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


Revised January 22, 2014


(formally called Healthy Options)


Purpose: The Washington Apple Health (WAH) managed care (MC) plan is responsible to pay for nursing facility (NF) days that are considered qualifying 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 days end. This section gives instructions for the financial worker (FW) when a client enrolled into WAH MC 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.

Consult the LTC overview program responsibility chart


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 Washington Apple Health (WAH) Managed Care (MC) 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 WAH MC 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 it is determined that rehabilitation days are over and no longer covered by the plan,  the NF needs to notify the financial worker via the DSHS 15-031  notice of action and request a social service intake as ALTSA is responsible to authorize 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 correct term is long term care or institutional services. 

The WAH Managed Care (MC) 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 WAH MC 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 WAH MC enrollment is voluntary. Refer clients to their WAH MC plan for coverage issues.  (see phone numbers below). 
  • Your Washington Apple Health Medical Benefits book  lists what is covered by the health plan.

NOTE:

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

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 WAH MC plan the first of the month following the date the medical opened.

The WAC MC plan is responsible to pay for rehabilitation in a NF.  Once rehabiliation ends, the NF is paid by Provider One as a 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.


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 WAH MC such as change in a WAH MC plan, exemption data, enrollment/discharge dates. 

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

Nursing Facility providers check for WAH MC plans searching in the client benefit inquiry under managed care information.  If the client is on WAH MC, 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 WAH MC  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 WAH MC 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 WAH MC client's rehabilitation days are over (if otherwise eligible), WAH MC 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 WAH MC when the client is receiving rehabilitation services in the NF. 

Developmental Disabilities Administration (DDA) RHC clients are dis-enrolled from WAH MC once they are in the institution over 29 days.  The WAH MC plan does not cover services in a DDA state institution. 

Once the client is dis-enrolled from WAH MC, they are considered a "fee for service" (FFS) client. 


EXAMPLE

WAH MC client enters the nursing facility under rehabilitation on 9/4/2012.  On 10/15/2012, it is determined (by the plan) that 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 client is not dis-enrolled by 10/30/2012, the client will be fee for service (FFS) on 12/1/2012.

 


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 WAH MC 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.  Add text to the short stay letter WAH MC rehabilitation day ends on XX-XX-19XX (enter date).
  • 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 "WAH MC  Rehab Admit" with the date

 

See short stay  information for NF admissions not under WAH MC

30 days or more admissions

  • Once a WAH MC 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 WAH MC.  Indicate in the text of the award letter "Washington Apple Health Managed Care Rehabilitation Admission". 
  • During rehabilitation days paid by WAH MC, 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 "WAH Managed Care rehab admit"  and the date, if the NF reports HO rehabilitation ends, indicate WAH MC 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 WAH MC  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 WAH MC 


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 WAH MC because the client is on medicare.   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 WAH MC  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 WAH MC 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 WAH MC 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 WAH Mc 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 WAH MC 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 WAH MC 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


Nursing Facility Responsibilities

 
  • The NF is responsible to check the system to see if a Medicaid client is enrolled in a WAH MC plan prior to admission into the NF.  WAC 182-501-0200 Third Party Resources and WAC 182-502-0100 General Conditions of payment describe that Medicaid fee for service is the payer of last resort. 
  • The NF is responsible to get a pre-approval and contract with the WAH MC before admitting a WAH MC client into the NF.
  • The NF will send a DSHS 15-031  to the DSHS financial worker. Indicate if the admission is under WAH MC rehabilitation. 
  • The NF will submit the WAH MC rehabilitation claim to Provider One as a class code 55.   This notifies the NF billing unit at HCA that the admission is WAH MC rehabilitation and the claim will be paid at -0-.
  • The NF will request an HCS social service intake once it is projected that the WAH MC rehabilitation status will end.
  • The NF will submit the claim to Provider One as a class code 20 along with the verification from the WAH MC plan 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 Washington Apple Health Managed Care 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 WAH MC is indicated here with an active date, the client is covered under a WAH MC plan. 

Provider Billing Guides:


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)
388-106-0700 What services may I receive under PACE?
388-106-0705 Am I eligible for PACE services?
388-106-0710 How do I pay for PACE services?
388-106-0715 How do I end my enrollment in the PACE program?
WASHINGTON MEDICAID INTEGRATION PARTNERSHIP (WMIP)
388-106-0745 What services may I receive under WMIP?
388-106-0750 Am I eligible to enroll in WMIP?
388-106-0755 How do I pay for WMIP services?
388-106-0760 How do I dis-enroll from WMIP?
388-106-0765 What is the fair hearing process for enrollee appeals of managed care organization actions?

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: January 22, 2014