Provider Notice issued 07/01/16

Nursing Home Participation in the Medicare Medicaid Alignment Initiative (MMAI) and Medicaid Managed Long Term Services and Supports (MLTSS) Program

This notice provides information on a number of issues raised by providers related to nursing home participation in the Department of Healthcare and Family Service’s (HFS) managed care initiative in the Medicaid-Medicare Alignment Initiative (MMAI) and the Managed Long Term Services and Supports (MLTSS) Program.

MMAI is an initiative of both HFS and federal CMS to place beneficiaries who are eligible for both Medicaid and Medicare Parts A & B (“dual eligibles”) into Managed Care Organizations (MCOs) that are responsible for all services covered by both Medicare and Medicaid. This initiative is designed to provide better care coordination and improve health outcomes for individuals who have historically been left on their own to navigate two separate health care systems. MMAI began in March 2014. To see the specific MMAI counties and the MCOs involved, please visit the HFS Care Coordination Expansion webpage (pdf).

MLTSS is a mandatory program for dual eligibles receiving long term services and supports in the Greater Chicago Region who opt out of MMAI (“MLTSS eligibles”). MLTSS eligibles include dual eligibles residing in a nursing facility and individuals on the following HCBS waivers: Supportive Living Facilities, Persons with Disabilities, Persons with HIV or AIDS, Persons with Brain Injury, and Persons who are Elderly. Individuals receiving HCBS on a Developmental Disabilities (DD) waiver or residing in a DD facility are excluded from the MMAI and MLTSS programs. The MLTSS program will operate in Cook, DuPage, Kane, Kankakee, Lake, and Will Counties beginning July 1, 2016. The MCOs contracted for MLTSS are Aetna Better Health, BlueCross Blue Shield, IlliniCare, and Meridian. The county and MCO options for the MLTSS program also are available on the HFS Care Coordination Expansion webpage (pdf).

Rates

Rates paid to providers of services in managed care are a contractual relationship between the MCO and the provider who negotiate their rate and payment structure. This includes reimbursement agreements that are based on quality and outcome incentives. HFS will provide MCOs with Medicaid rates as MCOs may have contractual relationships with providers based on Medicaid rates. 

Enrollment

Enrollment in MMAI in the Greater Chicago and Central Illinois regions began March 1, 2014 and continues in both regions.

Beginning July 1, 2016, the MLTSS program will be a mandatory program for MLTSS eligibles in the Greater Chicago region who opt-out of MMAI. HFS has begun mailing MLTSS enrollment packets that explain the MLTSS eligible’s choice of enrolling in MMAI or MLTSS. MLTSS eligibles who do not choose to enroll in MMAI will choose an MLTSS plan or will be auto-enrolled in an MLTSS plan if a voluntary choice is not made. The MLTSS plan auto-enrollment process considers in order: 1) the MLTSS eligible’s current Medicare Advantage plan, 2) the long term care facility the MLTSS eligible is currently admitted to, 3) the MLTSS eligible’s most recent (prior) MLTSS plan enrollment, 4) the MLTSS eligible’s most recent (prior) Integrated Care Program (ICP) plan enrollment, and 5) a random plan selection when an assignment cannot be made based on any of the previous criteria.

Please review the MMAI and MLTSS enrollment materials on the Illinois Client Enrollment Services enrollment webpage. The MLTSS Program will not be rolled out in the Central Illinois region at this time. 

Opportunity for Nursing Homes to Participate in MMAI/MLTSS Networks

MMAI and MLTSS MCOs are required to maintain an adequate provider network sufficient to provide enrollees with a reasonable choice within each county provided that each affiliated provider meets all applicable state and federal requirements for participation in the Medicaid program. MCOs must establish and maintain the same conditions of participation for their MLTSS program as their MMAI program. MCOs may require that a nursing facility agree to provide access to the MCO’s care management team to coordinate care or provide or arrange for covered services.

Continuity of Care 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. MMAI and MLTSS MCOs will honor a 180-day transition period for new enrollees and a 90-day transition period for enrollees switching from another health plan in which enrollees can continue receiving covered services with out-of-network providers. MCOs are responsible to pay for those covered services.

Providers may choose to contract with all MCOs or may limit their contracts to select MCOs. If an agreement cannot be reached or if a provider elects not to contract with an MCO and an enrollee is residing in the facility, the enrollee can change MCOs; however, the enrollee cannot opt-out of MMAI or MLTSS into Medicaid fee-for-service. Providers are encouraged to contract with all MCOs to avoid any unnecessary limitations on current or future residents.  

Care Plan Adherence

When a resident first transitions to managed care or is switching to another health plan, 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 consistent with the requirements of the Resident Assessment Instrument (RAI) Manual.

For authorizations for enrollees residing in a nursing facility, if a response to the authorization is not provided within 24 hours of the request and the nursing facility is required by regulation to provide a service because a physician ordered it, the MCO is required to pay for the service if it is a covered service, provided that the request is consistent with the policies and procedures of the MCO. 

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

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. 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. The state and its MCOs are obligated to try to serve individuals in the least restrictive setting of their choice.

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.  MLTSS enrollees must be placed into a Medicaid certified bed.

Access to Prescription Drugs

An MMAI MCO’s pharmacy prior approval department not being open after hours or on weekends and holidays 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.

MLTSS MCOs will not cover prescription drugs. MLTSS enrollees will receive prescription drugs through their Medicare coverage or Medicaid fee-for-service, depending on the drug.  

Appeals

HFS, CMS, and the MCOs have established an integrated unified system of appeals for MMAI enrollees. 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 of whether the appeal stems from a Medicare or Medicaid covered service or item. Residents 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, please see the Illinois Unified Medicare-Medicaid Appeals Process webpage (pdf)

Appeals for MLTSS covered services should be filed directly with the MCO. Except for a denial of waiver services, MCOs must have procedures allowing an enrollee to request an external independent review within 30 calendar days after the MCO’s decision notice. Final decisions of appeals not resolved wholly in favor of the enrollee also may be appealed by the enrollee to the state under its Fair Hearings system within 30 calendar days after the MCO’s decision notice.

Medicare Bad Debt

In the regular Medicare program some providers, including nursing homes, 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 makes partial payments for this bad debt.

Enrollment in MLTSS does not impact the Medicare bad debt policy. However, 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. 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.

HFS Contact Information

Questions or issues regarding MMAI or MLTSS may be sent to HFS.MMAI@illinois.gov. Nursing facilities having MCO-specific issues should first attempt to resolve those issues directly with the MCO.

Robert Mendonsa, Deputy Administrator

Division of Medical Programs