Provider Notice issued 08/31/16

Informational Notice

Date:      August 31, 2016

To:         All Medical Assistance Program Providers

Re:         The Medical Electronic Data Interchange (MEDI) system and the Medicaid Managed Long Term Services and Supports (MLTSS) Program

This notice provides information for providers about how to identify Medicaid Managed Long Term Services and Supports (MLTSS) program enrollees on the Medical Electronic Data Interchange (MEDI) system. It also provides information for providers serving MLTSS enrollees about when to bill the MLTSS health plan, Medicare, or Medicaid Fee-for-Service (FFS). 

MLTSS is a mandatory program for individuals who live in the Greater Chicago Region, are eligible for full Medicaid and Medicare benefits (“dual eligible individuals”), receive long term services and supports, and opt-out of the Medicare Medicaid Alignment Initiative (MMAI).

MLTSS Indicator in MEDI

In MEDI, MLTSS enrollees are identified by information in the Managed Care Organization (MCO) segment.  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 designate the individual as enrolled in an MLTSS health plan.

Here is an example:

The MLTSS health plan only covers certain Medicaid services: non-Medicare long term services and supports, non-Medicare behavioral health, and non-emergency transportation. As a dual eligible individual, the MLTSS enrollee’s medical benefits that are not covered by the MLTSS health plan are covered by Medicare or Medicaid FFS. 

How Providers Know to Bill Medicare, Medicaid FFS, or the MLTSS Health Plan

Individuals who choose to enroll in MLTSS instead of enrolling in MMAI still have access to full Medicare and Medicaid benefits. Therefore, when a provider verifies an MLTSS health plan segment on MEDI, the provider must determine if the claim should be submitted to Medicare, Medicaid FFS, or the MLTSS health plan based on the service being provided.

Medicare remains the primary payer of most medical services for all MLTSS enrollees.

·         All Medicare covered services must be billed to Medicare.

·         All non-Medicare 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 MLTSS health plan in which the MLTSS client is enrolled. 

·         All other non-Medicare services covered by Medicaid (e.g., non-Medicare Durable Medical Equipment, non-Medicare prescription drugs, inpatient hospital stays that are non-Medicare covered stays or additional days, non-Medicare dental services, non-Medicare 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 MLTSS health plan) that is responsible for covering the service.

MLTSS Eligibility and Enrollment

MLTSS enrollees include dual eligible 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.

The MLTSS program began operating in Cook, DuPage, Kane, Kankakee, Lake, and Will Counties on 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).  

Illinois Client Enrollment Services mails enrollment packets to dual eligible individuals to explain their choice of enrolling in MMAI or MLTSS. The MLTSS eligible individuals who do not choose to enroll in MMAI must voluntarily choose an MLTSS plan or will be auto-enrolled in an MLTSS plan. The MMAI and MLTSS enrollment materials are posted on the Illinois Client Enrollment Services enrollment webpage.  Members must call Illinois Client Enrollment Services to choose a plan; online enrollment is not an option for MMAI or MLTSS. 

Billing Examples for MLTSS Enrollees

Example 1:

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

·         Provider bills Medicare.

Example 2:  

MLTSS Enrollee Receives Behavioral Health Services

·         Provider bills Medicare when services are covered by Medicare.

·         Provider bills MLTSS health plan when services are not covered by Medicare, but are covered by Medicaid.

Example 3:     

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

·         Provider bills MLTSS health plan.

Example 4:  

MLTSS 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:  

MLTSS Enrollee Receives Vision Services

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

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

Example 6:      

MLTSS 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 MLTSS health plan for Medicaid-covered days that are not covered by Medicare.

Example 7:      

MLTSS Enrollee Receives Hospice Care

·         Provider bills Medicare for hospice care.

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

HFS Contact Information

Questions or issues regarding MLTSS or MMAI 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.

Robert Mendonsa, Deputy Administrator

Division of Medical Programs