Provider Notice issued 10/01/14

CountyCare Program

The purpose of this notice is to provide clarification regarding responsibility between Healthcare and Family Services (HFS) and Cook County for payment for services provided to participants enrolled in the CountyCare program. CountyCare was a Medicaid waiver program operated by Cook County and HFS to provide early coverage to the population in Cook County that would become Medicaid eligible under the Accountable Care Act (ACA) as of January 1, 2014. The CountyCare waiver ended June 30, 2014, and CountyCare now operates as a Managed Care Organization (MCO) similar to the other MCOs operating in Medicaid.

Payment of Services during a Retroactive Eligibility Period Prior to January 1, 2014

Like all Medicaid recipients, CountyCare enrollees were at times eligible for up to three months of coverage prior to the month of application for coverage under the waiver. However, under the terms of the waiver, only Cook County Health and Hospital System providers were eligible for payment for services rendered during the retroactive period to the extent that period was prior to January 1, 2014. During the retroactive eligibility period, HFS was responsible for direct payment to CCHHS for services. HFS cannot reimburse providers other than CCHHS for services provided during the retroactive eligibility period when dates of service fall between November 1, 2012 and December 31, 2013. At the time of service, the Medical Electronic Data Interchange (MEDI) did not reflect full coverage, so providers checking eligibility on MEDI on the date of service should have treated the client as not having Medicaid. MEDI was not revised to reflect Medicaid eligibility until the retroactive eligibility period was established.

Payment of Services during a Retroactive Eligibility Period after December 31, 2013

Beginning with dates of service on January 1, 2014, and later, any Medicaid enrolled provider was eligible for payment for services during a retroactive eligibility period. HFS is responsible for paying these claims directly.

Payment during non-retroactive periods of eligibility

During the operation of the waiver, up through June 2014, CountyCare was responsible for paying all of their network providers (and out-of-network providers of emergency services) for services rendered beginning with dates of service in the month the enrollee applied for CountyCare.

Tables one and two below illustrate the payment responsibilities for both the retroactive period and the non-retroactive or prospective period.

Table 1: Summary of Retroactive Period (three months prior to month of application) Payment Responsibility for CountyCare Members

Table 2: Summary of Non-retroactive Period Payment Responsibility for CountyCare Members

Family Planning Services

CountyCare participants have open access for family planning services, so any Medicaid provider rendering family planning services is eligible to bill CountyCare and receive reimbursement. Family planning services are not limited to the CountyCare provider network.

Prenatal and Delivery Services

CountyCare should always pay for prenatal and labor and delivery services for women enrolled in CountyCare on the date of the service. Providers who received rejections for any prenatal or labor and delivery services should resubmit these claims to CountyCare for reimbursement.

Table 3: CountyCare Error Messages

Any questions regarding this notice may be directed to the CountyCare Call Center at 1-312-864-8200.

Theresa A. Eagleson, Administrator

Division of Medical Programs