Managed Care and Long-Term Care
Purpose: The Washington Apple Health (AH) managed care organization (MCO) plan is responsible to pay for nursing facility (NF) days that are considered qualifying rehabilitative and skilled nursing services. Long-term care nursing facility services (sometimes called custodial care or long term care) is paid by Aging and Long Term Supports Administration (ALTSA) as a fee for service once AH MCO coverage days end. This section gives instructions for the financial worker (FW) when a client enrolled into AH MCO admits into a NF.
Program of all-inclusive care for the elderly (PACE) information.
Note: The instructions below are intended for Home and Community Service (HCS) and Developmental Disability Administration (DDA) LTC specialty financial workers. This section includes information for HCS and DDA social workers and case managers.
HCS and DDA do not determine medicaid eligibility for clients on a MAGI based medical programs (N track in ACES). The eligibility is done through the Health Benefit Exchange (HBE).
The HCS and DDA financial worker determines eligibility for Classic medicaid (Aged, Blind, Disabled) which includes Community First Choice (CFC), Institutional, and Home and Community Based (HCB) Waiver medical programs.
What are rehabilitative services or skilled nursing services?
Definition: Rehabilitative services means the planned interventions and procedures which constitute a continuing and comprehensive effort to restore an individual to the individual's former functional and environmental status, or alternatively, to maintain or maximize remaining function.
Rehabilitative services can last for a few days to several weeks as long as a physician determines a client is in need and is responding to rehabilitation.
During rehabilitation days and skilled nursing days in a NF when the client has AH managed care, the client does not pay participation toward the cost of care. The AH MCO plan is responsible to pay the NF for qualified skilled nursing and rehabilitation days. Individuals that are near the Medicaid resource limit, may need to be monitored by the financial worker (FW). This is the same process as a Medicare/Medicaid client receiving NF services under Medicare.
Once the MCO deems the stay is no longer medically necessary and not covered by the plan, the NF needs to notify the financial worker via the DSHS 15-031 notice of action and request a social service intake as ALTSA is responsible to determine NFLOC in order to authorize the payment for the services once AH MCO coverage ends and coverage as a long-term care service begin.
What are long-term care services in a NF?
Long-term care services in a NF are when an individual does not meet the criteria for skilled nursing or rehabilitation. Most long-term care assists people with support services, (Sometimes this is called custodial care). The correct term is long term care or institutional services.
The AH MCO contract does not cover custodial long-term care services in a nursing facility. Long-term care services in a NF are approved by Home and Community Services (HCS) for medicaid eligible clients that meet nursing facility level of care (NFLOC). Medicaid eligibility for individuals needing long-term care services over 29 days is described in WAC 182-513-1315.
Who is enrolled in a Washington Apple Health (AH) Managed Care Organization (MCO)?
All noninstitutional categorically needy (CN) and alternate benefit plan (ABP) medicaid clients are enrolled or may be enrolled into an AH MC plan. There are some exceptions such as:
- Individuals on Medicare
- Individuals with an approved HCA exemption requested by the client due to tribal status.
- Individuals who are living in a county where AH MCO enrollment is voluntary. Refer clients to their AH MCO plan for coverage issues. (see phone numbers below).
Note: A medical benefit covered under the AH MCO plan or the fee for service (FFS) medicaid program is considered a covered service. If an AH MCO client chooses to go outside the MCO network without MCO approval for a covered medical service, the client will be responsible to pay out-of-pocket. This cost is not allowed to reduce participation because it is medical care covered under the state's Medicaid plan. See WAC 182-513-1350 and Allowable medical expenses.
Nursing Home admissions under a Modified Adjusted Gross Income (MAGI) Medical group
The instructions for financial workers below are limited to individuals on Classic Medicaid programs. Classic Medicaid programs are for those who are Aged, Blind or Disabled. About 80 + percent of individuals on Classic Medicaid programs are also receiving Medicare and are not enrolled into AH MCO.
Individuals active on a MAGI-based program determined by the Health Benefit Exchange (HBE) are eligible to receive nursing facility services as part of the state plan or alternate benefit plan (ABP). The only exception is the AEM MAGI programs called N21 and N25 in ACES. AEM does not cover NF care.
Individuals on a MAGI based program with few exceptions such as tribal affiliation are enrolled into an AH MCO plan.
The AH MCO plan is responsible to pay for rehabilitation and skilled nursing in a NF. Once rehabilitation ends, the NF is paid by Provider One as a claim.
No NF award letter is issued for a client receiving N track MAGI based medical.
No participation is paid to the NF provider for MAGI based clients.
How does a client change a Washington Apple Health Managed Care plan?
A client can choose to change plans by contacting Health Care Authority (HCA) by the Provider One portal or calling 1-800-562-3022.
Any issues regarding coverage needs to be addressed directly to the plans. For a complete list of current plans, see Apple Health Managed Care Medical Programs
How do I check to see if a Medicaid client is currently on an Apple Health (AH) managed care MCO plan?
