Managed Care - MCS Managed Care Statewide Expansion

Revised April 22, 2013

CLARIFYING INFORMATION

1. Managed Care or Fee for Service

Both CHPW and FFS offer that same basic services; however, CHPW provides access to additional or limited benefits that FFS does not provide. The chart below shows the differences:

 

BENEFITS	COMMUNITY HEALTH PLAN of WASHINGTON (CHPW)	FEE-for-SERVICE (FFS)
Guaranteed access to primary care providers (PCP) and specialists	Yes. Already have a doctor? CHPW will help you find a PCP or specialist that will work for you. Need help finding a PCP and/or specialist? CHPW will help you find a PCP or specialist that will work for you.	No You will need to find your own PCP and specialists who will accept your HCA Services Card.
Limited to providers in the PCP network YES (unless CHPW refers you outside the network	YES (unless CHPW refers you outside the network	NO You can see any PCP or specialist who will accept your Services Card.
Mental Health Benefits	YES CHPW is able to provide you with mental health benefits.	Mental health providers do not have to provide mental health services.
Care Coordinator	YES CHPW provides you with a care coordinator who an help you access mental health and drug and alcohol dependency services. These care coordinators are here to help you, and are conveniently located in primary care clinics.	NO You will need to coordinate your own care.
Advice Hotline	YES CHPW offers a 24-hours medical help/advice hotline.	NO

  2. Legal immigrants must be FFS due to ProviderOne coding change restrictions.

3.       Enrollment

a.       MCS recipients who elect CHPW are generally enrolled into managed care the month after being determined eligible. If the date is after the Health Care Authority's (HCA) cutoff, the individual will be enrolled for the following month.

b.      MCS recipients enrolled in managed care must choose a clinic and Primary Care Provider (PCP) with CHPW 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.    MCS recipients who elect to disenroll from CHPW are generally disenrolled into fee-for-service (FFS) the first of the following month.

d.       ABD cash recipients who are eligible for Medicaid 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 MCS 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 becky.mcaninch-dake@hca.wa.gov to exempt the individual from managed care.

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

c.       If the recipient has been enrolled in MCS Managed Care, and is admitted to a nursing home, the nursing home must coordinate the member’s care with CHPW 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 MCS recipient is residing in a state approved DASA facility that can’t work with CHPW to provide medical care, the individual will be FFS while residing in the facility.