incapacity - Managed care - King and Pierce Counties
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incapacity - Managed care - King and Pierce Counties

Revised March 19, 2008

Purpose: Documents all actions in ICMS

Managed Care Pilot Project in King and Pierce Counties

  1. Most GAU clients in King and Pierce Counties are required to choose and enroll in managed care at a Community Health Plan of Washington (CHP) clinic. The CHP clinic is responsible for providing primary medical care and pharmacy services. The clinic is responsible for coordinating the delivery of specialty services by referring the person to other medical providers.

    General Assistance recipients who are eligible for Medicaid coverage are not included in the pilot and will continue getting their health care paid by HRSA as fee-for-service, e.g., GAX or Aged cases.
  2. A person may be exempted from managed care if she or he:
    1. Is receiving care in a nursing home under certain circumstances.

    2. Is a Native American or Alaska Native who opts out from mandatory enrollment in managed care. In these cases, the client should call Medical Assistance at 1-800-562-3022.

    3. Could have his or her life or health or ability to attain, maintain, or regain maximum function jeopardized by an interruption of treatment. In these cases, the client or the social worker should call Medical Assistance at 1-800-562-3022. This exemption will be approved on a case-by-case basis only.

  3. For new applicants:

    1. Obtain a Consent form (14-012) for communicating with CHP, and give a copy to CHP when coordinating services.

    2. When possible, obtain a medical evaluation form completed by CHP if there is no treating physician. Giving background medical information to the clinic assists in completing the medical evaluation and ongoing treatment.

    3. If GA is approved, send the person notice of managed care. An attachment is available in ICMS that adds information to the GA Case Plan that tells the person that s/he will be in managed care, must call CHP to choose a clinic, and that s/he will be getting more detailed information in the mail.


NOTE:

Let the person know they need to identify themselves as a GAU client when calling CHP or a CHP clinic to expedite care.

  1. ICMS will generate an attachment for the DSHS 14-249 GA Case Plan that includes additional information (such as how to ask for an exemption).

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

  3. MMIS will use ACES information to automatically enroll any nonexempt GAU client into managed care the next month, or if it is after deadline, the following month based on the client's residential zip code. (See appendix 1 of the Managed Care chapter in the EA-Z manual for a list of zip codes in King and Pierce County). 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.

  4. The client will have a fee-for-service Medical Assistance ID card to cover his or her medical needs until s/he is enrolled in managed care.

  1. It is important to advise a person who will be enrolled in Managed Care that the CHP clinic may remove them from enrollment if they are abusive, aggressive or threatening toward clinic staff. Also inform the person that they could lose benefits because we will consider such behavior or losing enrollment as failing to cooperate with required treatment.

Transferring Cases

  1. Transfer-Out Cases: Persons who are enrolled in managed care are required to get authorization from their primary care provider for all care, except true emergencies, even if they are out of the area. Medical premium payments are made for a month, so if a client moves out of the pilot areas. The change of address needs to be entered into ACES as soon as possible to avoid making any additional managed care payments and ensure the person gets a fee-for service medical assistance ID (MAID) card for the following month. CHP will be responsible to treat the person until the system shows they are not enrolled.

  2. If the person wants to be exempted from managed care, the person must call HRSA at 1-800-562-3022. If approved, a fee-for service MAID will be issued by MAA.

  3. Once new ACES information is passed to the MAA system (MMIS), the new address will trigger MMIS to take the person out of (disenroll) managed care for the following month.

  4. Transfer-In Cases: MMIS will automatically enroll the person in managed care based on the new address and send out a letter with detailed information.

    1. Most persons will be enrolled into managed care the beginning of the following month. If the address changes during the last seven working days of the month, it will take an additional month to enroll the client in managed care.

    2. The Social Worker sends out a new DSHS 14-249 with the managed care information attachment. The Social Worker urges these persons to call CHP at 1-800-440-1561 right away to choose a clinic or CHP will assign a clinic for them.

    3. If the person is going into a nursing home, the HCS financial worker should notify Amandalei Bennett to exempt the case from managed care by providing the person's name, ACES CLID, facility name, admission date, and estimated discharge date (if known).

Change of Program (to or from GAX)

If a person changes from GAU to GAX, MMIS 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 and receives a fee-for-service MAID.

If a person changes from GAX to GAU:

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

  2. The social worker must send out a new DSHS 14-249 and attachment to tell the person about managed care.

Nursing Home Admission or Discharge

  1. For persons who are admitted to nursing homes, once eligibility is determined:
  2. If the person has been on GAU long enough to be enrolled in managed care, CHP will have to work with an HCS social worker to place the person in a nursing facility. (NOTE: The person is enrolled if the MAID shows "CHPG" in the HMO column.) The nursing home will coordinate with CHP to provide medical services.

  3. If the person is not on GAU and is applying for nursing home care, he or she should be exempted from managed care.

  4. The HCS financial worker should notify Amandalei Bennett so the case can be exempted from managed care and will not be enrolled.

  5. Send an email with the person's name, ACES CLID, facility name, admission date, and estimated discharge date (if known).

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

Substance Abuse Treatment

The Social Worker or CHP will coordinate treatment with DASA, as needed, to obtain substance abuse assessment or treatment for GAU persons in managed care.

Links

GA Managed Care Website

Client Materials for GA Managed Care

GAU

ESA  Policy Review Page (Blue Page)

 

 

 

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Modification Date: March 19, 2008
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