Managed Care
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Managed Care


Revised April 6, 2012



Purpose: Beginning November 1, 2009, most Medical Care Services (MCS) recipients will access MCS benefits through Community Health Plan of Washington (CHP).


WORKER RESPONSIBILITIES

1.   Enrollment:

a.    Most MCS recipients will be enrolled in managed care with the Community Health Plan of Washington (CHP). CHP is responsible for providing primary medical care and pharmacy services and for coordinating the delivery of specialty services, by referring the person to other medical providers.

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 based on their zip code.

c.    ABD recipients who are eligible for Medicaid coverage are not eligible for managed care  and will continue receiving their healthcare paid by HCA as fee-for-service (DL-X, DL-D, DL-A, DL-B, DL-R and DL-I). Native American and Alaska Natives are not enrolled but may choose to enroll by calling 1-800-562-3022. ADATSA recipients, legal aliens, and recipients with other insurance are also not enrolled.


2.    A person may be exempted from managed care if:

a.    The person is receiving care in a nursing home under certain circumstances.

b.    CHP is unable to provide continuity of care. MCS recipients may call the MACSC line at 1-800-562-3022 to request a medical needs exemption.


NOTE:

When calling CHP (1-800-440-1561) or CHP clinic, let the client know they need to identify themselves as a new MCS client to expedite care. New MCS clients are not yet enrolled in the managed care system generally until the month following case opening.


3.    A person may be exempted from managed care if:

a.     The person is receiving care in a nursing home under certain circumstances.

b.     CHP is unable to provide continuity of care.  MCS recipients may call the MACSC line at 1-800-562-3022 to request a  medical needs exemption.

4 .   If MCS is approved, send the managed care welcome letter attachment with the 14-249 case plan.

a.   ICMS will generate an attachment for the DSHS 14-527 MCS Case Plan that includes additional information.

b.   HCA will mail out a detailed letter to the client within a week or so explaining coverage, exemptions, and how to use managed care.

c.   ProviderOne will use ACES information to automatically enroll any nonexempt MCS recipient into managed care the next month, or if it is after deadline, the following month. The information from ACES will not identify the clients who are in a nursing facility. Staff will have to be aware of the living arrangement for possible exemptions.

d.    The recipient will have fee-for-service (“open”) coverage for his or her medical needs until s/he is enrolled in managed care.


5.  Change of Medical Program

a.    If a person is approved for Medicaid (DL-U to DL-A, DL-D, or DL-X) ProviderOne will automatically disenroll the person from managed care at the beginning of the following month based on the new program code. No CSO action will be necessary. CHP will be responsible for the person's care until the person is disenrolled.

b.    If a person changes from Medicaid to MCS:

                      i.        ProviderOne will enroll the person based on the new program code and send out a letter with detailed information.

                    ii.        The social worker must send out a managed care welcome letter to tell the person about managed care.


6.      Nursing Home Admission or Discharge

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 P1 code, 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.

d.      The CSO Social Worker should notify the HCS worker to remove any managed care exemptions once a MCS recipient is discharged from a nursing home and the case is transferred to the CSO.


7 .    Substance Abuse Treatment

The Social Worker or CHP will coordinate treatment with Division of Behavioral Health and Recovery (DBHR), to obtain substance abuse assessment or treatment for MCS persons in managed care.


Links

MCS Managed Care Website

Managed Care Provider Information

Search IESA Clarification Database

Email Becky McAninch-Dake by email at mcanibj@dshs.wa.gov with comments or questions about the content of the MCS Managed Care section of the Social Services Manual. For problems with the website, see info below.

Modification Date: April 6, 2012