Managed Care - GAU Managed Care Statewide Expansion

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Managed Care - GAU Managed Care Statewide Expansion

Revised November 5, 2009

Purpose: Beginning November 1, 2009, most General Assistance-Unemployable (GA-U) recipients will access Medical Care Services (MCS) benefits through Community Health Plan of Washington (CHP). CHP has been providing medical benefits to GA-U recipients in King and Pierce Counties since January 2005 through a managed care pilot project. A mental health component was added to the pilot in December 2007.

WAC 388-538-063

CLARIFYING INFORMATION

Mandatory Managed Care

Enrollment with CHP is mandatory for all GA-U recipients except:

a.       Native Americans/Alaskan Natives.

b.      Legal immigrants.

c.       Nursing facility residents.

Native Americans/Alaskan Natives may choose to enroll in CHP. Legal immigrants are exempt due to Provider One coding change restrictions, and will be mandatory enrollees once the necessary changes can be made by Provider One.

2.       CHP Coverage

CHP managed care benefits include the following components

a.       MCS medical benefits.

b.      Mental health care.

c.       A 24/7 nursing hotline.

d.      Care coordination.

3.       Enrollment

a.       GA-U recipients are generally enrolled into managed care the month after being determined eligible. If the date is after Health and Recovery Service Administration's (HRSA) cutoff, the individual will be enrolled for the following month.

b.      GA-U recipients enrolled in managed care must choose a clinic and Primary Care Provider (PCP) with CHP or they will be assigned to one. The PCP will ensure the person receives the Medical Care Services (MCS) current scope of care by providing the medical services or referring the person to other medical providers.

c.       GA recipients who are eligible for Medicaid (GA-X, GA-D, GA-A, GA-B, GA-R and GA-I) will remain in fee-for-service medical coverage and are not eligible for managed care.

WORKER RESPONSIBILITIES

1.       Nursing Facility Residents

Once eligibility is determined for a GA-U recipient, who is residing in, or being admitted to, a nursing facility:

a.       The HCS financial worker will notify Becky McAninch-Dake by email at mcanibj@dshs.wa.gov to exempt the individual from managed care.

b.      The email will include the person’s name, ACES CLID or PIC code, facility name, admission date, and estimated discharge date.

c.       If the recipient has been enrolled in GAU Managed Care, and is admitted to a nursing home, the nursing home must coordinate the member’s care with CHP to provide medical services.

2.      Native Americans/Alaskan Natives

a.       Native Americans/Alaskan Natives who self identifies a tribal affiliation will not be automatically enrolled in managed care.

b.      See Worker Responsibilities in the TANF/SFA Time Limits – Indian Country Disregard section of the EAZ Manual for instructions on asking about and recording tribal affiliation.

c.       Native Americans/Alaskan Natives who wish to be enrolled in managed care may call to the Medical Assistance Customer Service Center (MACSC) at 1-800-562-3022.

3.       DASA Facilities

a.       If a GA-U recipient is residing a state approved DASA facility that can’t work with CHP to provide medical care, the individual will be exempted while residing in the facility.

4.      Medical Needs Exemptions

a.       GA-U recipients may also call the MACSC line to request a medical needs exemption.

b.      MACSC will process the member’s request for an exemption by determining need and the ability of CHPW to provide continuity of care.

c.       If the member’s exemption request is allowable within mandatory managed care parameters, MACSC will process the exemption request for the next available month, according to HRSA’s cut off dates.

Managed Care - GAU Managed Care Statewide Expansion
Revised November 5, 2009

Purpose: Beginning November 1, 2009, most General Assistance-Unemployable (GA-U) recipients will access Medical Care Services (MCS) benefits through Community Health Plan of Washington (CHP). CHP has been providing medical benefits to GA-U recipients in King and Pierce Counties since January 2005 through a managed care pilot project. A mental health component was added to the pilot in December 2007.
WAC 388-538-063
CLARIFYING INFORMATION Mandatory Managed Care Enrollment with CHP is mandatory for all GA-U recipients except: a. Native Americans/Alaskan Natives. b. Legal immigrants. c. Nursing facility residents. Native Americans/Alaskan Natives may choose to enroll in CHP. Legal immigrants are exempt due to Provider One coding change restrictions, and will be mandatory enrollees once the necessary changes can be made by Provider One. 2. CHP Coverage CHP managed care benefits include the following components a. MCS medical benefits. b. Mental health care. c. A 24/7 nursing hotline. d. Care coordination. 3. Enrollment a. GA-U recipients are generally enrolled into managed care the month after being determined eligible. If the date is after Health and Recovery Service Administration's (HRSA) cutoff, the individual will be enrolled for the following month. b. GA-U recipients enrolled in managed care must choose a clinic and Primary Care Provider (PCP) with CHP or they will be assigned to one. The PCP will ensure the person receives the Medical Care Services (MCS) current scope of care by providing the medical services or referring the person to other medical providers. c. GA recipients who are eligible for Medicaid (GA-X, GA-D, GA-A, GA-B, GA-R and GA-I) will remain in fee-for-service medical coverage and are not eligible for managed care.
WORKER RESPONSIBILITIES 1. Nursing Facility Residents Once eligibility is determined for a GA-U recipient, who is residing in, or being admitted to, a nursing facility: a. The HCS financial worker will notify Becky McAninch-Dake by email at mcanibj@dshs.wa.gov to exempt the individual from managed care. b. The email will include the person’s name, ACES CLID or PIC code, facility name, admission date, and estimated discharge date. c. If the recipient has been enrolled in GAU Managed Care, and is admitted to a nursing home, the nursing home must coordinate the member’s care with CHP to provide medical services. 2. Native Americans/Alaskan Natives a. Native Americans/Alaskan Natives who self identifies a tribal affiliation will not be automatically enrolled in managed care. b. See Worker Responsibilities in the TANF/SFA Time Limits – Indian Country Disregard section of the EAZ Manual for instructions on asking about and recording tribal affiliation. c. Native Americans/Alaskan Natives who wish to be enrolled in managed care may call to the Medical Assistance Customer Service Center (MACSC) at 1-800-562-3022. 3. DASA Facilities a. If a GA-U recipient is residing a state approved DASA facility that can’t work with CHP to provide medical care, the individual will be exempted while residing in the facility. 4. Medical Needs Exemptions a. GA-U recipients may also call the MACSC line to request a medical needs exemption. b. MACSC will process the member’s request for an exemption by determining need and the ability of CHPW to provide continuity of care. c. If the member’s exemption request is allowable within mandatory managed care parameters, MACSC will process the exemption request for the next available month, according to HRSA’s cut off dates.