Transcript Wellcare Deck Template - Welcome to the Home Care

WELLCARE HEALTH PLANS OF NEW JERSEY, INC.
Managed Long Term Services and Supports(MLTSS)
April 24, 2015
© 2014 WellCare Health Plans Inc. All rights reserved.
Agenda:
• WELLCARE HEALTH PLANS OF NEW JERSEY, INC. COMPANY OVERVIEW
• Success Story
• MLTSS Care Management Model- (Nursing Facility Transitions, Assessment
& Care Management)
• Claims Processing
• Appeals/Grievances Process
• Coordination of Benefits
• Hospice – Room and Board
© 2014 WellCare Health Plans Inc. All rights reserved.
WELLCARE HEALTH PLANS OF NEW JERSEY, INC.
COMPANY OVERVIEW
WellCare Health Plans of NJ, Inc. is a State of New Jersey domiciled health maintenance
organization (“HMO”) and is a wholly-owned, indirect subsidiary of WellCare Health Plans, Inc.
(“WellCare”)
WellCare Health Plans, Inc. provides managed care services targeted to government-sponsored
health care programs, focusing on Medicaid and Medicare. Headquartered in Tampa, Fla.,
WellCare offers a variety of health plans for families, children, and the aged, blind, and disabled,
as well as prescription drug plans.
The company serves approximately 4 million members nationwide as of Sept. 30, 2014
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New Jersey Medicaid Presence
New Jersey Presence: April 2015
22,100 TANF Members
13,464 ABD Members
8,694 ABD W/Medicare
4,238 W/O Medicare
820 MLTSS Members
Effective July 1, 2014, we completed the acquisition of Medicaid
assets from HealthFirst Health Plan of New Jersey, Inc. ("HealthFirst
NJ").
oThe acquired assets primarily include approximately 42,000
Healthfirst Medicaid members, who were transferred to our
Medicaid plan, as well as certain provider agreements.
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WellCare’s Network Management
New Jersey Provider Network: April 2015
1,971 Adult PCPs
1,368 Pediatric Primary Care Providers
22 Hospitals (Medicaid- Medicare)
12,751 Specialist
511 MLTSS Specialty Providers * across
all specialties
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WellCare of New Jersey – Expansion
WellCare current service area
WellCare phase 3 expansion
Go live date: 7/15
WellCare phase 4 expansion
Go live date: 9/15
© 2014 WellCare Health Plans Inc. All rights reserved.
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MLTSS Care Management Model
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WellCare’s Integrated Care Model
Community-Based Social Services
Integrated Care Management and Coordination of Care can:
• Enhance quality of life for members and family caregivers • Provide value to state customers and members
• Significantly decrease inpatient readmissions • Reduce over-utilization across multiple segments
• Reduce non-emergency ground transportation costs • Reduce inpatient bed days
As of March 31, 2014
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WellCare Care Management Program Model
• Managed Long Term Services and Supports (MLTSS)- A program within the
MCO providing services to Medicaid eligible individuals with substantial functional
limitations due to chronic physical or cognitive limitations. MLTSS services are
generally provided in lieu of nursing facility care allowing individuals to be served
in the least restrictive and generally preferred community setting.
• The Care Management Team uses tools including the CNA and New Jersey
Choice tool to identify members at risk for inappropriate or unnecessary nursing
facility admission. Potential members may also be identified through referral
sources such as State agencies, self-referrals, and through network providers.
• Once enrolled, Care Managers work with MLTSS members to provide an
integrated program emphasizing physical and behavioral health and long-term
supports to maximize services and optimize outcomes.
