Department of Medical Assistance Services – Eligibility and Enrollment Unit MMIS WebEx Training

http://dmasva.dmas.virginia.gov/ 1

Department of Medical Assistance Services

Department of Medical Assistance Services – Eligibility and Enrollment Unit

MMIS WebEx TrainingNovember 2012

http://dmasva.dmas.virginia.gov 1




Agenda• Patient Patient (PP) Adjustments

• AC 058 Project Results

• New DMAS Desk Tools

• Transmittal # 97

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http://dmasva.dmas.virginia.gov



PP ADJUSTMENTS• If a resident requires medical services not covered by

Medicaid and the amount of the adjustment is greater than $500, the LDSS office must submit a DMAS-225 form with the necessary documentation attached. Such medical services must not be covered by Medicaid or be subject to third-party payment.

• Neither DMAS nor DSS can authorize an adjustment when the member’s patient pay amount is zero.



Limitations• A PP adjustment request of this type is completed

when no other payer source exists for the medical expense

• Supplies, equipment, or services used in the direct care and treatment of residents are covered

• Services received must be provided by the nursing home.



Adjustment Requests • PP adjustment requests are first submitted by the

NF directly to the LDSS• When the item/service cost is less than $500 the

LDSS makes the determination to adjust patient pay

• Examples include:– Routine dental care, dentures, & denture repair for members over 21 years of

age– Routine eye exams, eyeglasses, and repair– Hearing aids, and hearing batteries & repair– Batteries for power wheelchairs– Chiropractor services– Prescription drugs– Transportation costs



Adjustment Requests• All requests submitted for any adjustment must

include:– The member’s Medicaid ID number– Physician’s order for non-covered services – The service description and cost– If equipment repair or battery replacement;

documentation that that the equipment continues to be needed

– EOB or denial of payment from any other insurance– All identifying information for any TPL



Adjustment Requests • If the request submitted to the LDSS does

not include all required information:– The request should be returned to the facility– No authorization will be made until all

documentation has been provided– A copy of the letter to the facility will be sent to

the LDSS• Do not forward an incomplete request to

DMAS.



Adjustment Requests to DMAS• Adjustments to PP which exceed $500.00 are

submitted by the LDSS to DMAS for authorization

• Requests must include:– Documentation of the current or most recent PP amount– Medicaid ID #– Service description– Minimum Data Sheet (MDS) for any devices– Physician’s order & medical justification for non-covered

services– All identifying information for any TPL



Medical Justification

• Medical justification must include:

– The physician’s prescription– Diagnosis and medical findings– Identification of functional limitation– Documentation of required quantity,

frequency, and projected length of use– Identification of how service will be used



Mobility Requests

• Mobility requests must include:

– Description of mobility and postural impairments– Description of cognitive ability– Description of how needs were previously met– Components must match functional limitations– Requested wheelchair components must be matched to

the member’s functional limitations and must include an evaluation by a therapist



Communication Devices

• Adjustments for communication device requests must include:

– Medical documentation describing speech limitation, diagnosis, prognosis, and therapy

– Description of how current needs are being met– Documentation of why the device was chosen as well as

the member’s motivation & ability to use – Speech language pathologist evaluation– Documentation of planned device training



Hearing Aids

• Adjustment requests for hearing aids must include:

– Medical documentation– The audiologists evaluation and the

interpretation



Eyeglasses

• Adjustments for eyeglasses must include:

– Medical documentation– An ophthalmologic or optometric evaluation– Identification of cataracts or any cataract

surgery



Prescriptions

• Adjustment requests for drugs and biologicals must include:

– Medical documentation– The National Drug Code (NDC)– The condition being treated by the drug



Emergency Services• DMAS provides telephone pre-authorizations for

emergency medical services by calling (804) 786-2622

• A written response will be sent to the requestor preauthorizing the adjustment

• Normal procedures for the PP adjustment request must still be followed

• Attach a copy of DMAS’ written response to the adjustment package



Patient Pay Adjustment Responses• All letters of response are sent on last

business day of month to LDSS and facility.• If the request is an Emergency the LDSS

should follow the Emergency Procedure.• Incomplete packets – denied after 30 days



AC 058 Project Purpose• The DMAS AC 058 project which was

started in July was intended to assist with:

– Finding incorrect open ended enrollments in AC 058 in the MMIS

– Assisting local agencies with corrections and training issues.

– More projects to come from DMAS…



AC 058 Project Results• LDSS responses for the AC 058 project

were due to DMAS by 8/31/12.

– Replies for 987 members received to date.

– Of these replies 31% of the enrollments were correct and 69% of the enrollments were incorrect



AC 058 Project Findings• A majority of the incorrect enrollments

were due to:• Not end dating spenddown periods

• Not verifying applicant met non-financial requirement of applying for Title II benefits

• Non-reporting by member at start of Title II benefits

• Incorrect evaluation of bills used to meet spenddown



DMAS Desk Tool – Title II• A DMAS desk tool has been developed to assist

workers with questions regarding the non-financial requirement for individuals to apply for Title II benefits.

