Provider Notice issued 08/08/14

Nursing Home Participation in the Medicare Medicaid Alignment Initiative (MMAI)

Rates

Rates in managed care are a contractual relationship between the MCO and the provider, and each side may negotiate for a rate and structure that they desire. This includes reimbursement agreements that are based on quality and outcome incentives. However, all MCOs participating in MMAI have committed to paying at minimum the Medicaid reimbursement rate a facility would receive in the fee-for-service system using the Resource Utilization Group (RUGS) methodology that the state implemented January 1, 2014. The state will provide all MCOs with a quarterly update of the facility specific RUG-IV nursing component, the capital component and the support component for each facility as well as any add-ons for enhanced care services. HFS will continue to send nursing home providers rate sheets and monthly pre-pay rosters.

Determination of Need

Administration of the Determination of Need (DON) tool and the scoring needed to qualify for nursing home level of care is not within the control of the MCOs. In the immediate future, the system will remain as it is today. Any changes in the future will be the result of the state’s current review of that system and not related to the move to managed care. Moving this function to the MCOs is not being considered at this time. For patients with a DON score that qualifies for nursing home level of care, patient choice is central to the determination of whether services are received in the community or a facility. Obviously, the state and its MCOs are obligated to try to serve individuals in the least restrictive setting of their choice.

Timeline for Enrollment and Opt-Out Process

Voluntary enrollment in MMAI in the Greater Chicago and Central Illinois regions began March 1, 2014. In accordance with an agreement with the nursing home industry, HFS has placed nursing home residents in the second half of the MMAI mailing so that no default assignments of nursing home residents will occur before September 1, 2014. Despite this agreement, there are some circumstances that may result in a nursing home resident being enrolled in MMAI earlier than August. First, a resident may call the Client Enrollment Services Contractor at any time after January 1, 2014, and request to be enrolled. Second, although HFS has attempted to identify residents whose admission is pending, if the HFS eligibility system does not yet reflect a nursing home admission, an individual may receive a mailing earlier. Please review the materials on Illinois Client Enrollment Services MMAI enrollment webpage.

Dual eligibles have the right to opt-out of MMAI at any time by calling either the Client Enrollment Broker or 1-800-Medicare. Opting out moves the beneficiary back to regular Medicare Fee-for-Service (FFS). The MLTSS program then becomes mandatory for duals receiving long term services and supports. However, MLTSS may not be operational when nursing home residents first receive mailings on MMAI. In that case, opting out will initially move the beneficiary back to Medicaid FFS, also. These individuals will eventually receive a letter informing them of the need to enroll in MLTSS.

Bed Certification

Since the concept of MMAI is to unify the coverage of Medicaid and Medicare, an MMAI enrollee may be placed into either a Medicaid certified bed or a Medicare certified bed.

Assessment Tax

For a resident whose care is covered by the MMAI, Medicare Part A is considered the primary payer to the extent Medicare Part A would have been the primary payer in the absence of the demonstration. Enrollment of residents into MMAI should not increase the tax burden on any nursing facility.

Access to Prescription Drugs

Concerns have been raised about situations in which an MCO’s pharmacy prior approval department is not open after hours or on weekends and holidays. This situation is no different than under fee-for-service with the HFS prior approval unit, which is only open during business hours. Medicaid law requires that Medicaid agencies and their contracted MCOs must pay for a 72-hour supply of a medicine dispensed in an emergency situation. If a facility believes that immediate dispensing of a drug is necessary for the health and well-being of a resident, the drug should be dispensed.

Opportunity for Nursing Homes to Participate in MMAI/MLTSS Networks

MMAI/MLTSS MCOs are required to offer network contracts to all nursing homes in their service area. Either party may opt to limit the contract to existing residents. The MCO may terminate or refuse to renew these contracts only if the nursing facility commits a material breach of the contract, including failure to grant timely and reasonable access to the MCOs care coordinators, SNFists (physicians whose practice is primarily the care of nursing facility residents) or other providers. Contracts may also be terminated if a facility loses Medicare or Medicaid certification or licensure. Nursing homes must have an option to terminate a contract with an MCO on 60 days notice.

Also, contracts may be terminated or not renewed if the facility fails to meet quality standards if the following conditions are met:

1. The quality standards are made known to the nursing home prior to the measurement period;

2. The quality standards are measured through objective data;

3. The nursing home is measured on at least a year’s worth of performance;

4. The nursing home has the opportunity to contest the accuracy or measurement of the data through an arbitration process agreed to by contract.

Moving Residents when a Facility is not in Network

It is not the intent or desire of HFS or any of the MCOs to cause any significant moving of residents to new facilities as a result of the move to managed care. All nursing homes must be offered contracts by all MCOs operating in the region. Further, through a 180-day transition period, an enrollee may choose to maintain an existing provider relationship and MCOs must pay for services with pre-existing providers even if they are out of network. When an agreement cannot be reached with a facility, the MCO will make arrangements to move an enrollee to a network facility.

Continuity of Care and Care Plan Adherence

When a resident first transitions to managed care or between managed care MCOs, MCOs must honor and reimburse for services in the existing care plan and any necessary changes in that plan, to the extent the services are covered services under the MCO’s contract, until the MCO develops its own care plan.

MCOs are required to have a process to receive requests for prior approval 24 hours a day, 365 days a year. When a resident’s physician orders a covered service which requires prior approval from the MCO, the MCO must respond within 24 hours or pay for the covered service until a decision on the prior approval is made. If a prior approval is denied, the facility may pursue an expedited appeal process.

Facilities may not be cited by the Department of Public Health for failure to provide a service during the pendency of the expedited appeal or if the service is denied on appeal.

Nursing Home Liaison at HFS

HFS has an inbox dedicated to Long Term Care issues, and nursing home issues involving MMAI can be sent to this inbox. Please send your questions to HFS.LTC@illinois.gov. Nursing facilities having MCO-specific issues should first attempt to resolve those issues directly with the MCO first.

Appeals

HFS, CMS and the MCOs have established an integrated unified system of appeals for residents. Each MCO must have a mechanism in place to track and report all appeals. Residents are required to file their initial appeal with the MCO regardless if the appeal stems from a Medicaid or Medicare covered service or item. Residents will also have the opportunity to access an Independent Review Entity if the decision at the MCO level is adverse.

For more information on the MMAI appeals process, visit the Illinois Unified Medicare-Medicaid Appeals Process webpage (pdf).

Medicare Bad Debt

In the regular Medicare program some providers, including nursing homes, could submit as bad debt the amount of Medicare co-insurance and deductible payments not received from a Medicaid program as a result of the state Medicaid programs policy not paying these amounts if the Medicare payments received already exceed the Medicaid rate for the service. Medicare then made partial payments for this bad debt. Under MMAI, as in Medicare Advantage, these amounts cannot be submitted as bad debt to Medicare. To account for this, federal actuaries included some monies in the MMAI capitation payments to MCOs. CMS and HFS are currently working on clarifying for the MCOs how the process worked in Fee-For-Service and how much was included in their rates to represent these costs. How facilities are compensated for what they previously received under the bad debt policy is a matter to be negotiated between the MCOs and the facilities.

James Parker, Deputy Administrator

Division of Medical Programs