“Working to protect, preserve, and promote the health and safety of the people of
Michigan by listening, communicating, and educating our providers, in order to
effectively resolve issues and enable providers to find solutions within our
industry. We are committed to establish customer trust and value by providing
a quality experience the first time, every time.”
-Provider Relations
MMBA
Micki Smith
Agenda
What’s New
Healthy Michigan Plan
Provider Portal
Spend-down
Billing Beneficiaries
Health Plan Benefits Website
Document Management Portal
Agenda
Federal and State Law
Healthy Michigan Plan
Federal Eligibility Parameters
Covered Services
Service Delivery System
MI Health Account
Federal Law and State Law
Affordable Care Act.
Public Act 107 of 2013 was signed into law by Governor Snyder September 16, 2013.
Authorizes the Healthy Michigan Plan.
State law requires certain cost-sharing
requirements (co-pays and contributions).
Required an amendment to the Adult Benefits Waiver to implement.
Healthy Michigan Plan
Co-pays and contributions can be reduced by participating in healthy behavior activities.
The Healthy Michigan Plan promotes healthy behaviors and improved health outcomes.
Projected to provide health care to 300,000 - 500,000 people.
As of 5/5/2014, there are 206,842 Healthy Michigan Plan beneficiaries.
Federal Eligibility Parameters
Covers people ages 19-64.
Not receiving or eligible for Medicare.
Not eligible for current Medicaid program.
Not pregnant at the time of application.
Covers up to 133% of the federal poverty level (5% disregard = 138%).
No asset test.
Covered Services
Benefit coverage must be based on federal benchmark coverage and include 10 essential health care services:
1. Ambulatory patient services.
2. Emergency services. 3. Hospitalization.
4. Maternity and newborn care
5. Mental Health and
substance use disorder services, including
behavioral health treatment.
6. Prescription drugs.
7. Rehabilitative and
rehabilitative services and devices.
8. Laboratory services.
9. Preventive and wellness services and chronic
disease management; and
10. Pediatric services,
including oral and vision care.
Service Delivery System
Healthy Michigan Plan beneficiaries will enroll into one of the current Medicaid Health Plans.
Current Medicaid populations that are exempt or voluntary from managed care will remain exempt or voluntary.
Will use the current Prepaid Inpatient Health Plan (PIHP) system of care.
MI Health Account
Required by Public Act 107 of 2013.
Cost-sharing
Average co-pays.
Contribution of 2% annual income for beneficiaries
with income between 100% and 133% of the FPL.
Account will provide information on health care services cost and utilization.
Will show cost of services and amount of contribution in account.
MI Health Account continued
Healthy Behaviors.
Health risk assessment form completed.
If beneficiary engages in healthy behaviors, they may have their cost-sharing reduced.
Goal is to have beneficiary more involved in health care decisions and improved health outcomes.
Information Sources
New website –
www.michigan.gov/healthymichiganplan
New email address –
The Healthy Michigan Plan waiver amendment and approval is posted.
Will continue to post information as it becomes available.
Information Sources continued
New toll-free numbers for Modified Adjusted Gross Income (MAGI) related activities.
MI healthcare helpline is 855.789.5610.
The phone application assistance helpline is 855.276.4627.
ProviderName 1234567890 AnyProfile
Spend-Down
Some individuals are ineligible for MA because their countable income (after all applicable
disregards) exceeds the applicable MA standard. However, they can become eligible for MA by
"spending down" their excess income on eligible medical expenses.
An individual that is over-income for MA, but who is otherwise eligible, can qualify for MA if
allowable medical expenses exceed their spend-down "deductible."
Spend-Down
Beneficiaries who exceed the income
requirement must use their medical costs to get their monthly income at or below the allowable income limits for the month.
The spend-down/deductible amount is usually the amount of a beneficiaries income limit that is
OVER threshold.
Factors or amounts may vary by county. The exact formula is determined by the DHS county where the beneficiary resides.
Highlights
Spend-Down renews each month.
