Participant Eligibility. Why should you check eligibility? To verify a participant has Medicaid coverage on actual date of service

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1 Eligibility

2 Overview Importance of checking eligibility Define the eligibility receipt Review examples of eligibility responses Review benefit plans and coverage Identify resources available to check benefit plan and coverage 2

3 Participant Eligibility Why should you check eligibility? To verify a participant has Medicaid coverage on actual date of service To review a participant s eligibility plan and coverage codes Note: Medicaid card does not guarantee current Medicaid coverage. 3

4 Verifying Eligibility Three ways to check eligibility: MACS Medicaid Automated Customer Service 1(866) HIPAA compliant vendor software Health PAS-OnLine Trading Partner To obtain eligibility information from one of these systems, submit two pieces of identifying information from the following list: Medicaid ID number (ten digits) Social Security Number (SSN) Last Name, First Name Date of Birth 4

5 Navigating the Secure Portal 5

6 Verifying Eligibility 6

7 Verifying Eligibility Patient and PCP Roster 7

8 Verifying Eligibility Two pieces of identifying information required 8

9 Verifying Eligibility 9

10 Verifying Eligibility 10

11 Benefit Plans

12 Benefit Plans Benefit Plans: Idaho Medicaid Benefit Plan Part B Premium Medicare Medicaid Coordinated Plan (MMCP) For more information on these plans, visit or contact your regional Healthy Connections representative. Note: All plans and coverage are determined by IDHW. Molina Medicaid Solutions has no role in these decisions. 12

13 Coverage Codes

14 Coverage Medicaid offers several coverages that are aligned with health needs and include an emphasis on prevention and wellness. Coverage codes: Basic Coverage Enhanced Coverage (includes Katie Beckett) Pregnant Women Coverage (PW) Medicare Co-insurance & Deductible (QMB) Part B Premium Coverage (SLMB) MMCP Coverage 14

15 Coverage The following are considered secondary coverages. They are always preceded by a primary coverage. Long Term Care Aged and Disabled Waiver (A&D) Developmentally Disabled Waiver (DD) 15

16 Coverage The following are additional programs always preceded by a primary coverage. Preventative Health Assistance (PHA) Traditional DD Children s Waiver 16

17 Basic Coverage The Medicaid Basic Coverage type is for healthy, lowincome children, and adults with eligible dependent children. Provides complete health, prevention, and wellness Note: Most Medicaid participants will be enrolled with this coverage type. Visit for list of detailed services covered by each Medicaid plan. 17

18 Basic Coverage Example 18

19 Enhanced Coverage The Medicaid Enhanced Coverage type is for participants with disabilities or special health needs. Includes all benefits in Basic Coverage, plus additional benefits: o Nursing Facility o Intermediate Care for the Individuals with Intellectual Disabilities (ICF/IID) o Private Duty Nursing o Home & Community Based Waiver Services o Service Coordination Many of the services in this plan have medical eligibility and prior authorization requirements 19

20 Enhanced Coverage Example 20

21 Pregnant Women Program The Pregnant Women (PW) program is for pregnancy-related services only. This coverage ends on the last day of the month in which the 60 th day after delivery occurs Women have access to prenatal and postpartum care, including: o Normal prenatal services o Nutrition counseling o Risk reduction follow-up o Social service counseling o Chiropractic and physical therapy services o Family planning, including sterilization w/consent o Dental coverage 21

22 Pregnant Women Program Example 22

23 Medicaid and Medicare Not everyone qualifies for regular Medicaid, but they may be eligible for Qualified Medicare Beneficiary (QMB) programs where Medicaid helps pay for Medicare costs including: Monthly Medicare premiums Medicare co-insurance Medicare deductibles 23

24 QMB Example 24

25 Specified Low-Income Medicare Beneficiary Coverage What expenses does SLMB cover? Specified Low-Income Medicare Beneficiary (SLMB) Medicare Part B premium only Note: No Medicaid coverage for services. 25

26 SLMB Example 26

27 Medicare and Medicaid Eligible What expenses are covered for participants who are fully eligible for both Medicare and Medicaid? Medicare covered services Medicaid covered services 27

28 Medicare and Medicaid Eligible Example 28

29 Medicare-Medicaid Coordinated Plan The Medicare-Medicaid Coordinated Plan (MMCP) is for participants who are 21 years old or older, enrolled in Medicare Part A and Part B, eligible for full Medicaid, and reside in an MMCP coverage area. Participants voluntarily enroll in MMCP. Currently there are two MMCP programs; one offered administered by Blue Cross of Idaho, and one administered by Molina Healthcare. Note: Once a participant is on MMCP, they can choose to revert back to Medicare and Medicaid individually. 29

30 MMCP Example 30

31 Preventive Health Assistance Preventive Health Assistance (PHA) has a benefit designed to help participants and their families live a healthy lifestyle: Behavioral PHA Weight Management Note: To bill for this service, you must have the specialty set up on your provider record. For more information about the Preventive Health Assistance program, call 1 (877) or visit medicaidphaprogram@dhw.idaho.gov. 31

32 PHA Weight Management Example 32

33 Long Term Care Long Term Care (LTC) Assistance is available for participants who require hospice services, or if the provider states the participant needs to live in a Skilled Nursing Facility or Intermediate Care Facility for the Intellectually Disabled (ICF/ID). These services are approved by IDHW. The Medicaid Division determines whether or not the participant meets the level of care. These services require LTC coverage. 33

