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April 3, 2019


The Importance of Eligibility and Enrollment Processes

The SMMC rollout has completed and membership has been assigned to the health plans. Providers are billing these health plans for the services provided and issues are now beginning to bubble up. One of these issues is related to enrollment and eligibility.

A FAHA H&S member experienced an eligibility and enrollment issue that appears to be related to the SMMC rollout. Neither the provider, family member, DCF nor AHCA have a full understanding of how or why this issue is happening. But, they are all working to find the solution to the problem.

The scenario involves a resident already enrolled in Medicaid LTC who recently transitioned to a nursing home from an ALF. Somewhere in that transition process, the resident lost their Medicaid eligibility. There were similar situations that occurred in the last SMMC rollout six years ago.

The issue highlights the importance of checking eligibility and keeping proof of that eligibility through a print-screen or other means. Because, the exact dates and times of that record assist DCF and AHCA to find the root cause of the problem for resolution.

Once this issue has been resolved an explanation will be provided in the newsletter.
AHCA has reiterated the importance of filing complaints through their hub for these types of issues. They need as much information as possible to track and trend problems and to find the root cause of the issue.

Because there have been a few varied types of eligibility and enrollment issues the article from the last newsletter is being run again.

If you have questions, please contact Dana McHugh via email or by calling her at (850) 339-2909.

Residents Assigned Incorrectly to an MMA plan vs Comprehensive or LTC+ Health Plans

The final phase of the SMMC rollout occurred in February. The health plans new to the Medicaid LTC space have received new enrollees throughout the state. This process has been relatively smooth with a few items that have caused some confusion in the rollout. These items have included some health plan provider portal and claims systems alignment issues. And, what appears to be some long-term care enrollees being assigned to an MMA plan versus a comprehensive or LTC+ health plan.

Below is a breakdown of the Medicaid long-term care health plan enrollment statewide:

Please ensure eligibility has been verified on all Medicaid long-term care enrollees and assigned to one of the above health plans. If the long-term care enrollee has been assigned to an MMA plan please confirm the enrollee is ICP eligible by reviewing the aid category. The aid category indicator should begin with an MI if the resident is ICP eligible. AHCA is aware of an issue related to the health plan assignment. They are in the process of identifying those that need to be reassigned to a long-term care plan, with the first batch having been reassigned effective March 1.

AHCA is indicating the MMA plan is responsible for the payment prior to March 1. If the claim is denied, AHCA needs the denial reason and claim number when filing a complaint via the AHCA website. The reason for this needed information is for AHCA to investigate and to identify further enrollees to be assigned correctly.


Major Florida Medicaid Providers Merge in $17.3 Billion Deal. Centene Corp. will acquire Tampa-based WellCare Health Plans, Inc. in a $17.3 billion deal combining two of the biggest players in Florida’s Medicaid managed-care system, the companies said Wednesday. Read more...


Centene’s $15B WellCare Deal Takes a Bigger Share of The Booming Medicare Business. Centene’s decision to buy WellCare Health Plans for more than $15 billion gives the combined national health insurer a stronger presence in the fast-growing Medicare Advantage business. Read more...

Health plan updates

OfficeLink Updates. We are required to notify you of any change that could affect you either financially or administratively at least 90 days before the effective date of the change. This change may not be considered a material change in all states. For more information click here.

CMS Will Conduct a Contract-Level Risk Adjustment Data Validation Audit. The Centers for Medicare & Medicaid Services (CMS) recently let us know that they will perform a contract-level risk adjustment data validation (RADV) audit for Medicare Part C (Medicare Advantage) data for the 2013 benefit year. This means that Florida Blue may request medical records for your BlueMedicare Regional PPO(RPPO) Medicare Advantage patients selected for the audit. For more information click here.

Copyright 2019 — Publication of FAHA H&S
Chair: Brian Robare
President/CEO: Steve Bahmer
Principal/Editor: Dana McHugh

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