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Section
3.1 Accessing and Interpreting Eligibility and Enrollment Information
and Screening and Applying for AHCCCS Health Insurance including
Medicare Part D Prescription Drug Coverage and the Limited Income
Subsidy Program
3.1.1
Introduction
3.1.2 References
3.1.3 Scope
3.1.4 Did you know…?
3.1.5 Objectives
3.1.6 Procedures
3.1.6-A. Title XIX/XXI screening and eligibility
3.1.6-B. Reporting requirements for Title XIX/XXI Eligibility Screening
3.1.6-C. Medicare Part D Prescription Drug coverage and "Limited
Income Subsidy (LIS) program" eligibility
3.1.6-D. What if a person refuses to participate
with the screening and/or application process for Title XIX/XXI or
enrollment in a Part D plan?
3.1.1
Introduction
Eligibility status is essential for knowing the types of behavioral
health services a person may be able to access. In Arizona’s
public behavioral health system, a person may:
- Be eligible
for Title XIX (Medicaid) or Title XXI (KidsCare) covered services;
- Not qualify
for Title XIX/XXI entitlements but be eligible for services as
a person determined to have a serious mental illness (SMI);
- Be covered
under another health insurance plan, or “third party; or
- Be without
insurance or entitlement status and asked to pay a percentage
of the cost of services.
Determining
current eligibility and enrollment status is one of the first things
a Tribal/Regional Behavioral Health Authority (T/RBHA) or behavioral health provider does upon receiving a request
for behavioral health services. For persons who are not Title XIX
or Title XXI eligible, a financial screening and eligibility application
must be filed with the appropriate eligibility agency (e.g., The
Arizona Health Care Cost Containment System (AHCCCS),
the Department of Economic Security (DES), KidsCare or the Social
Security Income/Medical Assistance Only (SSI/MAO) program).
Beginning January 1, 2006, Medicare
eligible behavioral health recipients, including persons who are
dually eligible for Medicare (Title XVIII) and Medicaid (Title
XIX/XXI), started receiving Medicare Part D prescription drug benefits
through Medicare Prescription Drug Plans (PDPs) or Medicare
Advantage Prescription Drug Plans (MA-PDs).
The following
information will assist providers of behavioral health services in:
- Accessing
and interpreting eligibility and enrollment information;
- Conducting
financial screenings and assisting persons with applying for Title
XIX/XXI benefits; and
- Assessing
potential eligibility for Medicare Part D Prescription Drug
coverage and the "limited income subsidy (LIS) program."
3.1.2
References
The following citations can serve as additional resources for this
content area:
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3.1.3
Scope
To whom does this apply?
This standard applies to all persons who are currently or potentially
eligible for Title XIX or Title XXI behavioral health services.
3.1.4
Did you know…?
- The Arizona
Health Care Cost Containment System’s (AHCCCS’) Application
for Health Insurance (see the Assisting Behavioral Health Recipients
with AHCCCS Eligibility Manual) was designed to make the application
process easier. Applicants can fill out the application and it
will be routed to the correct eligibility determination office.
The application also permits a person to apply for all AHCCCS
programs for all family members on one application form. If the
results of the eligibility screening indicate that a person may
be eligible for the Medicare Part D prescription drug benefit,
Title XIX or Title XXI, in order to continue to receive
services, the applicant’s application must be submitted within
ten working days to the SSA, DES or AHCCCS, which shall
determine the applicant's eligibility.
- In most cases,
an eligibility determination is completed within 45 days after
the date of application, unless the person is pregnant (completed
within 20 days) or in an inpatient hospital at the time of application
(completed within 7 days).
- It is preferred
and advantageous to use a person’s AHCCCS identification
number as opposed to the person’s social security number
when inquiring about a person’s current eligibility status.
- Title XIX/XXI funding is not available to cover drugs
available through Medicare Part D for persons dually eligible for Medicare and Medicaid.
- Medicare Part D Prescription Drug
coverage is a voluntary benefit, but eligible persons who do not
enroll in a Part D plan MAY not have access to prescription drug
coverage through the T/RBHA.
