TRANSITIONING/TRANSFERRING OF ENROLLEES
A. Transitioning Recipients into MCOs The MCO will be responsible for enrollees as soon as they are enrolled and the MCO is aware of the enrollee in treatment. The MCO must have policies and procedures for transitioning enrollees currently receiving services in the FFS program into the MCO’s plan. The MCO must have policies and procedures including, without limitation, the following to ensure an enrollee’s smooth transition from FFS to the MCO:
- Enrollees with medical conditions such as:
a. Pregnancy (especially if high risk);
b. Major organ or tissue transplantation services in process;
c. Chronic illness;
d. Terminal illness; and/or,
e. Intractable pain.
- Enrollees who, at the time of enrollment, are receiving:
a. Chemotherapy and/or radiation therapy;
b. Significant outpatient treatment or dialysis;
c. Prescription medications or durable medical equipment (DME); and/or,
d. Other services not included in the Medicaid/NCU State Plans but covered by Medicaid under EPSDT for children.
- Enrollees who at enrollment:
a. Are scheduled for inpatient surgery(ies);
b. Are currently in the hospital;
c. Have prior authorization for procedures and/or therapies for dates after their
d. Have post-surgical follow-up visits scheduled after their enrollment The MCO may not request disenrollment of an enrollee for any of the following reasons:
a. An adverse change in the enrollee’s health status;
B. Transferring Enrollees Between MCOs It may be necessary to transfer an enrollee from one MCO to another or to FFS for a variety of reasons. When notified by the DHCFP that an enrollee has been transferred to another plan or to FFS, the MCO must have written policies and procedures for transferring/receiving relevant patient information, medical records and other pertinent materials to the other plan or current FFS provider. Prior to transferring an enrollee, the MCO (via their subcontractors when requested by the MCO) must send the receiving MCO or provider information regarding the enrollee’s condition. This information shall include,
without limitation, whether the enrollee is:
- Receiving dialysis;
- Chronically ill (e.g., diabetic, hemophilic);
- Receiving significant outpatient treatment and/or medications, and/or pending payment authorization request for evaluation or treatment;
- On an apnea monitor;
- Receiving behavioral or mental health services;
- Receiving Nevada early intervention services in accordance with an Individualized Family Service Plan (IFSP), which provides a case manager who assists in developing a plan to transition the child to the next service delivery system. For most children this would be the school district and services are provided for the child through an IEP.
- Involved in, or pending authorization for, major organ or tissue transplantation;
- Scheduled for surgery or post-surgical follow-up on a date subsequent to transition;
- Scheduled for prior authorized procedures and/or therapies on a date subsequent to
- Name and contact information of assigned PCP;
- Referred to a Specialist(s);
- Receiving substance abuse treatment for recipients 21 and older;
- Receiving prescription medications;
b. Pre-existing medical condition;
c. The enrollee’s utilization of medical services;
- Enrollee is in a nursing facility over 45 days;
- Enrollee is in an acute hospital swing bed over 45 days;
- Enrollee is placed in an out of home placement;
- Medicaid enrollee is placed in a hospice;
- Enrollees enters an ICF/ID;
- Enrollee enters a Home and Community Based Services (HCBS) Waiver Program hose enrollees transferring to or from FFS, another MCO, and/or the Statedesignated Health Insurance Exchange (HIX).
The MCO is not financially responsible for any services rendered during a period of retroactive eligibility except in the specific situation(s) described in this Chapter. The MCO is responsible for services rendered during a period of retroactive enrollment in situations where errors committed by the DHCFP or the DWSS, though corrected upon discovery, have caused an individual to not be properly and timely enrolled with the MCO. In such cases, the MCO shall only be obligated to pay for such services that would have been authorized by the MCO had the individual been enrolled at the time of such services. For in-state providersin these circumstances, the MCO shall pay the providersforsuch services only in the amounts that would have been paid to a contracted provider in the applicablespecialty. OOS providers in these circumstances will be paid according to a negotiated rate between the MCO and the OOS provider. The timeframe to make such corrections will be limited to 180 days from the incorrect enrollment date. The DHCFP is responsible for payment of applicable capitation for the retroactive coverage. As described in Section 3603.15(C)(1), the MCO is responsible for Medicaid newborns effective the first day of the month in which the infant was born.
The MCO must notify a recipient that any change in status, including family size and residence, must be immediately reported by the recipient to the DWSS eligibility worker.
B. Enrollment of Pregnant Women
The eligibility of Medicaid applicants is determined by the DWSS. The DWSS notifies the state’s Fiscal Agent who enrolls the applicant. Letters are sent to the new recipients requiring them to select an MCO or an MCO will be automatically assigned. The MCO will be notified of the pregnant woman’s choice by the State’s Fiscal Agent. The MCO shall be responsible for all covered medically necessary obstetrical services and pregnancy related care commencing on the date of enrollment.
C. Enrollment of Newborns
The MCO must have written policies and procedures for newborns of enrollees. The MCOis required to electronically report births as identified in the Forms and Reporting Guide. The MCO will be responsible for all covered medically necessary services included in the MCO benefit package to the qualified newborn.
Enrollment requirements for newborns are as follows:
- Medicaid Eligible Newborns
All Title XIX Medicaid eligible newborns born to enrollees are enrolled effective the first day of the month in which the infant was born. In situations where it is determined that eligibility decisions were made that caused incorrect enrollment decisions, the MMIS may be corrected to show correct enrollment and all payments due the MCO reconciled accordingly.
Freestanding Obstetric/Birth Centers
Section 2301 of the ACA requires coverage of services furnished at freestanding birth centers. The MCO is required to provide services at freestanding obstetric/birth centers. A freestanding birth center is described as a health facility that is not a hospital or physician’s office, where childbirth is planned to occur away from the pregnant woman’s residence. The birth center must be in compliance with applicable state licensure and nationally recognized accreditation organization requirements for the provision of prenatal care, labor, delivery and postpartum care. “Obstetric Center”, Nevada’s legal term for birth center, complies with Section 2301 of the ACA birth
- Receiving DME or currently using rental equipment;
- Currently experiencing health problems; or
- Receiving case management (including the case manager’s name and phone number).
When an enrollee changes MCOs or reverts to FFS while hospitalized, the transferring MCO shall notify the receiving MCO, the receiving provider, or the DHCFP Quality
Improvement Organization (QIO-like vendor) as appropriate, of the change within five calendar days.
A recipient may need to be transitioned between Medicaid and the HIX, due to changes in eligibility. When notified that a member is being transferred to the HIX, the MCO must have written policies and procedures for transferring/receiving relevant patient information and other pertinent materials to/from the HIX. This must be done in compliance with HIPAA and other privacy laws.