ACES online has current real time data from Provider One on managed care. ACES online does not show historical data on any changes that have occurred in AH MCO such as change in an AH MCO plan, exemption data, enrollment/discharge dates.
To see the current AH MCO status, go to ACES online and check the details tab. Scroll down to "Medical Information" section. Check to see if one of the AH MCO plans is indicated.
Nursing Facility providers check for AH MCO plans searching in the client benefit inquiry under managed care information. If the client is on AH MCO, it will show up under Plan/PCCM Name.
When are long-term care clients disenrolled from Washington Apple Health (AH) Managed Care Organization (MCO) plan?
Clients receiving long-term care services in a NF are disenrolled from AH MCO on the first of the following month. The date is based on when the disenrollment by Health Care Authority (HCA) is completed. There is a deadline for AH MCO disenrollment. This is usually on the 2nd to the last working day of the month.
Even though ALTSA starts the LTC services (custodial care) once the AH MCO client's rehabilitation days are over (if otherwise eligible), AH MCO is responsible to pay for the related physician and other medical services until the effective date of disenrollment.
A client is not disenrolled from AH MCO when the client is receiving rehabilitation services in the NF.
Developmental Disabilities Administration (DDA) RHC clients are disenrolled from AH MCO once they are in the institution over 29 days. The AH MCO plan does not cover services in a DDA state institution.
Once the client is disenrolled from AH MCO, they are considered a "fee for service" (FFS) client.
Example: AH MCO client enters the nursing facility under rehabilitation on 9/4/2016. On 10/15/2016, it is determined (by the plan) that rehabilitation days will end. The NF will notify HCA and if the client is disenrolled by 10/30/2016, the client will be fee for service (FFS) on 11/1/2016.
If the client is not disenrolled by 10/30/2016, the client will be fee for service (FFS) on 12/1/2016.
Note: The AH MCO plans do not cover long term services and supports (LTSS) for clients living in the community or residential settings. These services are not included in the AH MCO contract and considered a "carve out". In home care or residential services are authorized by either Home and Community Services (HCS) or the Developmental Disabilities Administration (DDA). AH MCO clients receiving services authorized by DDA or HCS get their prescription drugs, durable medical equipment, physician services and other medical services through their AH MCO plan.
Financial worker responsibilities
- For a nursing facility admission under AH MCO, don't change the case to a L01, L02, L95 or L99 unless it is confirmed the client will be or projected to be in the NF 30 days or more.
- If the client is on a noninstitutional CN program and has been admitted to the NF, check ACES online to see if the client is on AH MCO (details tab, scroll down to medical information).
- If the NF admission is a AH MCO client, do a barcode tickler for 30 days from the date of admission to check the status.
Submit a 65-10 referral through barcode to social service for a NFLOC determination. Even though it is not required for AH MCO rehabilitation days, it is required to generate a NF award letter when doing a program change once a client is institutionalized 30 days or more.
- Do not issue a short stay letter for an AH MCO client unless the NF has submitted a DSHS 15-031 indicating rehabilitation days or skilled nursing days through the AH MCO plan has ended with an end date.
- If the admission is under 30 days, and rehabilitation days has ended, indicate the day after the rehabilitation end date as the authorization date on the STAY screen. Add text to the short stay letter AH MCO rehabilitation day ends on XX-XX-19XX (enter date).
- A confirmation of NFLOC is required by the HCS SW before a short stay letter is issued.
- Most short stay NF admissions are considered rehabilitation. If the entire short stay is under AH MCO rehabilitation or skilled nursing status, do not issue a short stay letter.
- Indicate in the ACES narrative "AH MCO Rehab Admit" with the date.
See Short stay information for NF admissions not under AH MCO
30 days or more admissions
- Once a classic aged, blind, disabled (ABD) AH MCO client is in a NF 30 days or more, make the necessary changes in the ACES system.
- The authorization date on the INST for a recipient is normally the first date DSHS was notified of the admission. If the FW has information from the NF via DSHS 15-031 NOA that the rehabilitation days have ended, indicate the day after the rehab end date as the authorization date on the INST screen.
- ACES will issue an award letter even though the client may still be receiving rehabilitative services under the AH MCO . Indicate in the text of the award letter "Washington Apple Health Managed Care Rehabilitation Admission".
- During rehabilitation days paid by the AH MCO, the client does not participate toward the cost of care. If the client is close to the resource limit, monitor the resources with the same process used as Medicare days in the NF.
- Indicate in the ACES narrative "AH Managed Care rehab admit" and the date, if the NF reports AH MCO rehabilitation ends, indicate AH MCO rehab end date.