• Staffing for care management follows ratios as outlined below:
• Nursing facility and non-pediatric special care nursing facility – 1:240
• HCBS members residing in an alternative community setting – 1:120
• Members receiving Home and Community Based Services – 1:60
• Members receiving services in Special Care Nursing Facility – 1:48
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WellCare care Management Program Model
• Staffing- 18 Fulltime Care Managers serving 750 members
• RNs, LCSWs, Behavioral Health staff
• 85 % of members reside in home or community based settings
• Initial census on transition was 635
• Transitioned in March 2015 to an all in house care management
staffing model
• Staffing continues to grow to meet anticipated growth
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Community Transition/Money Follows the person
Money Follows the Person (MFP) - Community Transition Services
•
Community Transition Services are provided to identified members to assist in transitioning from an
institutional setting to a home setting in the community through coverage of non-recurring, one-time expenses.
•
This service is provided to support the health, safety and welfare of the member in the least restrictive environment and to meet
both their physical and psychosocial needs. Allowable expenses are those necessary to enable a person to establish a basic
household but do not constitute room and board.
•
A program supervisor within the care management department will serve as the MFP Liaison to act as the
primary point of contact between the Health Plan, OCCO and the nursing facility.
•
Responsibilities in the liaison role include ongoing identification of members who may be eligible for community
transition through participation in case conferencing with care managers and facility interdisciplinary team
meetings.
•
The MFP liaison will ensure a smooth transition from facility based care to home and community based care
through coordination of both needed services to establish the new residence and the ongoing supports to meet
ADL/IADL and quality of life needs. Once the member has transitioned home the MFP liaison will compile the
necessary statistical data to meet the requirements for ongoing tracking and reporting of member outcomes.
•
WellCare’s MFP Liaison is Lissette Verde
•
11 members successfully transitioned to date
•
3 additional members in progress
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Referral and Process Information
• If member is a fee for service Medicaid member the
facility should contact the Office of Community Choice
Options to request an assessment for community
transition and enrollment in MLTSS
• Northern OCCO number 973-648-4691
• If a member is a WellCare enrollee the facility should call 855642-6185 and we will arrange the assessment.
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Claims Processing
Unless otherwise stated in the Provider Participation Agreement (Agreement), providers must submit claims (initial,
corrected and voided) within six (6) months or 180 days from the Medicaid or primary insurance payment date,
whichever is later) from the date of service. Unless prohibited by federal law or CMS, WellCare may deny
payment for any claims that fail to meet WellCare’s submission requirements for clean claims, or that are
received after the time limit in the Agreement for filing Clean Claims. WellCare will adjudicate MLTSS claims
within 15 days of clean claim submission.
• WellCare is required to adjudicate (pay or deny) claims (for MLTSS members) for MLTSS services such as:
Assisted living providers, nursing facilities Custodial Care, special care nursing facilities, CRS providers,
adult/pediatric medical day care providers, PCA and participant directed Vendor Fiscal/Employer Agent
Financial Management Services (VF/EA FMS) claims within the following timeframes:
1. HIPAA compliant electronically submitted clean claims shall be processed within fifteen (15) calendar days of
receipt; and
2. Manually submitted clean claims shall be processed within thirty (30) calendar days of receipt.
• If the beneficiary is dually eligible; Medicare must be billed prior to Medicaid/Family Care if the service is covered
by Medicare. Medicare balances may be billed to the Medicaid/Family Care MCO if the Medicare Benefit is
exhausted.
• If the beneficiary is not enrolled in a MCO or the beneficiary’s Medicaid/Family Care eligibility lapsed and service
is a Medicaid/Family Care billable service, the beneficiary may be covered by Medicaid/Family Care FFS.
https://newjersey.wellcare.com/provider/resources/mltss
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What is an Appeal
An appeal is the procedure that deals with the review of any adverse decision (Plan Determination) or an action.
