Purpose: The Healthy Options (HO) managed care plan is responsible to pay for nursing facility (NF) days that are considered rehabilitative services. Long-term care nursing facility services (sometimes called custodial care) is paid by Aging and Disability Services Administration (ADSA) once rehabilitation days end.
This section gives instructions for the financial worker (FW) when a client enrolled into Healthy Options admits into a NF.
NOTE:
This section is currently under construction. Process is pending updated HCA NF billing instructions.
What are rehabilitative services?
Definition: Rehabilitative services means the planned interventions and procedures which constitute a continuing and comprehensive effort to restore an individual to the individual's former functional and environmental status, or alternatively, to maintain or maximize remaining function.
Rehabilitative services can last for a few days to several weeks as long as a physician determines a client is in need and is responding to rehabilitation.
During rehabilitation days in a NF, the client does not pay participation toward the cost of care as the Healthy Options (HO) plan is responsible to pay the NF during rehabilitation days. Individuals that are near the Medicaid resource limit, may need to be monitored by the financial worker (FW). This is the same process as a Medicare/Medicaid client receiving NF services under Medicare.
The HO contracts states: the contractor is responsible for services at nursing facilities (licensed under RCW 18.51) when nursing facility services are not covered by the DSHS Aging and Disability Services Administration and the contractor determines the NF care is more appropriate than acute hospital care. Inpatient physical rehabilitation services are included.
Once the physician, RN and/or disciplinary team determines rehabilitation days are over, the NF needs to notify the financial worker via the DSHS 15-031 notice of action and request a social service intake as ADSA is responsible for payment once rehabilitation days are over and long-term care services begin.
What are long-term care services in a NF?
Long-term care services in a NF are when an individual does not meet the criteria for rehabilitation. Most long-term care assists people with support services. (Sometimes this is called custodial care).
The Healthy Options contract does not cover long-term care services in a nursing facility. Long-term care services in a NF are approved by Home and Community Services (HCS) for medicaid eligible clients that meet nursing facility level of care (NFLOC). Medicaid eligibility for individuals needing long-term care services over 29 days is described in WAC 182-513-1315.
Who is enrolled in Healthy Options?
All non-institutional categorically needy (CN) medicaid clients are enrolled into a Healthy Options (HO) managed care plan with the exception of:
Institutional (L01, L02 )
Home and Community Based (HCB) Waiver L21, L22 (NOTE HCB Waiver clients will be enrolled in managed care around 3/2013)
Individuals that have credible coverage health insurance
Individuals on Medicare
Individuals with an approved HCA exemption requested by the client due to tribal status or on foster care services
Individuals who are living in a county where Healthy Options enrollment is voluntary. Healthy Options Service Map Refer clients to their HO plan for coverage issues. (see phone numbers below).
The Healthy Options medical benefit book lists what is covered by the health plan and what benefits are covered under the Medicaid fee for service (FFS) program.
NOTE:
A medical benefit covered under the HO plan or the fee for service (FFS) medicaid program is considered a covered service. If a HO client chooses to go outside the HO network for medical services, they are responsible to pay out of pocket. This cost is not allowed to reduce participation because it is medical care covered under the state's Medicaid plan. See WAC 182-513-1350 and allowable medical deductions, LTC.
What are the Healthy Options Plans?
Health Plan Contact Information and Plan Abbreviations
How do I check to see if a Medicaid client is currently on a Healthy Options plan?
ACES online has current real time data from Provider One on managed care. ACES online does not show historical data on any changes that have occurred in HO such as change in HO plan, exemption data, enrollment/discharge dates.
To see the current HO status, go to ACES online and check the details tab. Scroll down to "Medical Information" section. Check to see if one of the Healthy Options plans is indicated.
Nursing Facility providers check for HO plans searching in the client benefit inquiry under managed care information. If the client is on HO, it will show up under Plan/PCCM Name
When are long-term care clients dis-enrolled from Healthy Options?
Clients receiving long-term care services in a NF are dis-enrolled from Healthy Options (HO) on the first of the following month. The date is based on when the dis-enrollment by Health Care Authority (HCA) is completed. There is a deadline for HO disenrollment. This is usually on the 2nd to the last working day of the month.
Even though ADSA starts paying the LTC services (custodial care) once the HO client's rehabilitation days are over (if otherwise eligible), HO is responsible to pay for the related physician and other medical services until the effective date of dis-enrollment.
