Washington Apple Health Managed Care and Long-term Care
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Washington Apple Health Managed Care and Long-term Care


Revised September 8, 2014



Purpose: The Apple Health Managed Care Organization (MCO) plan is responsible to pay for nursing facility (NF) days that are considered qualifying skilled nursing or rehabilitative services. Long-term care nursing facility services (sometimes called custodial care or long term care) is paid by Aging and Long Term Supports Administration (ALTSA) as a fee for service once rehabilitation or skilled nursing days authorized by the MCO end. This section gives instructions for the financial worker (FW) when a client enrolled into Apple Health MCO admits into a NF.

NOTE:

The instructions below are intended for Home and Community Service (HCS) and Developmental Disability Administration (DDA) LTC specialty financial workers.  This section includes information for HCS and DDA social workers and case managers.

HCS and DDA do not determine  medicaid eligibility for clients on a MAGI based medical programs (N track in ACES).  The eligibility is done through the Health Benefit Exchange (HBE).

The HCS and DDA financial worker determines eligibility for Classic medicaid (Aged, Blind, Disabled) which includes  Institutional, Home and Community Based (HCB) Waiver medical programs.


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 skilled nursing or  rehabilitation under the Apple Health MCO contract.   Most long-term care assists people with support services.  (Sometimes this is called custodial care). The correct term is long term care or institutional services. 

The Apple Health MCO  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 Washington Apple Health (WAH) Managed Care (MC)?

 

All  non-institutional categorically needy (CN) medicaid clients are enrolled into a AH MCO plan with the exception of:

  • Institutional (L01, L02 )
  • 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 AH MCO enrollment is voluntary. Refer clients to their AH MCO plan for coverage issues.  (see phone numbers below). 
  • Your Washington Apple Health Medical Benefits book  lists what is covered by the health plan.

Note:  Individuals on state-funded medical care services (MCS) are not enrolled into a AH MCO.  


NOTE:

A medical benefit covered under the AH MCO plan or the fee for service (FFS) medicaid program is considered a covered service.  If a AH MCO client chooses to go outside the MCO 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.


Nursing Home admissions under a Modified Adjusted Gross Income (MAGI) Medical group

The instructions for financial workers below are limited to individuals on Classic Medicaid programs.  Classic Medicaid programs are for those who are Aged, Blind or Disabled.  About 80 + percent of individuals on Classic Medicaid programs are also receiving Medicare and are not enrolled into a MCO.  Individuals active on a MAGI-based program determined by the Health Benefit Exchange (HBE) are eligible to receive nursing facility services as part of the state plan or alternate benefit plan (ABP). The only exception is the AEM MAGI programs called N21 and N25 in ACES.  AEM does not cover NF care.

Individuals on a MAGI based program with few exceptions such as tribal affiliation are enrolled into a MCO plan the first of the month following the date the medical opened.

The MCO plan is responsible to pay for pre-approved skilled nursing and  rehabilitation in a NF.  Once skilled nursing or rehabiliation ends, the NF is paid by Provider One as a fee for service (FFS) claim. 

No NF award letter is issued for a client receiving N track MAGI based medical. 

No participation is paid to the NF provider for MAGI based clients. 

Clients on a MAGI based medical program do not have a financial worker at DSHS.  The medical for these clients is determined by the Health Benefit Exchange.

Clients on MAGI based medical must meet nursing facility level of care (NFLOC). 


What are the Washington Apple Health Managed Care Plans?

Health Plan Contact Information and Plan Abbreviations

AMG-Amerigroup Washington, Inc

Provider line: 1-800-454-3730
http://washington.joinagp.com

CHPW-Community Health Plan of Washington

Provider line: 1-800-440-1561
http://www.chpw.org/for-providers/

CCC-Coordinated Care Corporation

Provider line: 1-877-644-4613
http://www.coordinatedcarehealth.com/for-providers/become-a-provider/

MHC-Molina Healthcare of Washington, Inc.

Provider line: 1-800-869-7175
http://www.molinahealthcare.com/medicaid/providers/wa/Pages/home.aspx

UHC- UnitedHealthcare Community Plan

Provider line: 1-877-542-9231
http://www.uhccommunityplan.com/health-professionals


How does a client change a Washington Apple Health Managed Care plan?

A client can choose to change plans by contacting Health Care Authority (HCA) by the Provider One portal  or calling 1-800-562-3022. 

Any issues regarding coverage needs to be directed directly to the plan. 


How do I check to see if a Medicaid client is currently on a Washington Apple Health (WAH) managed care (MC) 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 MCO status such as change in a MCO plan, exemption data, enrollment/discharge dates. 

To see the current  MCO status, go to ACES online and check the details tab. Scroll down to "Medical Information" section.    Check to see if one of the MCO plans is indicated.  

Nursing Facility providers check for MCO plans searching in the client benefit inquiry under managed care information.  If the client is on MCO, it will show up under Plan/PCCM Name


When are long-term care clients dis-enrolled from Washington Appled Health Managed Care plan?



Clients receiving long-term care services in a NF are dis-enrolled from the AH MCO 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 AH MCO dis-enrollment.  This is usually on the 2nd to the last working day of the month. 

Even though ALTSA starts the LTC services (custodial care) once the AH MCO client's rehabilitation days are over (if otherwise eligible), AH MCO 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 AH MCO when the client is receiving skilled nursing or rehabilitation services in the NF. 

Developmental Disabilities Administration (DDA) The AH MCO plan does not cover services in a DDA state institution. 


NOTE:

The WAH MC plans do not cover medicaid personal care services (MPC) or home and community based (HCB) Waiver services for clients living in the community.  The WAH MC plan does not cover services for individuals living in a residential setting (Adult Family Home, Assisted Living, DDA Group Home).  These services are not included in the WAH MC contract and considered a "carve out".  In home care or residential services are authorized by either Home and Community Services (HCS) or the Developmental Disabilities Administration (DDA).  WAH MC clients receiving services authorized by DDA or HCS get their prescription drugs, durable medical equipment, physician services and other medical services through their WAH MC plan. 


Financial worker worker responsibilities


  • For a nursing facility admission under WAH MC, 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 WAH MC  (details tab, scroll down to medical information). 
  • If the NF admission is a WAH MC 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 WAH MC 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 MCO client.   

See short stay  information for NF admissions not under a AH MCO

30 days or more admissions

  • Once a MCO client is in a NF 30 days or more, make the necessary changes in the ACES system.
  • ACES will issue an award letter even though the client may still be receiving rehabilitative services under a MCO
  • During skilled nursing or rehabilitation days paid by the MCO, 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 ""AH Managed Care rehab admit"  and the date, if the NF reports HO rehabilitation ends, indicate WAH MC rehab end date. 

Quick Managed Care Links

Washington Apple Health Managed Care 

Managed Care Service Areas


Other LTC insurance, Third party resources information

LTC Medicare, LTC insurance, Third Party Resources, LTC partnership and SHIBA information
Modification Date: September 8, 2014