Provider Notice Issued 05/14/2019

Date:   May 14, 2019
 
To:       All Medical Assistance Program Providers
 
Re:      The Medical Electronic Data Interchange (MEDI) System – Identifying Dual Eligible
            Beneficiaries Enrolled in HealthChoice Illinois Managed Long Term Services and Supports (MLTSS)
 
 
Beginning July 1, 2019, the Managed Long Term Services and Supports (MLTSS) program will be part of HealthChoice Illinois statewide. This notice provides information on how to identify dual eligible beneficiaries who have a HealthChoice Illinois MLTSS health plan in the Medical Electronic Data Interchange (MEDI) system. It also provides information for providers on when to bill Medicare, the Medicaid MCO (also known as the HealthChoice Illinois MLTSS health plan), or Medicaid Fee-for-Service (FFS).  
 
How to Identify MLTSS Coverage in MEDI
 
In MEDI, HealthChoice Illinois MLTSS enrollees are identified by having an Exclusion Code of “6” and a “Special Information” message below the “End Date” and “City – State – Zip” line with the following message:  
 
“Medicare is primary payer. Medicaid MCO covers LTC, HCBS waiver services (excluding DD waivers), non-Medicare behavioral health, and non-emergency transportation. Medicaid FFS covers Medicare crossovers and other services not covered by Medicare or the MCO.”
 
 


How Providers Know to Bill Medicare, Medicaid FFS, or the HealthChoice Illinois MLTSS Health Plan
 
Dual eligible beneficiaries with a Medicare Advantage plan or Original Medicare plus a HealthChoice Illinois MLTSS health plan have access to full Medicare and Medicaid benefits.  Medicare remains the primary payor for all HealthChoice Illinois MLTSS enrollees.
 
·         All Medicare covered services must be billed to Medicare.
·         All non-Medicare covered 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 HealthChoice Illinois MLTSS health plan. 

·         All other non-Medicare covered services covered by Medicaid (e.g., non-Medicare Durable Medical Equipment, prescription drugs, inpatient hospital, dental services, vision services, etc.) must 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, the HealthChoice Illinois MLTSS health plan, or Medicaid FFS) that is responsible for paying for the service.
 
Billing Examples for Dual Eligible Beneficiaries Enrolled in a HealthChoice Illinois MLTSS Health Plan
 
Example 1:
Enrollee Has an Appointment with a Primary Care Provider or Medical Specialist
·         Provider bills Medicare.
 
Example 2:
Enrollee Receives Behavioral Health Services
·         Provider bills Medicare when services are covered by Medicare.
·         Provider bills the HealthChoice Illinois MLTSS health plan when services are not covered by Medicare, but are covered by Medicaid.
 
Example 3:   
Enrollee Receives Non-Emergency Transportation to Medicare and Medicaid-Covered Health Services
  • Provider bills the HealthChoice Illinois MLTSS health plan.
 
Example 4:
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:
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:
Enrollee Receives Dental Services
·         Provider bills Medicare when dental services are covered by Medicare.
·         Provider bills Medicaid FFS when dental services are not covered by Medicare, but are covered by Medicaid.
 
Example 7:   
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 the HealthChoice Illinois MLTSS health plan for Medicaid-covered days that are not covered by Medicare.
 
Example 8:   
Enrollee Receives Hospice Care
·         Provider bills Medicare for hospice care.
·         Hospice provider bills the HealthChoice Illinois MLTSS health plan for room and board if the enrollee resides in a nursing facility. The hospice provider pays the nursing facility.  
Questions regarding this notice may be directed to the Department’s Bureau of Managed Care at
217-524-7478 or HFS.MMAI@illinois.gov.
 
 
 
Doug Elwell
Medicaid Director

Notices

 

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