Managed Care - MCS Managed Care Statewide Expansion

Revised December 14, 2011

CLARIFYING INFORMATION

1. Mandatory Managed Care  

Enrollment with CHP is mandatory for all Medical Care Services (MCS) 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 scope of care medical benefits.

b.      Mental health care.

c.       A 24/7 nursing hotline.

d.      Care coordination.

3.       Enrollment

a.       MCS recipients 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 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.       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 mcanibj@dshs.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 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 MCS 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.      MCS 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 HCA’s cut off dates.