Eligibility Verification

Q:        How do I identify whether individuals I am serving are enrolled in Medicaid or PAC?

A:         Providers with a Medicaid provider number can access the DHMH Eligibility Verification System (EVS) to determine whether an individual is enrolled in PAC or Medicaid and to which MCO they are assigned.   EVS is available by phone or via the web.  You will have to register to use the EVS web access.  You will only be able to use this service once you have a Medicaid provider number. You must verify eligibility for each date of service.  You do not have to be an MCO provider to use EVS.

Q:         What do the terms in EVS mean?

A:         DHMH has a brochure which helps providers use the Eligibility Verification System (EVS).  The bottom line is that providers should use EVS to determine who to bill for services.  The following table summarizes the messages and who to bill:

 

 

The EVS system will say “eligible, federal” for those individuals enrolled in Medicaid or PAC and if enrolled in an MCO, will provide the name of the member’s MCO.  

EVS will provide information on whether an individual is currently enrolled or has been enrolled in the past year.   It will not provide information on whether they may be eligible for Medicaid or PAC on any future date.  You must verify eligibility for each date of service.  If a provider thinks an individual may have an income that is below the PAC threshold of $12,552, they should provide information about applying for PAC.  Substance abuse services will only be covered once an individual has been found eligible and enrolled in an MCO.

Q:         How often do I need to verify eligibility through EVS?

A:         While providers are not required to verify eligibility through EVS, it is strongly recommended that providers use EVS for each date of service in order to validate that the patient is eligible with the MCO and or Medicaid/PAC.   Eligibility within the Medicaid program can change at any time, and providers can use EVS to verify eligibility on a real time basis without waiting for an EOB to learn that a patient was no longer eligible.

Q:         Is MCO authorization for future services a guarantee of payment?

A:         No, an MCO authorization for future services is not a guarantee of payment.  Any authorizations given by an MCO are contingent upon the patient being eligible with the MCO at the time of the actual service.  

Q:         What is retroactive eligibility and can I back bill for services?

A:         Medicaid FFS/ Health Choice - Under Medicaid, individuals can be determined eligible back to the date of their original application for coverage.  In addition, Medicaid covers retroactive eligibility periods of up to three months for individuals that can document the need for this coverage.  This period of time is called the retroactive eligibility period.  Providers can be reimbursed for Medicaid services during the retroactive period; however, the individual will not be assigned to an MCO retroactively.   Providers may bill Medicaid fee-for-service (FFS) for the period prior to MCO coverage for Medicaid recipients.  Once the provider finds out that a person is being enrolled in the MCO, they should begin the procedures to notify and seek authorization for services through the MCO. 

            PAC - There is no retroactive coverage under the PAC program so coverage for substance abuse services will only begin after the individual is determined eligible for PAC and enrolled in a MCO.       

Q:         What happens January 1 when a client gets PAC but has not yet enrolled in an MCO.  Should a provider bill DHMH for that time or is it not a covered benefit until the MCO has been selected and the client would need to access block grants during the interim? Doesn’t that happen also with HealthChoice recipients too?

A:         Under Medicaid - HealthChoice, providers bill fee-for-service Medicaid until the patient is enrolled in a MCO.  With PAC, substance abuse services aren't covered until they are enrolled in the MCO.  For PAC, the services provided pre-MCO enrollment can be covered by the grant.

Q:         The PAC enrollment materials say that clients are not eligible for services until they are enrolled with an MCO.  I understand that it takes 45 days for the PAC eligibility to be determined.  How long does it take before an MCO is assigned to the client, if the client does not enroll with an MCO?

A:         It can take up to 45 days for PAC eligibility to be determined but the average time frame is about 30 days. Once they are eligible, if the client does not voluntarily choose an MCO, then they are assigned to an MCO after 28 days.  Providers who have assisted clients to enroll in Medicaid or PAC should encourage them to choose a MCO.  A provider may not direct a client to enroll in a specific MCO, but may share with them information on which MCOs they contract with.  People in PAC must apply every year.  Providers should also encourage individuals to recertify for PAC timely.

Q:         In determining the number of dependents for a PAC applicant, must a client have custodial responsibilities (full or partial) for a child to be counted?  Are dependents counted for parents who contribute but do not have custody?  How about joint custody situations?

