA at https://evs.flmmis.com (only a registered
provider with a PDA will have access to this site);
• X12N 270/271 Health Care <strong>Eligibility</strong> Benefit Inquiry
and Response; and
• <strong>The</strong> secure area on the <strong>Medicaid</strong> fiscal agent’s Web
Portal.
22

Where to Find <strong>Eligibility</strong>
Training Information
• Training on verifying eligibility using the fiscal
agent Web Portal can be found at:
http://portal.flmmis.com/FLPublic/Portals/0/St
aticContent/Public/Training/Web_Portal_CBT
_Lesson_4_-_<strong>Eligibility</strong>.exe
23

http://portal.flmmis.com/FLPublic/Portals/0/StaticContent/Public/Traini
ng/Web_Portal_CBT_Lesson_4_-_<strong>Eligibility</strong>.exe
This lesson introduces you to the information available from
the <strong>Eligibility</strong> menu in the Web Portal. You will learn how to
look up the eligibility status of recipients by using information
such as <strong>Recipient</strong> ID, Birth Date, Gender, Card Control
Number, Social Security Number, <strong>Recipient</strong> Name, and Date
of Service.
24

Information Available
<strong>The</strong> following recipient eligibility information is available
through all the listed Ways to Access <strong>Recipient</strong>
Information for dates of service within the past 12
months:
• <strong>Medicaid</strong> program code
• Hospital and other service limitations
• Managed care membership
• Third party insurance coverage and policy number
• Medicare number
• Medicare Part A & B coverage
• Nursing home status
25

<strong>The</strong> provider should record
the recipient’s <strong>Medicaid</strong> ID
number and other relevant
information obtained from
the eligibility verification for
billing and compliance
purposes.
26

Section 4
Benefit Plans and
Program Codes
27

What is a Benefit Plan?
• “Benefit Plan” is a term used by <strong>Medicaid</strong> to define the
scope of benefits an individual is eligible to receive.
• <strong>The</strong> aid category for an individual defines which Benefit
Plan (or Plans) the person has.
• A person may be in more than one Benefit Plan during
the same period.
• When the individual is in more than one Benefit Plan for
the date(s) of service for a claim, FMMIS determines
under which Plan to pay the claim, using a Benefit Plan
Hierarchy.
28

<strong>Eligibility</strong> Program Codes
<strong>The</strong> <strong>Medicaid</strong> program for which a recipient is
eligible is identified on the FMMIS by a unique
alpha identifier called a program code.
<strong>The</strong> provider needs to know a recipient’s
program code before providing services,
because some program codes indicate benefit
limitations.
29

Programs with
Full <strong>Medicaid</strong>
Benefits
30

BENEFIT
PLAN
DESCRIPTION
PROGRAM
CODES
BENEFITS
SSI
Supplemental
Security Income
recipients, full
<strong>Medicaid</strong>.
MS
FULL MEDICAID
BENEFITS
Can be in multiple Benefit
Plans.
This is not a long
term care (LTC)
plan - except for
Level of Care X
Medicare
coinsurance.
If an SSI recipient has
Medicare, the “QMB” may
not be listed, but they are
automatically considered
Qualified Medicare
Beneficiaries.
31

BENEFIT
PLAN
DESCRIPTION PROGRAM CODES BENEFITS
Title XIX
Full <strong>Medicaid</strong>,
not Long
Term Care
(LTC)
MCAE
MCAN
ME I
MH P
MM S
MO P
MP C
MRHH
MRIM
MRMP
MRPN
MT D
MX
MB C
ME C
ME T
MH S
MM T
MO S
MP N
MRHM
MRIP
MRMS
MRR
MT S
MA I
MCFE
MH A
MM C
MN
MO T
MP U
MRHP
MRIT
MRMT
MS
MT W
MA R
MCFN
MH H
MM I
MO A
MO U
MREI
MRIA
MRMC
MRN
MT A
MW A
MA U
MI T
MH M
MM P
MO D
MO Y
MRHA
MRII
MRMI
MROT
MT C
MW C
FULL MEDICAID
BENEFITS
Can be in multiple
Benefit Plans.
32
32

