Incapacity - Managed Care

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Incapacity - Managed Care

Revised October 21, 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).

Managed Care

Transferring Cases

Change of Program (to or from GAX)

Nursing Home Admission or Discharge

Substance Abuse Treatment

Links

WORKER RESPONSIBILITIES

1.      Enrollment:

a.       Most GA-U 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.      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 based on their zip code.

c.       General Assistance recipients who are eligible for Medicaid coverage are not eligible for managed care and will continue receiving their healthcare paid by HRSA as fee-for-service (GA-X, GA-D, GA-A, GA-B, GA-R and GA-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. GA-U 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 GAU client to expedite care. New GA-U clients are not yet enrolled in the managed care system generally until the month following case opening.

3.   If GA-U is approved, send the managed care welcome letter attachment with the 14-249 case plan.
a.       ICMS will generate an attachment for the DSHS 14-249 GA Case Plan that includes additional information.

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

c.       MMIS/ProviderOne will use ACES information to automatically enroll any nonexempt GA-U 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.

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

4. Change of Medical Program
a.       If a person is approved for Medicaid (GA-U to GA-A, GA-D, or GA-X) MMIS/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 GAU:

                     i.            MMIS/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 letterto tell the person about managed care.

5.      Nursing Home Admission or Discharge
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.

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

6.    Substance Abuse Treatment
The Social Worker or CHP will coordinate treatment with Division of Behavorial Health and Recovery (DBHR), to obtain substance abuse assessment or treatment for GAU persons in managed care.

Links
GA Managed Care Website
Managed Care Provider Information

Email Melissa Mathson with comments or questions about the content of the GAU Managed Care section of the Social Services Manual. For problems with the website, see info below.