Showing posts with label medicaid. Show all posts
Showing posts with label medicaid. Show all posts

Thursday, May 23, 2019

Does out of state patient eligible for coverage ?


COVERAGE OUT OF STATE



A member, who is temporarily out of the state but still a resident of Arizona, is entitled to receive AHCCCS benefits under any of the following conditions:

1. Medical services are required because of a medical emergency. Documentation of the emergency must be submitted with the claim to AHCCCS.

2. The member requires a particular treatment that can only be obtained in another state.

3. The member has a chronic illness necessitating treatment during a temporary absence from the state or the member’s condition must be stabilized before returning to the state. Services furnished to AHCCCS members outside of the United States are not covered.


 GENERAL QUESTIONS

* We have patients that come from other states and have Medicaid from other states. How do we handle this?


Florida Medicaid cannot be billed for Medicaid recipients from other states.  Each state’s Medicaid program operates independently essentially 50 separate programs).Florida Medicaid  beneficiaries are covered for emergency care or prior approved care in other states. You would have to contact the other state’s Medicaid program to find out if they have a similar provision for their beneficiaries who need out-of-state care.

TRANSPORTATION REQUIRING PRIOR APPROVAL

Non-Emergency Medical Transportation (NEMT)


- All requests for out-of-state transportation and certain related expenses must have prior approval from the broker, except for travel to those facilities which have been granted in-network status. Facilities granted innetwork status are considered in-state providers. Members are required to contact the broker to schedule the travel for all medical appointments or visits, regardless of the in-network or out-of-network status.

NOTE: Individuals who receive both Medicare and Medicaid do not require prior approval for out-of-state transportation


Hospital - An entity that is licensed as an acute care hospital in accordance with applicable state laws and regulations, or the applicable state laws and regulations of the state in which the entity is located when the entity is out-of-state, and is certified under Title XVIII of the federal Social Security Act. The term “hospital” includes a Medicare- or state-certified distinct rehabilitation unit, a “psychiatric hospital” as defined in this section, or any other distinct unit of the hospital. (WAC 182-550-1050)


Out-of-state hospital admissions (does not include hospitals in designated bordering cities)


The agency pays for emergency care at an out-of-state hospital for Medicaid and CHIP clients only.

Note: The agency considers hospitals in designated bordering cities, listed in WAC 182-501-0175, as in-state hospitals for coverage and as out-of-state hospitals for payment, except for critical border hospitals. The agency considers critical border hospitals “in-state” for both coverage and payment.

The agency requires PA for elective, non-emergency care. Providers should request PA when:

• The client is on a medical program that pays for out-of-state coverage. Example: Aged, Blind, Disabled (ABD) Assistance (formerly Disability Lifeline clients) have no out-ofstate benefit except in designated bordering cities.




ELIGIBILITY EFFECTIVE DATES

The following general guidelines apply to eligibility effective dates:

1. For most members, eligibility is effective from the first day of the month of application, the first day of the month in which the member meets the qualifications for the program, or their date of birth, whichever is later.

2. For KidsCare members, if the eligibility determination is completed by the 25th day of the month, eligibility begins on the first day of the following month. For eligibility determinations completed after the 25th day of the month, eligibility begins on the first day of the second month following the determination of eligibility.

3. For Medicare Savings Program (MSP) – QMB members, eligibility begins with the month following the month that QMB eligibility is determined.

4. For Breast and Cervical Cancer Treatment Program (BCCTP) members, eligibility begins on the later of the first date of the month (the application month for BCCTP is the month of the BCCTP diagnosis), or the first day of the month in which the customer meets all the BCCCTP eligibility requirements.

5. For a move into state or release from prison, the begin date is no sooner than that date.

Friday, March 29, 2019

Arizona Long Term Care System (ALTCS) program Basic information

ARIZON HEALTH CARE COST CONTAINMENT SYSTEM FEE-FOR-SERVICE PROVIDER BILLING MANUAL

GENERAL INFORMATION

All Arizona residents can apply for AHCCCS services or the Arizona Long Term Care System (ALTCS) program. There are many programs that individuals may qualify for in order to receive AHCCCS medical or behavioral health services or ALTCS coverage.

The programs have a number of different financial and non-financial requirements that applicants must meet, including, but not limited to:

1. Proof of Arizona residency at the time of application.
2. Proof of U.S. citizenship and identity or proof of qualified alien status.

 If a non-citizen does not meet the qualified alien status requirements for full services, but meets all other requirements for the Caretaker Relative, SOBRA Child, SOBRA Pregnant Woman, Young Adult Transitional Insurance (YATI), Adult, or SSI-MAO category, the individual is eligible to receive Federal Emergency Services (FES) only.

3. An income test that requires applicants to identify all individual and/or family earned and unearned income and to provide documentation if needed.