A:         The main target audience for the PAC program is adults without children.  If individuals have dependent children, they should apply for full Medical Assistance coverage.  Dependents are not counted for determining PAC eligibility.  The only other individual counted is a spouse that is residing in the home.  Their income is taken into consideration for eligibility for the applicant.  Children are not included in the calculations for PAC.

Q.         Dear ADAA MA-PAC Question Mailbox:  (Posted:  March 9, 2010 – Answers are underlined in GREEN)

The regional ADAA conference calls to review the pilot project were appreciated as it communicated a plan for training and technical assistance for LHDs as we navigate the new rules and requirements.  Ensuring that the new codes are fully understood and applied is critical to our recovering sufficient funds to meet our anticipated revenues for the remainder of the ever shortening fiscal year. 

Attachment B or the Alcohol and Drug Abuse Administration (ADAA) General Conditions of Award for Grant Number AS006SAS for FY10 item 5.d) states “no longer use ADAA funds for costs covered by PAC and MA.”

We are seeking clarification as to the meaning of that statement.  Are local health departments (LHDs) to interpret that as meaning:

a)     A LHD may not use ADAA grant funds to serve persons who are determined locally to be “PAC/MA eligible”.  Since PAC reimbursement doesn't begin until the patient is assigned to an MCO, grant funds can be used to support this patient's services until that time. 

1. b)    If a LHD submits a request for payment to PAC/MA for a client who is enrolled in PAC/MA then the LHD cannot also use ADAA grant funds to cover the same service?  That is correct.  The grant is intended to cover services not reimbursed through another funding source. 
2. c)     If a LHD receives payment from PAC/MA for a client who is enrolled in PAC/MA then the LHD cannot also use ADAA grant funds to cover the same service?  Correct.  If a service is reimburseable through MA/PAC, then grant funds should not be used to cover the costs of this service.
3.  

If the intent is for the General Conditions of Award to mean option a) above, then what is ADAA’s direction as to how to proceed when a person currently in treatment or newly seeking treatment from a LHD is determined locally to be PAC/MA eligible and is in need of services (either because of crisis, social factors, evidence based practice, etc.) yet a final determination by the State regarding enrollment is not yet available (either because person does not complete/submit application or processing time delays)?  Are LHDs to refuse treatment to those currently in treatment and to those newly seeking treatment if they are PAC/MA eligible?  If the answer is yes, LHDs are to refuse ADAA funded substance abuse treatment, then such a refusal would be in contradiction to COMAR 10.52.01.04 which states:

.04 Eligibility For Services.

1. A.    All persons shall be eligible for services.
2. B.    Ability to pay may not be a criterion of eligibility for service, but persons financially able to do so shall pay through their insurers or pay a fee determined by the State Ability to Pay Schedule.
3. C.    A person may not be denied services because of inability to pay.
4.  

Please reconcile those 2 seemingly different and contradictory directions from DHMH.

Are LHDs to charge full fee for all clients who are self-pay pending a local determination of PAC/MA eligibility?  If an individual states that it would be a hardship to pay full fee then the question arises again, Are LHDs expected to refuse to provide treatment to persons who are PAC/MA eligible and who are unable to pay the full fee? 

The requirement for determination of self-pay status has been an annual redetermination requirement.  Some LHD payor mix may be as high as 75% self-pay.  While we are making every attempt to identify persons who are not due for a redetermination for many more months, we have a practical implementation challenge as we have a limited capacity to temporarily perform redeterminations on ¾ of our clients and we are not able to compel persons to submit an application, let alone compel a timely submission.  We therefore respectfully request that DHMH/ADAA consider a phase-in of interpretation a) above, if that is the intended meaning stated in the General Conditions of Award. 

I would also like to verify something communicate don a regional conference call 1/28/10 – For persons born in the State of Maryland, those persons do NOT need to submit a birth certificate for PAC/MA application consideration?  Is that true?  Will failure to submit the birth certificate result in processing delays?  Are there any additional downsides to not submitting a birth certificate if one was born in the State of Maryland?  Although DHMH has the capability of processing applications without the birth certificate for applicants born in MD (DHMH can locate the birth certificate), it is recommended that the application include the birth certificate.  The approval process may be stymied by the lack of birth certificate.