BENEFIT
PLAN
DESCRIPTION PROGRAM CODES BENEFITS
LTC Long Term Care MI I
MI S
MI M
MI P
MI A
(any aid
category that
starts with MI,
except for MI T)
FULL MEDICAID
BENEFITS- must be in LTC
“MI” program code for
nursing facility, ICF/DD,
swing bed facility, and rural
hospital nursing facility bed.
EXCEPTION: eligible for
LOC X if SSI or has QMB
coverage.
Can be in multiple Benefit
Plans.
33
33

Programs with
Limited <strong>Medicaid</strong>
Benefits
34

Programs with
Limited <strong>Medicaid</strong> Benefits
PROGRAM PROGRAM CODES BENEFITS
Emergency <strong>Medicaid</strong> for
Aliens (EMA)
MLA, MLS, NLA, NLS
Eligible for emergency
services.
<strong>Family</strong> Planning Waiver FP Eligible for family
planning services.
35

Programs with
Limited <strong>Medicaid</strong> Benefits, cont’d
PROGRAM
PROGRAM
CODES
BENEFITS
MediKids MKA, MKB, MKC Eligible for all <strong>Medicaid</strong>
benefits except home and
community-based waiver
services.
Presumptively
Eligible Pregnant
Woman (PEPW)
MU
Eligible for outpatient, office
services, and transportation.
<strong>The</strong> woman must be
determined eligible for
another program for
<strong>Medicaid</strong> to cover inpatient
and delivery services.
36

Programs with
Limited <strong>Medicaid</strong> Benefits, cont’d
PROGRAM
Non-Institutional Care
Only
Qualified Medicare
Beneficiaries
PROGRAM
CODES
MIT, MRIT
QMB, QMBR
BENEFITS
Eligible for all services
except nursing facility,
swing bed, rural hospital
nursing facility services,
and HCBS waiver
services.
Eligible for payment of
Medicare premiums,
deductibles and
coinsurance within limits.
37

Programs with
Limited <strong>Medicaid</strong> Benefits, cont’d
PROGRAM
Special Low Income
Medicare Beneficiary
SLMB
PROGRAM
CODES
BENEFITS
Eligible for payment of
Medicare Part B premium
only.
Qualified Individuals I QI1 Eligible for payment of
Medicare Part B premium
only.
Note on:
SLMB and QI1
<strong>Recipient</strong>s may be eligible
for SLMB or QI1 and a full
<strong>Medicaid</strong> coverage
program for the same date
of service.
38

Programs with
Limited <strong>Medicaid</strong> Benefits, cont’d
PROGRAM
Medically Needy
PROGRAM CODES
Program codes that begin with “N”.
NLS and NLA are designation codes
for Emergency <strong>Medicaid</strong> for Aliens
(EMA) who also are Medically needy
recipients.
39

Medically Needy
• A Medically Needy recipient is an individual who would
qualify for <strong>Medicaid</strong>, except that the individual’s income
or resources exceed <strong>Medicaid</strong>'s income or resource
limits.
• A Medically Needy recipient becomes eligible on the day
that the recipient incurs allowable medical expenses that
equal or exceed the amount by which his income
exceeds the <strong>Medicaid</strong> income standard (share of cost).
40

Medically Needy, cont’d
Period of Medically Needy <strong>Eligibility</strong>
• On a month-by-month basis, the individual’s medical
expenses are subtracted from the individual’s income,
and if the remainder falls below <strong>Medicaid</strong>’s income
limits, the individual may qualify for <strong>Medicaid</strong>.
Coverage begins from the date the medical expenses
meet or exceed the share of cost until the end of the
month.
• <strong>The</strong> recipient must submit his medical bills to DCF,
and DCF makes the eligibility determination.
• <strong>The</strong> recipient will be eligible through the end of the
month.
41

Medically Needy, cont’d
Month of <strong>Eligibility</strong>
A Medically Needy recipient may be
eligible for a full month or part of a
month. <strong>The</strong> provider must check the
recipient’s eligibility before providing
services.
42