A client is not dis-enrolled from HO when the client is receiving rehabilitation services in the NF.
Division of Developmental Disabilities (DDD) RHC clients are dis-enrolled from HO once they are in the institution over 29 days. The HO plan does not cover services in a DDD state institution.
Currently Home and Community Based (HCB) Waiver clients are not enrolled in Healthy Options. If a HO client is on MPC and changed to a HCB Waiver, the system will dis-enroll the client from HO on the first of the following month.
Enrollment for the L21 and L22 group into HO is pending (projected enrollment is 3/2013).
Once the client is dis-enrolled from HO, they are considered a "fee for service" (FFS) client.
EXAMPLE
HO client enters the nursing facility under rehabilitation on 9/4/2012. On 10/15/2012, the physician determines rehabilitation days will end. The NF will notify HCA and if the client is dis-enrolled by 10/30/2012, the client will be fee for service (FFS) on 11/1/2012.
If the HO client is not disenrolled by 10/30/2012, the client will be fee for service (FFS) on 12/1/2012.
NOTE:
The Healthy Options plan does not cover medicaid personal care services (MPC) or home and community based (HCB) Waiver services for clients living in the community. The HO plan does not cover services for individuals living in a residential setting (Adult Family Home, Assisted Living, DDD Group Home). These services are not included in the Healthy Options contract and considered a "carve out". In home care or residential services are authorized by either Home and Community Services (HCS) or the Division of Developmental Disabilities (DDD). HO clients receiving services authorized by DDD or HCS get their prescription drugs, durable medical equipment, physician services and other medical services through their HO plan.
Financial worker worker responsibilities
For a nursing facility admission under HO, do not change the case to a L01, L02, L95 or L99 unless it is confirmed the client will be or projected to be in the NF 30 days or more.
If the client is on a non-institutional CN program and has been admitted to the NF, check ACES online to see if the client is on HO. (details tab, scroll down to medical information).
If the NF admission is a HO client, do a barcode tickler for 30 days from the date of admission to check the status.
Submit a 65-10 social service referral for a NFLOC determination. Even though it is not required for HO rehabilitation days, it is required to generate a NF award letter when doing a program change once a client is institutionalized 30 days or more.
Short Stays
Do not issue a short stay letter for a HO client unless the NF has submitted a DSHS 15-031 indicating rehabilitation days ended with an end date.
If the admission is under 30 days, and rehabilitation days has ended, indicate the day after the rehabilitation end date as the authorization date on the STAY screen.
A confirmation of NFLOC is required by the HCS SW before a short stay letter is issued.
Most short stay NF admissions are considered rehabilitation. If the entire short stay is under HO rehabilitation status, do not issue a short stay letter.
Indicate in the ACES narrative "HO Rehab Admit" with the date
See short stay information for NF admissions not under Healthy Options.
30 days or more admissions
Once a HO client is in a NF 30 days or more, make the necessary changes in the ACES system.
The authorization date on the INST for a recipient is normally the first date DSHS was notified of the admission. If the FW has information from the NF via 15-031 NOA that the rehabilitation days have ended, indicate the day after the rehab end date as the authorization date on the INST screen.
ACES will issue an award letter even though the client may still be receiving rehabilitative services under HO. Indicate in the text of the award letter "Healthy Options Rehabilitation Admission".
During rehabilitation days paid by HO, the client does not participate toward the cost of care. If the client is close to the resource limit, monitor the resources with the same process used as Medicare days in the NF.
Indicate in the ACES narrative "Healthy Options rehab admit" and the date, if the NF reports HO rehabilitation ends, indicate HO rehab end date.
EXAMPLE
Short Stay #1
S02/SSI related client, not on medicare admits to a NF on 11/5/2012. 15-031 NOA from NF indicates the 11/5/2012 admission under HO rehabilitation. A 2nd NOA from the NF indicates a discharge date of 11/20/2012 back home. In this example, a short stay letter is not needed. A NFLOC determination from the HCS SW is not needed. The NF admission is covered by HO.
EXAMPLE
Short Stay #2
S02/SSI related client, on Medicare admits to a NF on 11/5/2012. 15-031 NOA from NF indicates the 11/5/2012 admission date. A 2nd NOA from the NF indicates a discharge date of 11/20/2012 back home. In this example, the client is not on HO because it is a medicare client. A short stay award letter is needed in order for the NF to bill. Send a 65-10 referral for NFLOC. Once NFLOC is received, indicate the admission and discharge on the STAY screen in ACES in order to generate a short stay letter.
