To all nursing facilities in the Southwest (SW) and Southeast (SE) Community HealthChoices (CHC) zones.
As the Department of Human Services, Office of Long-Term Living (OLTL) transitions from a fee-for-service model to the CHC managed care model, a payment gap has been identified for some nursing facility (NF) residents seeking CHC enrollment who were determined to be Nursing Facility Clinically Eligible (NFCE). The identified gap is for NF residents who have been determined to be NFCE and applied for CHC but have discharged or passed away prior to the approval of CHC eligibility. Until further notice, the following procedures are being put into place to establish a payment mechanism to ensure continuity of care for NF residents and payment to the NFs.
In accordance with Medical Assistance Bulletin 03-18-20, “Changes to Managed Care Coverage of Nursing Facility Services”, the HealthChoices Physical Health Managed Care Organization (PH-MCO) will pay the NF for the first 30 days of the participant’s stay. The PH-MCO will pay for days 31 and onward, until the day the participant is determined eligible for CHC, assuming the participant remains in the NF. For example, the participant is admitted to a NF on April 1. The PH-MCO will pay for the first 30 days (April 1 to April 30). The participant remains in the NF beyond 30 days and is determined eligible for CHC on June 15; the PH-MCO will continue to pay from May 1 to June 14. The CHC-MCO will begin paying the NF on June 15.
In the scenario that the participant is not determined eligible for the CHC program while they are still in the NF, the PH-MCO is not responsible for payment after day 30. Beginning in the year 2020, the PH-MCO will be responsible for payment from day 31 and onward until the participant leaves the facility even if they are not determined eligible for CHC. However, the Department is setting up a payment mechanism to cover NF stays for years 2018 and 2019 for participants who were never determined CHC eligible prior to leaving the facility. These payment exceptions will be reviewed and processed for payment through OLTL.
In order to request a payment exception, NFs should submit a request with supporting documentation to OLTL’s Provider Operations. Please list the following in the subject line of the email – Day 31 to Discharge Claims. Supporting documents to be included should follow the 180-day exception documentation submission guidelines. They should include the PA 162, the PA 600L, the MA 103, any third-party Explanation of Benefits (EOB), and any other supporting documentation that you have on file. If you have questions about what to submit, please call the Provider Helpline listed below.
OLTL will continue to work with the Nursing Facility Associations and all NF in the SW and SE CHC counties to resolve any issues and to review and process these claims.
If you have any questions, please contact the OLTL Provider Helpline at 1-800-9320939, Option 2.