3.1.5
Objectives
- To identify methods for accessing and interpreting Title XIX and
Title XXI eligibility
- For persons who are not Title XIX/XXI
eligible, describe the procedures to screen persons for Title XIX/XXI
eligibility and, if indicated, apply for AHCCCS health insurance
and
- To identify and assist persons eligible for Medicare with
enrolling in a Part D plan and with applying for the Limited Income
Subsidy (LIS)
program to pay the cost sharing of Medicare Part D.
3.1.6
Procedures
3.1.6-A.
Title XIX/XXI screening and eligibility
What is the process?
- First…Verify
the person’s Title XIX or Title XXI eligibility;
- Next…for
those persons who are not Title XIX or Title XXI eligible, screen
for potential Title XIX and Title XXI eligibility; and
- Finally…as
indicated by the screening tool, assist persons with applications
for a Title XIX or Title XXI eligibility determination.
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Step #1-Accessing Title XIX/XXI eligibility information
Behavioral health providers who need to verify the eligibility and
enrollment of an AHCCCS member can use one of the alternative verification
processes 24 hours a day, 7 days a week. These processes include:
- AHCCCS’
web-based verification. (Customer Support 602-417-4451)
This web site allows the providers to verify eligibility and
enrollment. To use the web site, providers must create an
account before using the applications. To create an account, go
to:
https://azweb.statemedicaid.us/Home.asp and follow the
prompts. Once the providers have an account they can view
eligibility and claim information (claim information is limited
to FFS). Batch transactions are also available. There is no
charge to providers to create an account or view transactions;
-
AHCCCS’ contracted Medical Electronic Verification Service
(MEVS).
The AHCCCS member card can be “swiped” by providers to
automatically access AHCCCS’ PMMIS system for up to date
eligibility and enrollment. For information on MEVS, contact the
MEVS vendor: Emdeon at 1-800-444-4336;
-
Interactive Voice Response (IVR) system.
IVR allows unlimited verification information by entering the
AHCCCS member’s identification number on a touch-tone telephone.
This allows providers access to AHCCCS’ PMMIS system for up to
date eligibility and enrollment. Maricopa County providers may
also request a faxed copy of eligibility for their records.
There is no charge for this service. Providers may call IVR
within Maricopa County at (602) 417-7200 and all other counties
at 1-800-331-5090, and • Medifax. Medifax allows providers to
use a PC or terminal to access AHCCCS’ PMMIS system for up to
date eligibility and enrollment information. For information on
EVS, contact Emdeon at 1-800-444-4336.
- Medifax. Medifax allows providers to use a PC or
terminal to access AHCCCS’ PMMIS system for up to date
eligibility and enrollment information. For information on EVS,
contact Emdeon at 1-800-444-4336.
If a person’s
Title XIX or Title XXI eligibility status still cannot be determined
using one of the above methods, a behavioral health provider must:
- Call their
contracted T/RBHA Enrollment and Eligibility Coordinator at (602)
528-7141 for assistance during normal business hours (8:00 am
through 5:00 pm, Monday-Friday); or
- Call the AHCCCS Verification Unit,
which is open Monday through Friday, from 7:00 a.m. to 7:00 p.m.
The Unit is closed Saturdays and Sundays and on the following
holidays: New Years Day, Memorial Day, Independence Day,
Thanksgiving Day and Christmas Day. Callers from outside
Maricopa County can call 1-800-962-6690or call (602) 417-7000 in
Maricopa County and remain on the line for the next available
representative. When calling the AHCCCS Verification Unit, the
behavioral health provider must be prepared to provide the
verification unit operator the following information:
- The behavioral
health provider’s identification number;
- The
recipient’s name, date of birth, AHCCCS identification
number and social security number (if known); and
- Dates
of service(s).
Step #2-Interpreting eligibility information
A behavioral health provider will access two important pieces of
information when using the eligibility verification methods described
in Step #1: AHCCCS eligibility key codes and/or AHCCCS rate codes.
Key codes and rate codes are assigned to AHCCCS eligibility categories
and are important for determining:
- If a person
is eligible for Title XIX/XXI covered behavioral health services;
and
- If ADHS/DBHS
(behavioral health providers) is responsible for providing the
person’s Title XIX/XXI covered behavioral health services;
or whether it is the AHCCCS Health Plan or Arizona Long Term Care
System (ALTCS) Program Contractor’s responsibility.