Appealable actions are but not limited to:
The denial or limited authorization of a requested service, including the type or level of service;
Reduction, suspension, or termination of a service previously authorized by the Department, its agent or Plan;
Denial in whole or in part of payment for a service;
Failure to provide services in a timely manner , as defined by the Department;
Failure of the Plan to act within the timeframes required by 42 CFR 438.408 (b);
Or for a resident of a rural area with only one Plan, the denial of a Medicaid enrollee’s request to exercise his or her right, under 42
CFR 438.52 (b)(2)(ii), to obtain services outside the Plans region
Member Rights Related to Appeals
• Right to a timely appeal review
• Right to request an expedited appeal determination
• Right to request and receive appeal data from the Plan
• Right to receive notice as to how to appeal to the State
• Right to request and be given timely access to the member’s case file and a copy of the case file subject to federal and state
law regarding confidentiality of patient information.
• Right to submit additional evidence documents or allegation of fact or law in person or in writing.
• Right to be treated with dignity and respect.
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Parties to an Appeal
A member may appoint any individual to assist them with their request for an appeal. Parties to an appeal may include a member, a
provider on behalf of member with the member’s written consent, member representative (including an attorney) or the legal
representative of a deceased member’s estate.
A representative who is appointed by the court or who is acting in accordance with State law may also file an appeal on behalf of a
member.
•A surrogate could include, but is not limited to, a court appointed guardian, an individual who has Durable Power of Attorney or a
health care proxy, or a person designated under a health care consent statute.
A representative may:
1. Obtain information about the member’s appeal to the extent consistent with current Federal and State laws
2. Submit Evidence
3. Make statements of facts and law; and
4. Receive notice about the appeals proceedings
A notice is an "equivalent written notice" if it:
– Includes the member’s name and Medicaid number
– Includes the name, of the individual being appointed
– Contains a statement that the member is authorizing the representative to act on his/her behalf for the claim (s) at issue,
and a statement authorizing disclosure of individually identifying information to the
representative
– Is signed and dated by the member making the appointment
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Filing Methods
There are multiple ways a member or provider on behalf of member can file an
appeal.
Available filing methods:
– Orally: by using the appropriate customer service phone number located
on the back of the member’s ID Card.
– Fax: 1-866-201-0657 (toll free)
– Fax: 813-262-2907 (local)
– Postal Mail: WellCare Health Plans
Attn: Appeals Department
P.O. Box 31368
Tampa, FL 33631-3384
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Provider Filing Methods
There are two ways a provider can file an appeal.
Available filing methods:
– Fax: 1-866-201-0657 (toll free)
– Fax: 813-262-2907 (local)
– Mail: WellCare Health Plans
Attn: Appeals Department
P.O. Box 31368
Tampa, FL 33631-3384
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New Jersey Appeals Overview
New Jersey Medicaid Appeal Levels
There are 2 internal level of appeals
 Appeal Standard Resolution Timeframe- Stage 1 Appeals: 10 Calendar days
 Appeal Standard Resolution Timeframe- Stage 2 Appeals: 20 Business days
 Stage 3 appeals
Extending the Time Frame to Obtain Additional Information
The Plan may extend the time frame for standard resolution of the Appeal by up to fourteen (14) calendar
days if the member, the member’s authorized representative, or the provider acting on behalf of the member
with the member’s written consent, requests the extension or the Plan demonstrates that there is need for
additional information and how the delay is in the Member’s interest. If the Plan extends the time frame, it
must, for any extension not requested by the member, get the member’s verbal consent and give the
member written notice of the reason for the delay.
Appeal Overview 19
New Jersey Appeals Overview
Provider Appeals Timeframe
The timeframe to submit and process a Medicaid Provider Appeal varies by State and lines of business.
The timeframe to request a provider appeal for this State/Product is:
 Appeal Submission Timeframe: 90 Calendar days
 Appeal Standard Resolution Timeframe: 30 Calendar days
Appeal Overview 20
New Jersey Appeals Overview
Appeals Timeframe
The timeframe to submit and process a Medicaid Appeal is listed below.