Example: Short Stay #1
S02/SSI related client, not on Medicare admits to a NF on 11/5/2016. 15-031 NOA from NF indicates the 11/5/2016 admission under AH MCO rehabilitation. A 2nd NOA from the NF indicates a discharge date of 11/20/2016 back home. In this example, a short stay letter is not needed. A NFLOC determination from the HCS SW is not needed. The NF admission is covered by the AH MCO. Added CFC to note.
Example: Short Stay #2
S02/SSI related client, on Medicare admits to a NF on 11/5/2016. 15-031 NOA from NF indicates the 11/5/2016 admission date. A 2nd NOA from the NF indicates a discharge date of 11/20/2016 back home. In this example, the client is not on AH MCO because the client is on medicare. A short stay award letter is needed in order for the NF to bill. Send a 65-10 referral for NFLOC. Once NFLOC is received, indicate the admission and discharge on the STAY screen in ACES in order to generate a short stay letter.
Example: Short Stay #3.
S02/SSI related client not on Medicare admits to a NF on 11/5/2016. 15-031 NOA from NF indicates 11/5/2016 admission under AH MCO rehabilitation. A 2nd NOA from the NF indicates rehabilitation days end on 11/20/2016. The FW sends a 65-10 to the HCS SW for a NFLOC determination. Set a barcode tickler to check the status on 12/4/2016. 3rd NOA from NF received indicating client discharged home on 12/1/2016. 14-443 received by the FW from the SW indicating NFLOC and discharged home on 12/1/2016 on MPC services. FW uses the short stay screen to issue the NF A/L. The payment authorization date on the STAY screen is 11/21/2016 (the day after the AH MCO rehabilitation days end). Update the INST with MPC service information.
Example: 30 day or more admission #1
S02/SSI related client not on Medicare admits to a NF on 11/5/2016. 15-031 NOA from NF indicates 11/5/2016 admission under AH MCO rehabilitation. A 2nd NOA from the NF indicates rehabilitation days end on 12/1/2016. The FW sends a 65-10 to the HCS SW for a NFLOC determination. Set a barcode tickler to check the status on 12/15/2016. 14-443 received by the FW from the SW indicating NFLOC and no discharge plan. FW does a program change from S02 to L02. The payment authorization date on the INST screen is 12/2/2016 (the day after the AH MCO rehabilitation days end). Once the program change is completed, the NF award letter is generated.
Example: 30 day or more admission #2
S02/SSI related client not on Medicare admits to a NF on 11/5/2016. 15-031 NOA from NF indicates 11/5/2016 admission under AH MCO rehabilitation. Set a barcode tickler for 12/5/2016 to check the status. 14-443 sent by SW to FW indicating NFLOC, will be in NF 30 days or more and client is still considered under rehabilitation status. The FW will need to do a program change from S02 to L02 as over 30 days. The FW does not know when AH MCO rehabilitation days end, so indicate the first date it was known the client was admitted into the NF. Once the program change is completed, the NF award letter is generated.
Nursing Facility Responsibilities
- The NF is responsible to check the system to see if a Medicaid client is enrolled in an AH MCO plan prior to admission into the NF. WAC 182-501-0200 Third Party Resources and WAC 182-502-0100 General Conditions of payment describe that Medicaid fee for service is the payer of last resort.
- The NF is responsible to get a preapproval and contract with the AH MCO before admitting an AH MCO client into the NF.
- The NF will send a DSHS 15-031 to the DSHS financial worker and indicates if the admission is under an AH MCO.
- The NF will submit the AH MCO rehabilitation claim to Provider One as a class code 55. This notifies the NF billing unit at HCA that the admission is AH MCO rehabilitation and the claim will be paid at -0-.
- The NF will request an HCS social service intake once it is projected that the AH MCO rehabilitation status will end.
- The NF will submit the claim to Provider One as a class code 20 along with the verification from the AH MCO plan that rehabilitation days has ended. A NF award letter is needed in the system before a NF can submit a class code 20 claim.
- The NF payment unit at Health Care Authority (HCA) will notify the HCA managed care section to disenroll the client from HO once they are notified by the NF the rehabilitation days has ended.
How does the NF provider check the Provider One system to see if a Medicaid client is covered under a Washington Apple Health Managed Care plan?
- Log in to the Provider Portal, client benefit level (EXT Provider eligibility checker-claims submitter profile)
- Search in the client benefit inquiry, go to managed care information
- Under managed care information, look under Plan/PCCM Name. If AH MCO is indicated here with an active date, the client is covered under a AH MCO plan.
Provider Billing Guides:
- Health Care Authority Nursing Facility Provider Billing Guide
- ProviderOne Billing and Resource Guide (includes provider notices)
Other managed care information: MCS admissions into a nursing facility
Medical Care Services (MCS) program formally Disability Lifeline-Unemployable (DL-U) (formally GA-U). Instructions for managed care and MCS-State fund medical and nursing home admissions. A nursing home award letter and NFLOC determination will be needed for NF admissions under the MCS program.