Available
Resources for Interpreting Eligibility Information
-
PM
Attachment 3.1.1 is a behavioral health eligibility key code index
and may be used by behavioral health providers to interpret key
code information. The key code index will indicate if the ADHS/DBHS
system (and T/RBHA contracted behavioral health provider) is responsible
for the delivery of Title XIX/XXI covered behavioral health services.
-
PM
Attachment 3.1.2
is a listing of all AHCCCS rate codes and descriptions that include
Title XIX/XXI behavioral health covered services that are provided
by a T/RBHA and/or contracted behavioral health provider.
-
PM Attachment 3.1.3
is a summary of AHCCCS rate codes for use by T/RBHAs and/or contracted
behavioral health providers in determining responsibility for
providing behavioral health services.
If Title XIX
or Title XXI eligibility status and behavioral health provider responsibility
is confirmed, the behavioral health provider must provide any needed
covered behavioral health services in accordance with the ADHS/DBHS
Provider Manual and the
ADHS/DBHS Covered Behavioral Health Services Guide.
There are some
instances that a person may be Title XIX eligible but the ADHS/DBHS
behavioral health system is not responsible for providing covered
behavioral health services. This includes persons enrolled as elderly
or physically disabled (EPD) under the ALTCS Program and persons
eligible for family planning services only through the Sixth
Omnibus Reconciliation Act (SOBRA) Extension
Program. A person who is Title XIX eligible through ALTCS must be
referred to their ALTCS case manager to arrange for provision of
Title XIX behavioral health services. However, ALTCS-EPD individuals
who are Seriously Mentally Ill
may also receive Non-Title XIX SMI services from the T/RBHA. ALTCS-Division
of Developmental Disabilities (DDD) persons’ behavioral health
services are provided through the ADHS/DBHS behavioral health
system.
If the person
is not currently Title XIX or Title XXI eligible, proceed to step
#3 and conduct a screening for Title XIX/XXI eligibility.
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Step #3-Screening for Title XIX/XXI eligibility
When and who do I screen for Title XIX/XXI eligibility?
The T/RBHA or behavioral health provider must screen all non-Title
XIX/XXI persons using
PM Form ADHS AE-01:
- Upon initial
request for behavioral health services, and;
- At least
annually thereafter, if still receiving behavioral health services;
and
- When significant
changes occur in the person’s financial status.
A screening
is not required at the time an emergency service is delivered but
must be initiated within 5 days of the emergency service if the
person seeks or is referred for ongoing behavioral health services.
How do I
conduct a screening for Title XIX/XXI eligibility?
The T/RBHA or behavioral health provider meets with the person and
completes the AHCCCS Eligibility Screening Tool (PM Form ADHS AE-01)
for all Non-Title XIX persons. PM Form ADHS AE-01 must be included
in a person’s comprehensive clinical record upon completion after
initial screening, annual screening and screening conducted when a
significant change occurs in a person’s financial status (see
PM
Section 4.2, Behavioral Health Medical Record Standards).
What’s
Next?
Once the screening tool is completed, the screening tool will indicate
one of two options:
- That
the person is potentially AHCCCS eligible.
If the person is potentially eligible, then T/RBHAs or behavioral
health providers must reference the Assisting Behavioral Health
Recipients with AHCCCS Eligibility Manual and follow the appropriate
steps.
Pending
the outcome of the Title XIX or Title XXI eligibility determination,
the person may be provided services in accordance with Section
3.4, Premiums and Co-payments and Section 3.21, Service Prioritization for
Non-Title XIX/XXI Funding.
Upon the
final processing of an application, it is possible that a person
may be determined ineligible for AHCCCS health insurance. If
the person is determined ineligible for Title XIX or Title XXI
benefits, the person may be provided behavioral health services
in accordance with Section 3.4, Premiums and Co-payments and Section 3.21,
Service Prioritization for Non-Title XIX/XXI Funding.
- That
the person does not appear Title XIX/XXI eligible.