The timeframe to request a member appeal is:
 Appeal Submission Timeframe: 90 Calendar days
 Appeal Expedited Resolution Timeframe: 72-Hours
 Appeals Acknowledgment Timeframe: 10 Business days (Stage 2 appeals only)
 Appeal Standard Resolution Timeframe- Stage 1 Appeals: 10 Calendar days
 Appeal Standard Resolution Timeframe- Stage 2 Appeals: 20 Business days
Extending the Time Frame to Obtain Additional Information
The Plan may extend the time frame for standard resolution of the Appeal by up to fourteen (14) calendar
days if the member, the member’s authorized representative, or the provider acting on behalf of the member
with the member’s written consent, requests the extension or the Plan demonstrates that there is need for
additional information and how the delay is in the Member’s interest. If the Plan extends the time frame, it
must, for any extension not requested by the member, get the member’s verbal consent and give the
member written notice of the reason for the delay.
Appeal Overview 21
New Jersey Appeals Overview
Who can conduct an Appeal?
The Plan must designate someone other than the person involved in making the initial Plan Determination
to decide an appeal/redetermination. If the original denial was based on medical necessity or the lack
thereof, the appeal/redetermination must be performed by a physician with expertise in the field of
medicine that is appropriate for the benefit issues.
Member Appeal Coordinator Responsibility:
The Member Appeal Coordinator is responsible for reviewing and processing appeal request received from
members, member representatives and providers acting on behalf of members with consent. Member
appeals are reviewed and determinations are made in compliance with State, Federal and Plan contractual
guidelines. Appeals requiring medical necessity review are forwarded to the department Nurse for clinical
review.
Appeals requiring clinical review:
The Plan will ensure that the individuals who make decisions on Appeals are clinical peers; hold an active,
unrestricted license to practice medicine or a health profession; are board-certified; are in the same
profession and in a similar specialty as typically manage the medical condition, procedure, or treatment as
mutually deemed appropriate; and are neither the individual who made the original non-certification, nor the
subordinate of such individual (i.e., directly supervised by), when treating the enrollee’s condition or disease if
reviewing any of the following:
1. An Appeal of a denial that is based on lack of medical necessity; and
2. Any Appeal that involves clinical issues.
Appeal Overview 22
New Jersey Appeals Overview
Member Appeal Levels
Medicaid Fair Hearing
•NJ FamilyCare Plan A and ABP members have the right to access the Medicaid Fair Hearing process at any
time during the appeal process only and cannot access a Stage 3 appeal.
•Members eligible solely through NJ FamilyCare B, C and D do not have the right to a Medicaid Fair
Hearing.
•A request for a Medicaid Fair Hearing must be made within 20-days of the date of the denial letter.
•A request for a Medicaid Fair Hearing must be made to the following address
State of New Jersey
Division of Medical Assistance and Health Services
Fair Hearing Section
P.O. Box 712
Trenton, NJ 08625-0712
•
•The member must include their name, address, telephone number, and a copy of the denial letter with their
request for a Medicaid Fair Hearing.
Appeal Overview 23
New Jersey Appeals Overview
Member Continuation of Benefit
Benefits are automatically continued during all Stages (1-3).
•The Plan shall continue the member’s benefits if all of the following are met:
•The Plan receives a valid appeal;
•The member or the provider on behalf of member files the appeal timely;
•The appeal involves the termination, suspension, or reduction of a previously authorized course of
treatment;
•The services were ordered by an authorized service provider;
•For those eligible who requested the Medicaid Fair Hearing Process, continuation of benefits must be
requested in writing within 10 days of the date of the denial letter or prior to the intended effective date of the
Plan proposed action, whichever is later.
Appeal Overview 24
New Jersey Appeals Overview
Provider Appeal Process
•A request for an appeal must be submitted within 90-calendar days from the initial denial.
•Providers appealing payment denials are allowed 1 level of appeal with the Plan.
•The Plan has 30 calendar days to resolve a provider appeal. When the Plan receives a valid request for
appeal from a provider the process below will be followed.
•Review the denial issued by the Plan;
•Determine if the denial issued by the Plan is correct;
•Determine if medical necessity review is required or if an administrative determination can be made;
•Send final notification of the appeals determination to the provider.
