Adult Medicaid Admin. Letters

DMA ADMINISTRATIVE LETTER NO: 10-08 (CCNC/CA EXEMPTIONS)

DATE: August 25, 2008

SUBJECT: CCNC/CA Exemption policy changes

DISTRIBUTION: County Directors of Social Services

Medicaid Eligibility Staff

I. BACKGROUND

Over 80% of North Carolina’s Medicaid recipients who are eligible to be enrolled are enrolled in Community Care of North Carolina/Carolina ACCESS (CCNC/CA). Maintaining access to quality primary care services is necessary to have a vital managed care health plan. Enrollment in CCNC/CA provides the best medical care and the most cost effective care for North Carolina Medicaid citizens. While most people benefit by being enrolled in CCNC/CA, there are certain life and health situations that preclude enrollment in CCNC/CA as being in the best interest of the individual.

Policy in MA-2425 and MA-3435 provides guidelines for exempting Medicaid recipients from CCNC/CA. It establishes procedures for a system of coordination between the state Medicaid program and the county departments of social services in determining the appropriateness of exempting a recipient from CCNC/CA and the appropriate exempt code.

To assure recipients are being enrolled and exempted properly, the DMA Managed Care Section will discontinue the use of the temporary exemption code 9900030 effective September 1, 2008. A letter (Attachment 1) is being mailed on August 29, 2008 to all recipients who currently have 9900030 temporary code exemptions, informing them that they are in a program aid category that requires them to be enrolled in Carolina ACCESS and instructing them to call their caseworker at the county Department of Social Services to select a medical home.

In an effort to assist caseworkers in using the correct exempt code when temporarily exempting a recipient from Carolina ACCESS, changes are being made in policy and procedures regarding temporary exemptions. New codes and procedures for exemptions will be effective September 1, 2008.

II. New Exempt COde Procedures AND POLICY CHANGES:

A. Effective September 1, 2008, DO NOT ENTER 9900030. This code is obsolete.

B. Effective September 1, 2008, a new enrollment form has been designed and named the Carolina ACCESS Enrollment Form for Medicaid Recipients (Attachment 2). Use to enroll all recipients eligible for CCNC/CA.

C. Effective September 1, 2008, when a recipient requests exemption for medical reasons, provide the recipient with a medical exempt request form (Attachment 4) to be taken to his doctor, and have him choose a medical home in the event his medical exempt request is denied. Enter exempt code 9900023 on the 8125. Complete the Carolina ACCESS Enrollment Form for Medicaid Recipients with the exempt code and fax to the managed care section at 919-715-5235. If the medical exempt request is not received within 30 days or if the medical exempt request form is received and exemption is denied, the county will be contacted by the DMA Managed Care Section via fax number provided on the enrollment form that the recipient must be enrolled. If the applicant/recipient did not choose a provider at the time the medical request form was given, auto-assign. If the recipient is approved for exemption, the managed care section will fax the county the appropriate exempt code to be used. (THE ENROLLMENT FORM MUST BE FAXED TO THE MANAGED CARE SECTION. THIS FORM DOES NOT GO TO THE COUNTY MCR)

D. Effective September 1, 2008, when requesting an exemption for reasons other than those found on the EXEMPT CODES chart (Attachment 3) complete the new Carolina ACCESS Enrollment Form for Medicaid Recipients (Attachment 2) providing a detailed explanation for requesting the temporary exemption on the Carolina ACCESS Enrollment Form. Fax the enrollment form to the Managed Care section at the Division of Medical Assistance at 919-715-5235. If a county has a managed care representative (MCR), the DMA Managed Care Section has authorized the MCR to approve or deny the temporary exemption. If your county has an MCR, submit the enrollment form to your MCR.

E. Effective September 1, 2008, Benefit Diversion is an optional CCNC/CA enrollment category.

F. If the recipient states that exemption is needed because the recipient has had an organ transplant or is in end-stage cancer treatment, the DMA Managed Care Section has authorized the MCR to approve. If your county has an MCR, submit the enrollment form to your MCR.

G. The Carolina ACCESS Medical Exemption Request Form with the revision date of April 24, 2007 will be added to policy (Attachment 4).

H. New exemption code 9900058 has been created and will be system generated when a living arrangement of 16 (Recipient is incarcerated) is entered by the caseworker.

I. New exemption code 9900059 has been created and will be system generated when living arrangement code 17 (Recipient is in an Institution for Mental Disease) is entered by the caseworker.

J. New exemption codes:

New exemption codes below will be manually entered.

9900006	Medicaid	Temporary code: USED ONLY WHEN APPROVED BY DMA MANAGED CARE or MCR.
9900023	Medicaid	Temporary code: Medical exemption requested. Decision pending.

New Exemption codes below will be system generated.

9900058	Medicaid	Recipients who are Incarcerated.( Living arrangement 16)
9900059	Medicaid	Recipients who are in an Institution for Mental Disease (Living arrangement 17)
9900070	Medicaid	Mass exemption by practice; USED ONLY BY THE STATE

III. PROCEDURES to follow IN RESPONSE TO LETTERS MAILED AUgust 29, 2008, TO 9900030 RECIPIENTS

A. A list of recipients in your county who currently have the 9900030 code can be found in NCXPTR. The name of the report is DHREJ EXEMPT PVDR CODE.

B. Key the PCP code when the recipient contacts the IMC selecting a medical home.

C. If a recipient has not contacted the agency by September 30, 2008, the county caseworker must assign a PCP. This must be completed by October 15, 2008.

D. If the recipient requests an exemption for medical reasons, DO NOT ENTER 9900030. Provide the recipient with a medical exempt request form (Attachment 4) to be taken to his doctor. Complete the Carolina ACCESS Enrollment Form for Medicaid Recipients with the exempt code 9900023 and fax to the managed care section at 919-715-5235. Have the recipient choose a medical home in the event his medical exempt request is denied. If the recipient does not select a medical home, the IMC must assign one. Enter exempt code 9900023 on the 8125.

E. When requesting an exemption for reasons other than those found on the EXEMPT CODES chart (Attachment 3), complete the new Carolina ACCESS Enrollment Form for Medicaid Recipients (Attachment 2) providing a detailed explanation for requesting the temporary exemption on the Carolina ACCESS Enrollment Form. Fax the enrollment form to the Managed Care section at the Division of Medical Assistance at 919-715-5235. The DMA Managed Care Section has authorized the MCR to approve or deny the temporary exemption. If your county has an MCR, submit the enrollment form to your MCR.

The form will be returned to the fax number provided marked denied or approved with the exempt code to be used. If approved, caseworker will enter the assigned code provided by DMA Managed Care or the county MCR on the 8125. If denied, the county will enroll with the provider listed on the enrollment form.

If you have any questions regarding this information, please contact your Medicaid Program Representative. For any other issues that are not able to be handled through that venue, Mrs. Angela Floyd, Assistant Director for Recipient and Provider Services, will be your point of contact and can be reached at (919) 855-4000.

William W. Lawrence, Jr. M.D.

Acting Director

This material was researched and written by Susan K. Castle, Policy Consultant, Medicaid Eligibility Unit.