EXAMPLE
Short Stay #3.
S02/SSI related client not on Medicare admits to a NF on 11/5/2012. 15-031 NOA from NF indicates 11/5/2012 admission under HO rehabilitation. A 2nd NOA from the NF indicates rehabilitation days end on 11/20/2012. The FW sends a 65-10 to the HCS SW for a NFLOC determination. Set a barcode tickler to check the status on 12/4/2012. 3rd NOA from NF received indicating client discharged home on 12/1/2012. 14-443 received by the FW from the SW indicating NFLOC and discharged home on 12/1/2012 on MPC services. FW uses the short stay screen to issue the NF A/L. The payment authorization date on the STAY screen is 11/21/2012 (the day after the HO rehabilitation days end). Update the INST with MPC service information.
EXAMPLE
30 day or more admission #1
S02/SSI related client not on Medicare admits to a NF on 11/5/2012. 15-031 NOA from NF indicates 11/5/2012 admission under HO rehabilitation. A 2nd NOA from the NF indicates rehabilitation days end on 12/1/2012. The FW sends a 65-10 to the HCS SW for a NFLOC determination. Set a barcode tickler to check the status on 12/15/2012. 14-443 received by the FW from the SW indicating NFLOC and no discharge plan. FW does a program change from S02 to L02. The payment authorization date on the INST screen is 12/2/2012 (the day after the HO rehabilitation days end). Once the program change is completed, the NF award letter is generated.
EXAMPLE
30 day or more admission #2
S02/SSI related client not on Medicare admits to a NF on 11/5/2012. 15-031 NOA from NF indicates 11/5/2012 admission under HO rehabilitation. Set a barcode tickler for 12/5/2012 to check the status. 14-443 sent by SW to FW indicating NFLOC, will be in NF 30 days or more and client is still considered under rehabilitation status. The FW will need to do a program change from S02 to L02 as over 30 days. The FW does not know when HO rehabilitation days end, so indicate the first date it was known the client was admitted into the NF. Once the program change is completed, the NF award letter is generated.
The NF is responsible to get a pre-approval and contract with the HO before admitting a HO medicaid client into the NF.
The NF will send a DSHS 15-031 to the DSHS financial worker. Indicate if the admission is under HO rehabilitation.
The NF will submit the HO rehabilitation claim to Provider One as a class code XX (this section is pending confirmation of the class code number by HCA). This notifies the NF billing unit at HCA that the admission is Healthy Options rehabilitation and the claim will be paid at -0-.
The NF will request an HCS social service intake once it is projected by the NF team/physician that the HO rehabilitation status will end.
The NF will submit the claim to Provider One as a class code 20 along with the doctor's order that rehabilitation days has ended. A NF award letter is needed in the system before a NF can submit a class code 20 claim.
The NF payment unit at Health Care Authority (HCA) will notify the HCA managed care section to dis-enroll the client from HO once they are notified by the NF the rehabilitation days has ended.
How does the NF provider check the Provider One system to see if a Medicaid client is covered under a Healthy Options (HO) plan?
Log in to the Provider Portal, client benefit level (EXT Provider eligibility checker-claims submitter profile)
Search in the client benefit inquiry, go to managed care information
Under managed care information, look under Plan/PCCM Name. If Healthy Options is indicated here with an active date, the client is covered under a HO plan.
Other managed care information: WMIP and MCS admissions into a nursing facility
Managed Care (Including information on WMIP project)
Managed Care and Medical Care Services (MCS) formally Disability Lifeline-Unemployable (DL-U) (formally GA-U). Instructions for managed care and MCS-State fund medical and nursing home admissions. Note: Nursing facility rehabilitation is not covered under the state funded MCS managed care plan. A nursing home award letter will be needed for NF admissions under the MCS program. The Medical Care Services (MCS) program-also known earlier as General Assistance Unemployable or Disability Lifeline-was a mandatory managed care program operated by the Community Health Plan of Washington. Effective December 1, 2012, MCS became a voluntary managed care program. MCS clients can choose between managed care or fee for service.
LTC managed care WACs
PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE)