Appeal Overview 25
New Jersey Appeals Overview
Member Expedited Appeals Process
•Expedited Appeals
•The Plan offers members an Expedited appeal when taking the time for a standard resolution could
seriously jeopardize the enrollee’s life or health or ability to attain, maintain or regain maximum function.
Such a determination is based on:
•A request from the member
•A provider’s support of the members request
•A provider request on behalf of the member; or
•The Plan’s independent determination.
•The Plan will make the Expedited Appeal decision and notify (both orally and in writing) the member,
member’s authorized representative or provider acting on the member’s behalf as expeditiously as the
medical condition requires, but no later than the timeframe outlined in the timeframe grid from the receipt of
the appeal.
•A request for payment of a service already provided to an enrollee is not eligible to be reviewed as an
Expedited Appeal and is handled as a standard review.
Appeal Overview 26
New Jersey Appeals Overview
Appeal Notification
The Plan shall issue a decision, in writing, to the member, the member’s authorized representative or
providers acting on behalf of the member within the appropriate timeframe listed on the timeframe grid.
There are two (2) primary types of notifications:
Uphold notice – The Plan affirms the initial Plan determination and has determined that the denial of
authorization and or payment is correct.
Overturn notice-The Plan makes a new Plan determination to overturn the original Plan determination and
issue authorization to cover service or issue payment for service rendered.
Appeal Overview 27
Coordination of Benefits
Coordination of benefits (COB) is used when a member is covered by more than one insurance policy.
If the member has other coverage and Wellcare is secondary, the provider
should first submit the claim to primary insurer. Then the secondary claim must be submitted
on paper with the Commercial Insurance EOB attached to the claim to WellCare.
If the beneficiary is dually eligible
–Medicare must be billed prior to Medicaid/Family Care if the service is covered by Medicare
–Medicare balances may be billed to the Medicaid/Family Care MCO if Medicare benefit is exhausted
If the beneficiary has coverage with private insurance (TPL)
–Private insurance must be billed prior to Medicaid/Family Care
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Hospice Care Overview
WHAT IS HOSPICE CARE?
Hospice care is compassionate end-of-life care that includes medical and supportive services intended
to provide comfort to individuals who are terminally ill. Care is provided by a team. Often referred to as
“palliative care,” hospice care aims to manage the patient’s illness and pain, but does not treat the
underlying terminal illness.
Hospice care may include spiritual and emotional services for the patient, and respite care for the
family. Many hospitals and skilled nursing facilities have hospice units, but most hospice care is
provided at home. The Goal of Hospice Care is to keep the terminally ill comfortable, independent for
as long as possible. Hospice allows the individual to receive care and receive support through the
stages of dying and more importantly it allows the terminally ill to die with dignity.
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Hospice Overview
MEDICARE HOSPICE CARE INCLUDES:
Generally, hospice care includes services which are reasonable and necessary for the comfort and management of
a terminal illness. These services may include:
•Physician services.
•Nursing care.
•Physical therapy, occupational therapy, and speech-language pathology services.
•Medical social services.
•Hospice aide services.
•Homemaker services.
•Medical supplies, including drugs and biologicals and medical appliances.
•Counseling, including dietary counseling, counseling about care of the terminally ill patient, and bereavement
counseling.
•Short term inpatient care for respite care, pain control, and symptom management
IF MEDICAID is the sole Payer -COVERED HOSPICE SERVICES:
The services to be covered under Medicaid are essentially those described above for Medicare-covered hospice.
The state Medicaid agency will pay the hospice program a daily rate for the hospice patient’s room and board;
the hospice program must then reimburse the nursing facility for the room and board. Room and board
services include the performance of personal care services, assistance in the activities of daily living,
socializing activities, administration of medications, maintaining the cleanliness of the resident’s room, and
supervising and assisting in the use of durable medical equipment and prescribed therapies.
