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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. Step #1-Accessing Title XIX/XXI eligibility
information
3.1.6-B. Step #2-Interpreting eligibility information
3.1.6-C. Step #3-Screening for Title XIX/XXI eligibility
3.1.6-D. Medicare Part D Prescription Drug coverage
and "extra help" eligibility
3.1.6-E. 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?
3.1.6-F: Reporting requirements
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 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., AHCCCS,
DES).
Effective January 1, 2006, Medicare
eligible behavioral health recipients, including persons who are
dually eligible for Medicare (Title XVIII) and Medicaid (Title
XIX/XXI), will receive 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 "extra help."
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.
- 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.
- Effective with the implementation
of Medicare Part D Prescription Drug coverage on January 1, 2006,
Title XIX/XXI funding will no longer be available to cover those
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 and, 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.
Also, to identify and assist persons eligible for Medicare with
enrolling in a Part D plan and with applying for the “extra help”
program to pay the cost sharing of Medicare Part D.
3.1.6
Procedures
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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3.1.6-A.
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 (https://scertsrv.ahcccs.state.az.us/Home.asp);
-
AHCCCS’ contracted Medical Electronic Verification Service
(MEVS).
MEVS uses “swipe card” technology to verify eligibility
and enrollment. For information on MEVS, contact one of the MEVS
vendors: Envoy at 1-800-366-5716 or Potomac Group at 1-800-444-4336;
-
Interactive Voice Response (IVR) system.
IVR allows unlimited verifications by entering information on
a touch-tone telephone. Providers may call IVR at: Maricopa County
at (602) 417-7200 and all others at 1-800-331-5090; and Eligibility
Verification System (EVS). EVS, also known as Medifax, allows
providers to use a PC or terminal to access eligibility and enrollment
information. For information on EVS, contact the Potomac Group
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
- After normal
business hours, call the AHCCCS Verification Unit, which is available
until midnight. On weekends and holidays, the AHCCCS Verification
Unit is available between 6:00 a.m. and midnight. Callers from
outside Maricopa County can call 1-800-962-6690. In Maricopa County,
call (602) 414-7000. 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).
3.1.6-B.
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) 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.
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 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 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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3.1.6-C.
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:
- 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.
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, 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, 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, Co-payments and
Section 3.21, Service Prioritization for Non-Title XIX/XXI Funding.
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3.1.6-D. Medicare Part D Prescription Drug
coverage and "extra help" 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, with a
behavioral health recipient’s permission and personal information.
Once a person is determined Medicare eligible, T/RBHAs or providers
must assist 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.
Applying for the Limited Income
Subsidy (LIS)
The Limited Income Subsidy (LIS) or “extra help” 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. To
be eligible for the “extra help,” the person must have income below
150% of the Federal Poverty Limit (FPL) and resources below $11,500
for an individual and $23,000 for a couple. If the T/RBHA or
provider determines that a person may be eligible for the “extra
help,” they 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 “extra help” 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.
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3.1.6-E.
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. 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. The following conditions
do not constitute a refusal to participate:
- A person’s
inability to obtain documentation required for the eligibility
determination; and
- A person
who is unable or refuses to participate due to his/her mental
status and who does not have a legal guardian.
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 or 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 form (PM FORM ADHS AE-08 or
PM FORM ADHS AE-08 Spanish). Before discontinuing
the person’s behavioral health services, the Arizona Department
of Health Services/Division of Behavioral Health Services (ADHS/DBHS)
Clinical Services, Bureau of Adult Services (602-364-4602) must
be notified and approve the decision.
For all
persons who refuse to cooperate with the AHCCCS eligibility and/or
application process
The T/RBHA or behavioral health provider representative must inform
the person who they 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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3.1.6-F:
Reporting requirements
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
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: 11/08/2005
Effective Date: 03/15/2006 |