4. A resource test that requires applicants to identify resources (e.g., homes, other property, liquid assets, vehicles, and any other item of value) and provide documentation of their value.

NOTE: A resource test is only required for the ALTCS program.

5. Other requirements
    * Each program has certain non-financial and/or financial requirements that are unique to the program and are aimed at servicing specific groups of people.


Eligibility

Eligibility determination is not performed under one roof, but by various agencies, depending on the eligibility category.

For example:

* Pregnant women, caretaker relatives, children, and single individuals enter AHCCCS by way of the Department of Economic Security.

* The blind, aged or disabled, who receive Supplemental Security Income, enter through the Social Security Administration.

* Eligibility for categories such as ALTCS, SSI – Medical Assistance Only (Aged, Blind and Disabled, who do not qualify for Supplemental Security Income cash payment),

KidsCare, Freedom to Work, Breast and Cervical Cancer Treatment Program and Medicare Cost Sharing programs are handled directly by the AHCCCS Administration.

Each eligibility category has its own eligibility criteria.

1. Coverage for parents and caretaker relatives is provided under Caretaker Relatives.
2. Coverage for children is provided under the following eligibility categories:
a. ALTCS
b. KidsCare
i. KidsCare is Arizona’s version of the Title XXI State Children’s Health
Insurance Program.
ii. It covers low-income children under age 19, if the family income is less
than 200 percent of the Federal Poverty Level (FPL).
c. Child Group
d. SSI Cash (Title XVI) or SSI MAO
e. Young Adult Transitional Insurance (YATI) for former Foster Care Children
aged 18 to 26
f. Foster Care Children
g. Adoption Subsidy Children
h. Newborns

All babies born to AHCCCS-eligible mothers are also deemed to be AHCCCS eligible and may remain eligible for up to one year, as long as the newborn continues to reside in Arizona.
i. Newborns born to mothers receiving Federal Emergency Services (FES) also are eligible up to one year of age. While the mother will be covered on a Fee-For-Service basis under FESP, the newborn will be enrolled with a health plan.

ii. Newborns born to mothers enrolled in KidsCare will be approved for KidsCare beginning with the newborn’s date of birth, unless the child is Medicaid eligible.

iii. Newborns receive separate AHCCCS ID numbers and services for them must be billed separately using the newborn's ID. Services for a newborn that are included on the mother's claim will be denied.

3. Coverage for single individuals and couples is provided under the following eligibility  categories:

a. ALTCS
b. Breast and Cervical Cancer Treatment Program
c. Family Planning Services (FPS) provides family planning services for up to 24
months to SOBRA pregnant women after a 60-day post partum period.
d. SOBRA Pregnant Women
e. SSI Cash (Title XVI) or SSI MAO
f. Adults
g. Freedom to Work
h. Transplants
i. Medicare Cost Sharing
j. Hospital Presumptive Eligibility (HPE)

Various Medicare Savings Programs help members pay Medicare Part A & B premiums,deductibles, and coinsurance.
1. Qualified Medicare Beneficiary (QMB)
2. Qualified Individual 1 (QI-1)
3. Specified Low Income Medicare Beneficiary (SLMB)

Tuesday, October 30, 2012

Medicaid update - Limit on office visit - General physician



General Physician Visit Exception

Beginning August 1, 2012, reimbursement for procedure codes 99201-99215 is limited to two per month for general services.  This affects the following provider types and specialties: provider types 25, 26, 29 and 30 with a specialty code of 009 (Family Practice), 011 (General Practice), 012 (Preventive Medicine), 018 (Internal Medicine), 045 (Public Health), 075 (Adult Primary Care), 077 (College Health Nurse), 080 (Family Nurse).
Exemption to this limit automatically applies to the following:
  • Recipients under the age of 21
  • A pregnancy-related diagnosis code associated with the visit
  • Visits provided in county health departments, federally qualified health clinics or rural health clinics
  • The rendering provider has another specialty on their enrollment file
Claims with documentation may be submitted for consideration to your local Medicaid area office to override the limit for the following diagnoses:
  • End-stage cirrhosis and ascites (requiring adjustments to diuretic medications and check of potassium levels)
  • Diabetes with complications of peripheral neuropathy resulting in infected foot ulcer (requires frequent visits for antibiotics, debridement)
  • Pneumonia and comorbidities (to monitor treatment response)
  • New onset of syncope (evaluation, review of studies and follow-up)
The Agency for Health Care Administration (Agency) may consider additional diagnoses to exempt from the limit.

Send your claims with documentation describing the medical necessity of the visit to your local Medicaid area office addressed with “Attention: Exceptional Claim Process.”  Contact information for the Medicaid area offices can be found at http://www.mymedicaid-florida.com/.
The Agency wishes to thank you for your continued care of our Medicaid recipients.  Your cooperation in this effort is appreciated.

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