Spend-Down dollar amount may change monthly.
Determining factors:
Income
Employment
Address
Others in household
Sample of Expenses
Care from: hospitals, doctors, nurses, clinics, dentists, podiatrists and chiropractors.
Most medicines.
Medical supplies and equipment.
Transportation to and from medical care.
Personal care services provided in an AFC home or home for the aged.
Beneficiaries cannot apply costs already paid by any other insurances.
Beneficiaries can report old unpaid bills and each new medical cost on their “deductible report” submitted to the county worker
.
“Old Bills” Criteria
The expense was incurred within a month prior to the month being tested.
The expense is/was still unpaid, and:
Liability for the expense still exists (existed).
A third party resource is not expected to pay the expense.
The expense was not previously used to establish MA income eligibility.
Submitting Proof
Beneficiaries can submit proof of Incurred charges to DHS
worker in different formats
.
DHS-114A Deductible Report
• changes in circumstances
Proof cont.
Unpaid Bills
Paid receipts
Other statements
Superbills
The statements must show:
The date of service
The amount owed or paid
Specialist Process
Beneficiary submits application to DHS for Medicaid coverage.
DHS Specialist establishes coverage.
DHS worker sends a letter titled “Deductible
Notice” to the beneficiary.
This notice is also labeled as NOTICE OF CASE
ACTION (DHS-1605 ).
Notice includes the deductible amount and hearing rights.
Spend-Down Process
MSA-Pub. 617 is the brochure sent out to beneficiaries explaining spendown/deductible guidelines and process.
It is the beneficiary’s responsibility to provide the required documents to
the DHS caseworker.
Some counties have a central location for submitting this documentation.
The local DHS worker reviews the medical bills incurred and
determines if the amount of beneficiary liability is met and the first date of Medicaid eligibility.
Not all forms submitted will be counted.
Caseworker will organize the dates of service chronologically.
Bills for services rendered prior to the effective date of Medicaid eligibility are the beneficiary's responsibility.
When the beneficiary turns in the bills that does not “pay” for the services. It
is the responsibility of the beneficiary to make arrangements with the provider for payment.
Spend-Down Process
For the first date of eligibility, the DHS worker sends letters to those providers whose services are:
Entirely the beneficiary's responsibility.
Partly the beneficiary's responsibility and partly Medicaid's responsibility.
A letter is also sent to the beneficiary indicating
which services are the beneficiary’s responsibilities for that first date of Medicaid eligibility.
Spend-Down Process (cont.)
The provider must verify MA eligibility on every visit.
Utilize CHAMPS Eligibility Inquiry to verify when the beneficiary became eligible and when their eligibility was updated.
Once the deductible amount is incurred, eligibility is established through the end of the month.
CHAMPS Eligibility Screens
• Transaction date reflects when eligibility was last updated.
• CHAMPS is updated once the application process is completed by DHS.
• Eligibility may be retroactive up to three months prior to the month of the application.
Dual Coverage
Beneficiary may be in a MSP (Medicare Savings Plan) and also have a spend-down.
Benefit Plan assignment will be QMB until the spend-down is met.
For any Medicare non-covered service, please provide the beneficiary with proof of the
incurred medical expense.
The beneficiary may present these items to
DHS which may be used to satisfy their spend-down. (QMB only pays Medicare Deductible/Co-insurance)
Billing Beneficiaries
General Information for Providers Chapter Section 11
Non-billable Highlights
When a provider accepts a patient as a Medicaid beneficiary, the beneficiary cannot be billed for:
Medicaid-covered services.
Providers must inform the beneficiary before the service is provided if Medicaid does not cover the service.
Medicaid-covered services for which the provider has been denied payment because of:
Improper billing,
Failure to obtain PA, and/or
Over filing limit (retro eligibility MSA-1038)
Missed appointments.
Copying of medical records for the purpose of supplying them to another health care provider.
Billable Highlights
Copayment, PPA.
