Provider Notice Issued 12/08/2017

Date: December 8, 2017             

To:    All Medical Assistance Providers

Re:   The Medical Electronic Data Interchange (MEDI) System - Dual Eligible

  Beneficiaries Enrolled in Medicaid Managed Long Term Services and Supports (MLTSS) and Medicare

Beginning January 1, 2018, the Managed Long Term Services and Supports (MLTSS) program will become part of HealthChoice Illinois. This notice provides information on how to identify dual eligible beneficiaries who have a HealthChoice Illinois MLTSS plan in the Medical Electronic Data Interchange (MEDI) system. It also provides information for providers on when to bill the Medicaid MCO, Medicare, or Medicaid Fee-for-Service (FFS).   

 How to Identify MLTSS Coverage in MEDI

Through December 31, 2017

In MEDI, through December 31, 2017, MLTSS enrollees are identified by information in the Managed Care Organization section. The Exclusion Code of “9” and the inclusion of “LTSS” at the end of the health plan’s name in the Site Name and Organization Name fields identify the individual as enrolled in an MLTSS health plan.

Beginning January 1, 2018

Beginning January 1, 2018, the MLTSS program will be part of HealthChoice Illinois. In MEDI, HealthChoice Illinois MLTSS enrollees will be identified by having an Exclusion Code of “6” and a “Special Information” message underneath the “End Date” and “City – State – Zip” line with the following message:   

“Medicare is primary payer.  Medicaid MCO covers LTC, HCBS waiver services (excluding DD waivers), non-Medicare behavioral health, and non-emergency transportation.  Medicaid FFS covers Medicare crossovers and other services not covered by Medicare or the MCO.”

Example:

Special Information: Medicare is primary payer. Medicaid MCO covers LTC, HCBS waiver services (excluding DD waivers), non-Medicare   behavioral health and non-emergency transportation. Medicaid FFS covers Medicare crossovers and other services not covered by Medicare  or the MCO.

How Providers Know to Bill Medicare, Medicaid FFS, or the Medicaid MCO

Dual eligible beneficiaries with a Medicare Advantage plan or Original Medicare plus a Medicaid MCO have access to full Medicare and Medicaid benefits.  

Medicare Remains the Primary Payer for All Dual Eligible Beneficiaries

·       All Medicare covered services must be billed to Medicare.

·       All non-Medicare covered long term care services, home and community based waiver services, non-Medicare behavioral health services, and non-emergency transportation services must be billed to the Medicaid MCO  

·       All other non-Medicare covered services covered by Medicaid (e.g., non-Medicare Durable Medical Equipment, prescription drugs, inpatient hospital, dental services, vision services, etc.) should be billed to Medicaid FFS unless they are covered as part of a long term care facility per diem.

·       Any questions or appeals should be sent to the entity (Medicare, Medicaid FFS, or the Medicaid MCO) that is responsible for covering the service.

Eligibility and Enrollment

Dual eligible beneficiaries with a Medicare Advantage plan or Original Medicare plus a Medicaid MCO include individuals residing in a nursing facility and dual eligible individuals on the following Home and Community-based Services (HCBS) waivers: Supportive Living Facilities, Persons with Disabilities, Persons with HIV or AIDS, Persons with Brain Injury, and Persons who are Elderly. These beneficiaries may choose to enroll in the Medicare-Medicaid Alignment Initiative (MMAI) at any time through Illinois Client Enrollment Services if a MMAI is offered in their county.

Billing Examples for Dual Eligible Beneficiaries Enrolled in a Medicaid MCO and Separate Medicare Coverage

Example 1:

Enrollee Has an Appointment with a Primary Care Provider or Medical Specialist

·       Provider bills Medicare.

Example 2:

Enrollee Receives Behavioral Health Services

·       Provider bills Medicare when services are covered by Medicare.

·       Provider bills the Medicaid MCO when services are not covered by Medicare, but are covered by Medicaid.

Example 3:   

Enrollee Receives Non-Emergency Transportation to Medicare and Medicaid-Covered Health Services

·       Provider bills the Medicaid MCO.

Example 4:

Enrollee Receives Prescription Drugs from Pharmacy

·       Provider bills Medicare when prescription drugs are covered by Medicare.

·       Provider bills Medicaid FFS when prescription drugs are not covered by Medicare, but are covered by Medicaid.

Example 5:

Enrollee Receives Vision or Dental Services

·       Provider bills Medicare when vision or dental services are covered by Medicare.

·       Provider bills Medicaid FFS when vision or dental services are not covered by Medicare, but are covered by Medicaid.

Example 6:   

Enrollee Resides in Skilled Nursing Facility

·       Provider bills Medicare for Medicare-covered days.

·       Provider bills Medicaid FFS for co-insurance after Medicare adjudication showing Medicare as the primary payer when claims for Medicare-covered days do not successfully crossover from Medicare to Medicaid FFS.

·       Provider bills the Medicaid MCO for Medicaid-covered days that are not covered by Medicare.

Example 7:   

Enrollee Receives Hospice Care

·       Provider bills Medicare for hospice care.

·       Hospice provider bills the Medicaid MCO for room and board if the enrollee resides in a nursing facility. The hospice provider pays the nursing facility.  

HFS Contact Information

Questions or issues regarding Medicaid Managed Care Programs for dual eligible beneficiaries may be sent to HFS.MMAI@illinois.gov. Providers having health plan specific issues must first attempt to resolve those issues directly with the health plan.

Felicia F. Norwood
Director