If the screening tool indicates that the person does not appear
Title XIX or Title XXI eligible, the person may be provided behavioral
health services in accordance with Section 3.4, Premiums and Co-payments and
Section 3.21, Service Prioritization for Non-Title XIX/XXI Funding.
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3.1.6-B. Reporting requirements for Title XIX/XXI Eligibility Screening
The number of screenings completed for Title XIX/XXI eligibility
must be documented by providers and reported to the T/RBHA on a
monthly basis. The reporting must include the following elements:
| |
SMI |
NON-SMI |
CHILD |
|
New Applicant |
Currently
Receiving Services |
New Applicant |
Currently
Receiving Services |
New Applicant |
Currently
Receiving Services |
| Number
Screened |
|
|
|
|
|
|
Documentation
regarding eligibility screenings completed by Gila River RBHA contracted
providers is to be submitted to the RBHA by the 15th day of each
month utilizing the reporting format above. Please submit reports
to: ATT: RBHA Enrollment and Eligibility Coordinator, Hu Hu Kam Memorial
Hospital, P.O. Box 38, Sacaton, AZ 85247. Gila River RBHA contracted providers
may also contact the RBHA Enrollment and Eligibility Coordinator
at (602) 528-7141 to request technical assistance.
3.1.6-C. Medicare Part D Prescription Drug
coverage and Limited Income Subsidy (LIS) program eligibility
Persons must report to the T/RBHA or provider if they are eligible,
or become eligible, for Medicare as it is considered third party
insurance. See Section 3.5, Third Party Liability and Coordination
of Benefits, regarding how to coordinate benefits for persons with
other insurance, including Medicare. If a behavioral health
recipient is unsure of Medicare eligibility, T/RBHAs or providers
may verify Medicare eligibility by calling 1-800-MEDICARE
(1-800-633-4227), with a
behavioral health recipient’s permission and personal information.
Once a person is determined Medicare eligible, T/RBHAs or providers
must offer assistance and provide assistance with Part D enrollment and the Limited Income Subsidy (LIS)
application upon a behavioral health recipient’s request. T/RBHAs
and providers will be tracking behavioral health recipients’ Part D
enrollment and LIS application status and reporting tracking
activities, when required by ADHS/DBHS.
Enrollment in Part D
All persons eligible for Medicare must be encouraged to and assisted
in enrolling in a Medicare Part D plan to access Medicare Part D
Prescription Drug coverage. Enrollment must be in a Prescription
Drug Plan (PDP), which is fee-for-service Medicare, or a Medicare
Advantage Prescription Drug Plan (MA-PD), which is managed care
Medicare. Upon request, the T/RBHA or provider must assist Medicare
eligible persons in selecting a Part D plan. The Centers for
Medicare and Medicaid Services (CMS) developed webtools to assist
with choosing a Part D plan that best meets the persons’ needs. The
webtools can be accessed at
www.medicare.gov.
For additional information regarding Medicare Part D Prescription
Drug coverage, call Medicare at 1-800-633-4227 or the Arizona State
Division of Aging and Adult Services at 602-542-4446 or toll free at
1-800-432-4040.
Applying for the Limited Income
Subsidy (LIS)
The Limited Income Subsidy (LIS) is a program in
which the federal government pays all or a portion of the cost
sharing requirements of Medicare Part D on behalf of the person. If
the T/RBHA or provider determines that a person may be eligible for
the LIS (see www.ssa.gov for income and resource limits), the T/RBHA
or provider must offer to assist the person in completing an
application. Applications can be obtained and submitted through the
following means:
Reporting Part D enrollment and
LIS applications
T/RBHAs and providers must track Medicare eligible behavioral health
recipients’ Part D enrollment and LIS application status. ADHS/DBHS
has developed
PM Form 3.1.1, Tracking of Medicare Part D Enrollment, and
PM Form 3.1.2, Tracking of Limited Income Subsidy (LIS) Status,
which can be used by the T/RBHA or behavioral health provider to
track persons eligible for Medicare. This will assist the T/RBHA to
ensure that Medicare eligible persons are enrolled in a Part D plan
and apply for the limited income subsidy (LIS) program, if applicable. Providers
must report any Part D enrollment and LIS application status to
:ATTN: RBHA Enrollment and Eligibility Coordinator/ Gila River
Health Care Corporation, P.O. Box 38, Sacaton, AZ 85247. Gila River
RBHA contracted providers may also contact the RBHA Enrollment and
Eligibility Coordinator at (602) 528-7141 to request technical
assistance. Periodically, ADHS/DBHS will request T/RBHAs to report tracking of Part D
enrollment and LIS applications.