The provider has been notified by DHS that the
beneficiary has an obligation to pay for part or all of a service because services were applied to the
beneficiary's Medicaid deductible amount.
Medicaid does not cover the service.
If the beneficiary requests a service not covered by Medicaid, the provider may charge the beneficiary for the service if the beneficiary is told prior to rendering the service that it is not covered by Medicaid. If the beneficiary is not informed of Medicaid non-coverage until after the services have been rendered, the
Billable (cont.)
Patient refuses Medicare Part A or B.
Provider chooses not to accept the beneficiary as a
Medicaid beneficiary and the beneficiary had prior knowledge of the situation.
It is recommended that providers obtain the beneficiary's written acknowledgement of
payment responsibility prior to rendering any non-authorized or non-covered service the beneficiary elects to receive.
Spend-Down
Beneficiaries are responsible for payment of expenses that were incurred to meet the
deductible amount.
Payment does not have to be made before
Medicaid eligibility is approved. Providers may bill a beneficiary for services rendered after a claim rejects for lack of Medicaid eligibility.
Partial deductible met.
Reduce amount of providers charges by the spend-down amounts in Form Locator 24F.
Retro Eligibility
Could be several days – 3 months.
DHS may apply old bills to the past three months or may
prospectively apply them to the next several months, depending on the DOS and the date the bill was
presented to the DHS worker.
It is the provider's option to bill Medicaid if the beneficiary
has paid the provider for services rendered. MDCH encourages the provider to return the amount the beneficiary paid and bill Medicaid for the service.
If the provider decides to bill Medicaid, the provider must
return all money the beneficiary paid over and above the amount identified as the beneficiary's responsibility on the Medicaid deductible letter.
Health Plan Website
Resources
Web site developed and maintained by contractor.
Displays the spend-down amount in the eligibility response on their MI Health Plan Benefits page.
The information is yesterday’s information
because the eligibility file is sent each night via CHAMPS.
Document Management Portal
What is DMP?
The Document Management Portal (DMP)
provides a browser-based interface to perform various tasks pertaining to submission of
documents to Michigan Medicaid.
In Phase 1 of implementation, DMP will be
integrated within CHAMPS. Users will be able to access DMP functionality directly through
CHAMPS interface only.
DMP will be authenticated via the State’s Single
By directly accessing the DMP, providers will be
able to submit Medicaid documents that may or
may not be related to claims.
Users accessing the DMP will be able to:
Submit support documents.
Submit documents for authorization and
approval.
Send and receive messages pertaining to
submitted documents.
View documents and associated
correspondence history.
Directly upload documents.
Create cover sheets and fax documents.
Search existing documents that have
been uploaded.
View documents notifications in
CHAMPS.
Have messaging capabilities.
Receive notifications when documents
are approved
.Phase I
Access Points
• CHAMPS Provider Portal
• CHAMPS Direct Data Entry
CHAMPS PROVIDER PORTAL
Click on UPLOAD/VIEW Documents and DMP will launch in a different window. You can work in DMP and CHAMPS simultaneously. DMP remains open until you close out.
DMP will open a new window when you click Upload/View Documents.
Search
Documents
in DMP
When DMP is launched, your NPI is prepopulated. Any documents you have loaded in the past will be shown at the bottom. Search for
documents by entering different data in the search fields. If no date is entered then the last 100 documents in history based on upload date will display.
There are 2 options for Document Type: Consents or Claims
If Consents are selected you have 2 selections available for Document Title. • Hysterectomy Form
If Document Type selected is CLAIM you have multiple options for Document Title • See Drop down above
When searching by TCN the Header TCN must be entered (must end in 000 ).
All search filters MUST match documents in history or search will not yield any results.
Example above searched by BENE ID. As you can see multiple NPI’s were loaded for these documents.
Search results will be listed at the bottom of the screen in sortable fields. Click on the Document Title hyperlink to bring up document.
Click VIEW Message Icon to see messages associated with the document. Click SEND Message Icon to send a message regarding this document.
Searching by STATUS.