Section 5
Steps to Verify
<strong>Eligibility</strong>
43

Follow <strong>The</strong>se Steps:
• Read and review all the eligibility information.
• Confirm whether the recipient is enrolled in
managed care or fee-for-service.
• Check whether recipient has full <strong>Medicaid</strong>
coverage or limited benefits.
• Verify that the recipient is <strong>Medicaid</strong> eligible on
date of service and for the specific <strong>Medicaid</strong>
service.
• Make sure that you document the verification of
recipient eligibility.
44

Enhanced Benefit Account
For over the counter medical supplies; only in
counties with Florida <strong>Medicaid</strong> Reform Health
Plans. This is not a <strong>Medicaid</strong> eligibility code.
45
45

Read and review
all the eligibility
information.
46

Sample of resulting error when only the first
lines are read when verifying eligibility.
47
47

Read all the information, not just the first lines.
48
48

Managed Care Coverage
A provider must verify
whether the recipient is
enrolled in a managed care
program or fee-for-service
prior to delivering services
and bill accordingly.
49

Sample – Full <strong>Medicaid</strong> Eligible enrolled in
Managed Care
50
50

Managed Care
Enrollment Verification
• For certain managed care plans the provider must
receive authorization before rendering certain services.
• If recipients are enrolled in Health Maintenance
Organizations (HMOs) and Provider Service <strong>Network</strong>s
(PSNs), they are required to use a contracted network
provider for all of their medical services, except
emergency services.
51

Managed Care
Enrollment Verification, cont’d
• For service authorization or contracting opportunities,
providers should contact the plan.
• Services provided to recipients enrolled in managed
care should be billed to the health plan directly.
• If the recipient is in a managed care plan and the
provider bills <strong>Medicaid</strong> instead of the managed care plan
for covered services, any resulting <strong>Medicaid</strong> fee-forservice
reimbursements are overpayments.
52

Managed Care
Enrollment Verification, cont’d
Overpayment
An overpayment includes any amount that is not
authorized to be paid by the <strong>Medicaid</strong> program
whether paid as a result of inaccurate or improper
cost reporting, improper claims, unacceptable
practices, fraud, abuse or mistake.
53

Managed Care
Enrollment Verification , cont’d
• For MediPass, the provider must obtain authorization from the
MediPass primary care provider. <strong>The</strong> provider must enter the
MediPass authorization number on the claim when billing for
the service.
54

A word about dental
services
55

Non-Reform Health Plans that Cover
State Plan Dental Services
• Please remember that non-Reform health plans may
choose to cover State Plan dental services.
• This is referred as "optional dental.”
• If they choose to cover State Plan dental, then they
receive extra capitation and are responsible for all
State Plan dental services detailed in the <strong>Medicaid</strong>
Dental Services Coverage and Limitations
Handbook.
56

Non-Reform Health Plans that Cover
State Plan Dental Services, cont’d
• <strong>The</strong> following health plans currently cover optional
(State Plan) dental services in all of their non-Reform
counties of operation:
• JMH Health Plan
• Healthy Palm Beaches, Inc.
• Integral Quality Care
• Sunshine State Health Plan, Inc.
• Molina Healthcare of Florida, Inc.
• Please be careful to request service authorization and to
bill accordingly.
57

Always check
whether the
recipient has full
<strong>Medicaid</strong> coverage
or limited benefits.
58

Verify that the recipient
is <strong>Medicaid</strong> eligible on
date of service and for
the specific <strong>Medicaid</strong>
service.
59

Sample – Medically Needy and not eligible
for Long Term Care or HCBS waiver services.
60
60

Eligible for SSI <strong>Medicaid</strong> and Home and Community Based
Services. <strong>Recipient</strong> is not eligible for the assistance category MI
and its associated codes that indicate Long Term Care.
As the recipient is QMB eligible, a provider can bill for Level of Care
X (Medicare coinsurance).
61
61

Important
Do not rely on FMMIS to deny a
claim when processing the
payment for recipient who is not
eligible on the date of service.
Providers run the risk of being
overpaid and having the payment
recouped.
62

Section 6
Summary and
Resources
63

SUMMARY
When <strong>Verifying</strong>
<strong>Medicaid</strong> <strong>Eligibility</strong>
Answer the Following
Questions:
64