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3.1.6-D.
What if a person refuses to participate with the screening and/or
application process for Title XIX/XXI or enrollment in a Part D
plan?
On occasion, a person may decline to participate in the AHCCCS eligibility
screening and application process or refuse to enroll in Medicare
Part D plan. In these cases, the T/RBHA or
behavioral health provider must actively encourage the person to
participate in the process of screening and applying for AHCCCS
health insurance coverage or enrolling in a Medicare Part D plan.
Arizona state
law stipulates that persons who refuse to participate in the AHCCCS
screening and eligibility application process or to enroll in a
Medicare Part D plan are ineligible for
state funded behavioral health services (see
A.R.S. § 36-3408). As such, individuals who
refuse to participate in the AHCCCS screening and eligibility application or enrollment in
Medicare Part D, if eligible, will not be enrolled with a T/RBHA during his/her initial
request for behavioral health services or will be disenrolled if the person refuses to
participate during an annual screening. The following conditions
do not constitute a refusal to participate:
If a person
refuses to participate in the screening and/or application process
for Title XIX or Title XXI eligibility or to enroll in a Medicare
Part D plan, the T/RBHA or behavioral
health provider must ask the person to sign the Decline to Participate
in the Screening and/or Referral Process for AHCCCS (Title XIX/XXI)
Health Insurance or Medicare Part D Plan Enrollment form (PM FORM ADHS AE-08 or
PM FORM ADHS AE-08
Spanish). If the person refuses to sign the form, document their
refusal to sign in the comprehensive clinical record (See Section
4.2, Behavioral Health Medical Records Standards).
If a person meets one of the
conditions above, which is not considered refusal, and does not
enroll in a Medicare Part D plan, T/RBHAs may use state funds to pay
for his/her prescription drugs according to
Section 3.21, Service
Prioritization for Non-Title XIX/XXI Funding.
Special
considerations for persons with a serious mental illness
If a person is eligible for or requesting services as a person with
a serious mental illness and is unwilling to complete the eligibility
screening or application process for Title XIX/XXI or to enroll in a Part D plan, the T/RBHA or behavioral health
provider must request a clinical consultation (e.g., Clinical Liaison)
by contacting the person’s assigned Gila River RBHA Clinician.
If the person continues to refuse following a clinical consultation,
the T/RBHA or behavioral health provider must request that the person
sign the Decline to Participate in the Screening and/or Referral
Process for AHCCCS (Title XIX/XXI) Health Insurance or enroll in a
Medicare Part D plan and does not meet the conditions above, form (PM FORM ADHS AE-08 or
PM FORM ADHS AE-08 Spanish).
Prior to the termination of behavioral health services for persons determined to have a Serious
Mental Illness who have been receiving behavioral health services and subsequently decline to
participate in the screening/referral process, the T/RBHA must provide written notification of the
intended termination using
PM Form 5.5.1, Notice of Decision and Right to Appeal (see
PM Section 5.5,
Notice and Appeal Requirements (SMI and Non-SMI/Non-Title XIX/XXI)).
For all
persons who refuse to cooperate with the AHCCCS eligibility and/or
application process or who do not enroll in a Part D plan
The T/RBHA or behavioral health provider representative must inform
the person who he/she can contact in the behavioral health system
for an appointment if the person chooses to participate in the eligibility
and/or application process in the future. Persons are to be encouraged
to contact their assigned Gila River RBHA Clinician or the Gila
River RBHA Clinical Manager in the event that they choose to participate
in the eligibility and/or application process at a later date.
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3.1
Accessing and Interpreting Eligibility and Enrollment Information
and Screening and Applying for AHCCCS Health Insurance
including Medicare Part D Prescription Drug Coverage and the Limited
Income Subsidy Program
Last Revised: 1/15/2010
Effective Date: 1/15/2010 |