34 Long Term Care Example 34

35 Youth Empowerment Services Youth Empowerment Services (YES) is a condition code that enables individuals with Severe Emotional Disorder (SED) to acquire applicable health services. 35

36 YES Example 36

37 Secondary Coverage Waivers Idaho's Waivers for adults include: Aged and Disabled Waiver: Allows a person to receive services in his/her home, rather than a skilled nursing facility. Developmentally Disabled Waiver: Allows for increased flexibility and choices for enrollees who would traditionally receive services in an intermediate care facility. 37

38 Waiver Example 38

39 Secondary Coverage Children s Programs Idaho's programs for children include: Traditional DD Children s Waiver (Levels 1-5): Families who choose to access services through the traditional model will receive services from DD agencies who are paid for providing defined Medicaid benefits. Family-directed Services (FDS) DD Children s Waiver: Families who choose to access services through this model will continue to receive services and supports defined by the family from persons and businesses of their choice. 39

40 Children s Program Example 40

41 Share of Cost Participants may be required to pay for some of the costs of their Medicaid services. Share of Cost (SOC) Co-pays 41

42 Share of Cost: Did You Know? Participants may have to pay a share of cost for some services if they are on Long Term Care or have A&D or DD waiver coverage. SOC amounts are available online for a series of 365 days. Information is not available for future months. When verifying eligibility to retrieve SOC, you must enter the first day of the month in which you are requesting SOC. 42

43 Share of Cost Example 43

44 Co-pays: Did You Know? A small percentage of Medicaid recipients are required to pay a $3.65 co-pay. Check Medicaid eligibility for IDHW co-pay status each time you provide services. 44

45 Co-pay Verification 45

46 Therapy Limitations Available CAP amounts will be validated on the eligibility response. $1960 per calendar year for speech language pathologists (speech therapy) services and physical therapy combined. $1960 per calendar year for occupational therapy services. 46

47 Therapy Limitations Caps For questions relating to caps, contact the Division of Medicaid at 1 (208) , visit 47

48 Therapy Limitations Caps 48

49 Therapy Limitations Caps 49

50 No Medicaid Enrollment 50

51 Further Information Where to obtain more information: The Provider Handbook General Billing Instructions and General Provider and Participant Information, available at Idaho Medicaid Programs are listed in the Idaho Health Plan Coverage booklet available from Division of Medicaid, Department Regional Offices, or online at 51

52 Did You Know?

53 Announcements 53

54 Information Releases 54

55 Provider Handbook 55

56 Provider Handbook 56

57 Fee Schedules 57

58 Fee Schedules 58

59 MedicAide Newsletters 59

60 MedicAide Newsletters 60

61 User Guides 61

62 Training 62

63 Idaho Medicaid Training Center 63

64 Training Opportunities Monthly WebEx Trainings o o Available to all providers Calendar is located at Regional Workshops o o Yearly Information will be posted to Individual Training or Questions o Contact your local Provider Relations Consultant 64

65 Enrollment and Maintenance

66 Enrollment/Maintenance Be sure to keep your information up to date. o o o o o Current contact Mailing/W9/physical/ addresses Adding and terming rendering providers Adding and terming service locations Change of ownership 66

67 Enrollment and Maintenance 67

68 Enrollment and Maintenance Forms 68

69 Provider Maintenance 69

70 Provider Maintenance Maintenance is required when any information changes: Physical, mailing, and address Add, term, update service locations Rendering or service provider changes Name changes Change in ownership Note: Contact updates are made through Maintenance Demographic. 70

71 Maintenance Forms 71

72 Tips Use current forms Complete all sections of the form use N/A when appropriate Utilize the Provider Enrollment Requirements document in the Provider Handbook for type and specialty information, as well as additional requirements New W9 for 1099 changes W9 name and tax ID must match IRS records Update provider credentials (licenses, certifications, insurance, etc.) 72

73 Tips License Updates Updated Credentials: License As long as there are no changes to information, license updates are not required if you are licensed with the following: Idaho State Board of Nursing Idaho State Board of Medicine Idaho State Board of Pharmacy 73

74 Tips Provider Maintenance The Idaho Molina Medicaid website ( has the following resources: Provider Enrollment - Verifying Enrollment Application Status Provider Handbook User Guides Contact Molina at 1 (866) or idproviderenrollment@molinahealthcare.com for assistance with enrollment or maintenance 74

75 Provider Relations Consultants Region 1 and the state of Washington 1 (208) Region.1@MolinaHealthCare.com Region 2 and the state of Montana 1 (208) Region.2@MolinaHealthCare.com Region 3 and the state of Oregon 1 (208) Region.3@MolinaHealthCare.com Region 4 and all other states 1 (208) Region.4@MolinaHealthCare.com Region 5 and the state of Nevada 1 (208) Region.5@MolinaHealthCare.com Region 6 and the state of Utah 1 (208) Region.6@MolinaHealthCare.com Region 7 and the state of Wyoming 1 (208) Region.7@MolinaHealthCare.com 75

76 Thank you for attending our Eligibility Training. Please take a few minutes to complete the evaluation. This provides us with valuable information for future trainings.