• Did you accurately check recipient
eligibility?
• Is the recipient currently enrolled in Managed
Care?
• Does the recipient have full or limited benefits?
• Is the recipient eligible for the date of service
and the specific <strong>Medicaid</strong> service?
65

• Is the service in the <strong>Medicaid</strong> fee schedule for
your provider type?
• Does the service require a prior authorization?
• Did you document the verification of recipient
eligibility?
• Are you relying on FMMIS to deny the claim if
the recipient is not eligible on the date of
service?
66

Important DCF
Resources
67

DCF Provider
View Link
<strong>The</strong> provider web portal provides DCF ACCESS
provider view.
• This application provides a link to the DCF My
ACCESS Account Provider View where providers
can search and view <strong>Medicaid</strong> recipient
information.
68

DCF Provider
View Link, cont’d
• Please note that you cannot use DCF provider view to
confirm <strong>Medicaid</strong> eligibility; you must use the methods
described on the previous slides.
• DCF provider view does not provide <strong>Medicaid</strong> eligibility
information for SSI recipients; information may be in
DCF provider view but not in FMMIS.
• <strong>The</strong> information must be in FMMIS to be used to
adjudicate claims.
• If information is in DCF provider view and not in
FMMIS, contact your AHCA Area <strong>Medicaid</strong> Program
Office.
69

DCF Provider
View Link, cont’d
Download the “DCF ACCESS Provider View” System Guide at:
http://www.dcf.state.fl.us/programs/access/docs/MYACCESSAccountProviderView.pdf
70

DCF Provider
View Link, cont’d
<strong>The</strong> DCF provider view link allows you to:
• View current benefits
• View the date benefits will be available
• See when the next review is due
• See when an appointment is scheduled
• View <strong>Medicaid</strong> account history
• View a list of verifications needed
• View Personal Identification Number (PIN)
71

DCF Provider
View Link, cont’d
• <strong>The</strong> information displayed in the customer’s account is
stored nightly. Changes made during the day are
available for you to view the following day. <strong>The</strong> date of
the information is displayed at the top of the account
status screens for your reference.
• DCF provider view link does not allow you to obtain
information on <strong>Medicaid</strong> eligibility for SSI recipients.
72

Other <strong>Medicaid</strong>
Resources
73

Online Information
All <strong>Medicaid</strong> handbooks, fee schedules, forms, provider
notices, and other important <strong>Medicaid</strong> information are
available on the <strong>Medicaid</strong> fiscal agent’s Web Portal at:
http://mymedicaid-florida.com/
Click on Public Information for Providers, then on
Provider Support, and then click on Provider
Handbooks, Fee Schedules, Forms, or Provider
Notices.
74

75
75

Important Information
for <strong>Medicaid</strong> <strong>Eligibility</strong>
Verification
Florida
<strong>Medicaid</strong>
Provider
General
Handbook
Chapter 3
<strong>Medicaid</strong>
<strong>Recipient</strong>
<strong>Eligibility</strong>
77

Bureau of Managed
Health Care
Additional information about HMOs, PSNs and Prepaid Dental
Health Plans (PDHP) is available on the Bureau of Managed
Health Care’s website at:
.
http://ahca.myflorida.com/MCHQ/Managed_Health_Care/MHMO/index.shtml
78

http://www.mymedicaid-florida.com/
<strong>The</strong> Agency has thirteen <strong>Medicaid</strong> Area Offices in eleven
areas throughout the state that serve as the local liaisons
to providers and recipients. <strong>The</strong> area offices help with:
• Provider relations and training.
• Consumer relations.
• Conducting site visits to providers and potential
providers.
• Handling exceptional claims processing.
79
79

How Do I Ask Questions
During this Teleconference?
• Any questions that arise during the
teleconference may be emailed to Mr. Harold
Walker at: Harold.Walker@ahca.myflorida.com
• We will answer as many questions as possible
during the teleconference, in addition,
responses to all questions will be posted at:
http://ahca.myflorida.com/<strong>Medicaid</strong>/elibrary/index.shtml.
80