– The desk tool can be found on the Eligibility and Enrollment webpage (http://dmasva.dmas.virginia.gov/content_pgs/dss-elgb_enrl.aspx) under the “MMIS FAQ’s & Other Training Documents” section. The desk tool is titled “SSA Title II Disability Desk Tool”.

http://dmasva.dmas.virginia.gov/content_pgs/dss-elgb_enrl.aspx




DMAS Desk Tool – Evaluating Bills• A DMAS desk tool has been developed to assist

workers with questions regarding the application of bills to an individual’s spenddown.

– The desk tool can be found on the Eligibility and Enrollment webpage (http://dmasva.dmas.virginia.gov/content_pgs/dss-elgb_enrl.aspx) under the “MMIS FAQ’s & Other Training Documents” section. The desk tool is titled “Bill Evaluation Desk Tool”.





Transmittal # 97• Broadcast 7600 announced the release of

Transmittal # 97 which was effective 9/1/12

• Revised Policy – Medicaid covered groups now fall under one of two categories – CN and MN

• See Medicaid Manual subchapter M0320 for all ABD CN and MN covered groups

• See Medicaid Manual subchapter M0330 for all F&C CN and MN covered groups



Transmittal # 97

• VA Residence for Foster Care Children– Foster care children who receive SSI meet the Virginia

residency requirement regardless of whether another state’s child placing agency maintains custody.

• CNNMP & MI Classifications – Have been absorbed into the Categorically Needy

classification. Any references to CNNMP and MI that remain in the manual will be deleted in future transmittals.



Transmittal # 97• Additional clarifications in Transmittal # 97 include:

– Medicaid eligibility for individuals who refuse to cooperate with DCSE

– Evaluation of government benefits on government sponsored debit cards

– Verification of value of bank accounts– Determining value of countable annuity– Resource assessment and evaluation in M1480– Time frame for acting on reported changes and renewals– Procedure for Recipient Audit Unit referrals



Medicaid Covered Groups



ABD Covered Groups



ABD – Sequential Evaluation

• Determine an individual’s eligibility first in a CN covered group. If the individual is not eligible in a full-benefit CN covered group, determine the individual’s eligibility as MN (on a spenddown).



ABD Individual – Sequential Evaluation

– Current SSI/AG recipient– Former SSI or AG recipient– ABD with income < 80% FPL– Medicaid Works (if disabled, income < 80% FPL, & going to work)– Meets definition of institutionalized individual, evaluate in the

300% of SSI covered groups– Medicare beneficiary, evaluate in the Medicare Savings Programs

(MSP) groups (QMB, SLMB, QI, QDWI).– If the individual meets all the requirements, other than income, for

coverage in a full benefit Medicaid group, evaluate as MN– If the individual is not eligible for Medicaid coverage in an MSP

group AND he is at least age 19 years but under age 65 years or he requests a Plan First evaluation, evaluate in the Plan First covered group.



F&C Covered Group Hierarchy



F&C Covered Groups



F&C Sequential Evaluation

• First, determine an individual’s eligibility first in a CN covered group. If the individual is not eligible as CN, go to the MN groups.



F&C Child Sequential Evaluation– FC child, AA child, special medical needs AA child or an individual

under age 21– Newborn child group – Under the age of 19; evaluate in the FAMIS Plus group (no resource

test)– Child meets definition of institutionalized individual (including hospice);

F&C 300% groups.– Child does NOT meet the definition of an institutionalized individual,

evaluate for FAMIS eligibility (M21)– Child is a

• Child under age 1, • Child under age 18, • Individual under age 21 or • Special medical needs adoption assistance child, but has income in excess of the

appropriate F&C income limit, evaluate as MN.



F&C Adult – Sequential Evaluation– Parent/caretaker relative; LIFC covered group– Not LIFC, but meets definition of pregnant woman; pregnant

woman/newborn child group– Income exceeds LIFC limits, but meets definition of institutionalized

individual (including hospice), evaluate in the F&C 300% SSI groups– Pregnant woman whose income exceeds 133% FPL, evaluate as FAMIS

MOMS (M22)– Screened & diagnosed with breast or cervical cancer or pre-cancerous

conditions by Every Woman’s Life program & does not meet the definition of coverage as SSI, LIFC, Pregnant Woman or Child Under 19 individual; evaluate in the BCCPTA covered group

– Excess income for full coverage in a Medicaid covered group & between the ages of 19 and 64, evaluate for Plan First coverage

– Pregnant woman but has excess income for coverage in a CN group or FAMIS MOMS, evaluate as MN



Medicaid Fraud Referrals



Remember…• Send all questions and proposed topics to

[email protected] • If you have viewed this part of the

presentation through the Knowledge Center, don’t forget to join the DMAS Enrollment Unit for our live WebEx sessions.

Thank You!

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