Status indicator shows you what status the document is in: approved, hold, rejected, or currently in review/Process.
You can search status of a CONSENT by searching Beneficiary ID and Document TYPE= CONSENTS.
Upload
Select DOCUMENT UPLOAD from top menu bar. Guidelines for uploading documents are highlighted.
Enter required information that is marked with an asterisk (*). You can share documents across different NPI’s.
The example above shows that 5 documents are selected to upload. Options can be changed on each line.
Document Type and Title entered here will be used to search documents once uploaded.
Once the document is uploaded under a TCN, it will automatically be attached to the TCN and Beneficiary ID added to this screen.
Only TCN’s that are listed in CHAMPS as
IN PROCESS or SUSPENDED are eligible to
attach a document to in DMP.
If you do not have an IN PROCESS or
SUSPENDED TCN you can still upload
documents to the beneficiary ID.
To connect an electronic claim with
documentation submitted through the DMP,
when the TCN is not known, the following
notation must be included in the Claim Note
Documents sent via DMP
After all information is filled in CLICK BROWSE It will launch the file upload box.
Select the location where your file is stored and click on file. It will populate in FILENAME box. Once file is selected click OPEN.
Once document is submitted the DMP screen will flash. Upload Successful pop up will display.
Upload is complete. Click OK.
CHAMPS New claim
submission
After filling out all the necessary information to enter a claim in CHAMPS direct data entry (DDE) click SUBMIT CLAIM and you will receive a pop up box (as normal).
The pop up box now contains a new link that says UPLOAD DOCUMENT. Click the UPLOAD DOCUMENT link to launch the DMP portal.
The DMP will launch in a separate window and information from claim will be prepopulated.
You have the ability to make changes at this point and to add a message.
You can only update documents to a TCN that is IN PROCESS or SUSPENDED.
CHAMPS Claim
Adjustment
From CLAIMS menu Select Manage Claims
Select Adjust/Void Claim Provider
Enter Header TCN to be adjusted
Make any and all changes to the claim that are necessary. Hit SAVE .
Hitting save creates a new TCN. You can see the TCN change at the top of the page. Please Note the NEW TCN. You must hit SAVE for DMP to attach to the correct TCN.
Click UPLOAD/VIEW documents button to add document. The DMP will launch in a separate window.
Information from the claim in CHAMPS will be prepopulated in DMP. Verify the information is correct, and fill in remaining areas.
•
You MUST create a new FAX cover sheet for
each document submission.
•
Re-using the same fax cover sheet will result
in the documents being attached to an
incorrect beneficiary and/or claim and the
possibility of your claim(s) being rejected.
A FAX COVER sheet will launch in a new window.
You must create a NEW cover sheet for each documentation submission to DMP.
The BARCODE is created and used to store the PHI on the previous screen.
Print out FAX cover and attach to documents.
Send Fax to appropriate number listed on the cover sheet.
Add note to claim:
Documents sent via DMP
(Loop 2300 NTE segment ) Allow 1 business day for
Messaging
DMP has messaging capability.
These messages will be attached to the document they
are submitted under.
You will receive an EMAIL notification when you have a
new Message in your DMP message box.
The email notification will be sent to the email address that is attached to your single sign on (SSO) login.
Please add our email address to your address book so the email doesn’t delete the notification or add to SPAM or
Select the MESSAGES tab at the to of the DMP Portal.
Messages that are sent to your SSO login ID will be stored in this area. To view message click on the Message indicator
If there is a new message in your box, DMP will generate a generic email alerting you to the email address attached to your Single Sign On (SSO).
You can view the MESSAGE notations here.
Once in the message you have the options to REPLY to sender and VIEW document associated with the message.
Clicking OK takes you back to the Messages Screen. 250 Character limit.
New ICONS display in CHAMPS if there are documents or messages attached to the TCN .
The NOTE icon displays if documents are attached to the TCN.
The ENVELOPE shows if there are messages related to the TCN.
To see the documents /Messages attached you must click UPLOAD/View Documents.