In the State of New Jersey Hospice is reimbursed based on level of care and consistent with plan of care.
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Hospice Overview
HOSPICE LEVELS OF CARE:
Routine home care: Ninety-three percent of hospice care is provided at the routine home care level. Routine home
care is provided where a person resides. This might be a home, a skilled nursing facility, or an assisted living
facility. It is the level of care provided when the person is not in crisis.
Continuous home care: Occurs where a person resides when there is a medical crisis. During such periods, the
hospice team can provide up to around-the-clock care.
General inpatient care: Occurs in an inpatient facility. If care cannot be managed where the patient resides, the
patient will be moved to an inpatient facility until the patient’s condition is stabilized.
Inpatient respite care: Is provided in an inpatient facility. Because it is acknowledged that caring for a dying person
can be difficult, this level of care is available to give the caregiver a rest. It is available for periods of up to five
consecutive days.
ROOM and BOARD: Based communication from the Division of Medical Assistance and Health Services .
1.
In instances where Medicaid is the sole payor for Hospice, a contract between a hospice agency and a
nursing facility must exist. The MCO (WellCare) will only pay the hospice agency. Once someone is in
hospice, the hospice agency is responsible for making all arrangements for hospice and that includes which
facility. The rate paid to the hospice agency includes the cost of room and board. The hospice agency, based
on an agreement with the nursing facility, should pay room and board to the nursing facility. (Note: The
Medicaid/NJ FamilyCare Hospice beneficiary residing in a NF is not a beneficiary of the nursing facility, but a
Hospice beneficiary)
2.
If the member is eligible for Medicare, he or she shall elect his or her Medicare Part A benefits for hospice
care. For dually eligible Medicare and Medicaid hospice beneficiaries, the hospice benefits election applies
simultaneously under both the Medicare and Medicaid programs. Thus, Medicare is responsible for the
payment of claims for services provided, as first payer of the hospice benefit. Medicaid is responsible for
payment for services not covered under the Medicare hospice benefit, (e.g. room and board) when those
services are Medicaid covered services.
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Hospice Overview
NJ Medicaid Billing Codes:
The rates for the procedure codes marked with an asterisk (*) are subject to an adjustment based on regional
differences in wages as set by Federal statute and current annual Federal Register updates as referenced in
N.J.A.C. 10:53A-5.1(b) and (D)
Procedure code
Description
*T2042
Routine Home Care
*T2043
Continuous Home Care (full rate applies to 24 hours of care)
*T2044
Inpatient Respite Care
*T2045
General Inpatient Care
T2046
Room and Board
-The room and board rate is calculated at 95% of the approved Medicaid NF per diem rate (institutionally specific)
effective at the time services are provided, and excluding retroactive rate adjustments.
The calculated rate used by the hospice as the per diem rate and board rate may be obtained from:
Department of Health and Senior Services
Division of Senior Benefits and Utilization
Office of Nursing Facility Rate Setting and Reimbursement
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RESOURCES
https://newjersey.wellcare.com/provider/resources/mltss
Forms and Documents: newjersey.wellcare.com/provider/forms
Quick Reference Quick Reference Guides: newjersey.wellcare.com/provider/resources
Clinical Practice Guidelines: www.wellcare.com/provider/CPGs
Clinical Coverage Guidelines: www.wellcare.com/provider/CCGs
WellCare Companion Guide: newjersey.wellcare.com/provider/claimsupdates
Provider Training : newjersey.wellcare.com/Provider/ProviderTraining
MLTSS Provider
Communications:http://www.state.nj.us/humanservices/dmahs/home/AL_CRS_Administrators_Letter.pdf
MLTSS Provider Frequently Asked Questions (FAQs):
http://www.state.nj.us/humanservices/dmahs/home/MLTSS_Provider_FAQs.pdf
The Comprehensive Medicaid Waiver:
http://www.state.nj.us/humanservices/dmahs/home/waiver.html