|
Effective: December 1, 2006 |
|
|
28.10.05.10ar1 - MA/GAMC Fee-for-Service (Archive) |
Archived: June 1, 2009 |
DHS provides health care coverage to Medical Assistance (MA) and General Assistance Medical Care (GAMC) enrollees on a fee-for-service (FFS) basis for people who do not live in managed care counties, or, who live in managed care counties but are part of one of the groups described below.
Note: All counties are managed care counties for MA and GAMC except for Beltrami, Clearwater, Hubbard, and Lake of the Woods.
Some MA/GAMC clients who live in managed care counties may be part of a group that is excluded from managed care enrollment. These people will receive health care through fee-for-service unless they are part of an excluded group that may voluntarily enroll in managed care. If they choose to voluntarily enroll, their health care coverage will be through a managed care rather than a fee-for-service system.
Some people who live in managed care counties may need to be enrolled for the . These are people who are required to enroll in managed care but must be enrolled for a future month because enrollment could not be completed in time for a to be made for that month. Examples include:
l People who are approved for MA or GAMC for any months before the first month they can be enrolled in managed care. This will generally be for the application processing period and, for MA, any retroactive months.
Example:
Sheila applies for MA on November 12. She requests coverage retroactive to August. She attends a managed care presentation on November 15 and selects a health plan on December 7. MA is approved effective August 1.
Action:
Enroll Sheila in the health plan she selects effective January 1, which is the next available month. Her MA coverage will be delivered through the FFS system for August through December.
l People who move from a non-managed care county to a managed care county. These people will be enrolled for the next available month, so will continue to receive coverage on a fee-for-service basis for one or more months after the move.
l People who were in an excluded group who become mandatory managed care enrollees. These people will continue to receive coverage on a FFS basis until the next available month for managed care enrollment.
Example:
Doug lives in a managed care county. He is eligible for MA with a medical and is excluded from managed care.
n Doug submits his six-month income , due on March 8, on March 20.
n The worker determines that Doug no longer has a spenddown and is now required to enroll in managed care. The worker sends Doug a managed care education packet on March 25.
n Doug selects a health plan and returns the enrollment form on April 4; the worker completes the enrollment on the system April 5.
Action:
Enroll Doug in his selected health plan for May 1 (the next available month). Until May 1, Doug's MA coverage will continue to be through the FFS system.
l People who are reenrolled or reinstated after their MA or GAMC eligibility closed and they were disenrolled from their health plan. These people may be eligible on a FFS basis for any interim months in which they are eligible for MA or GAMC but their health plan reenrollment or reinstatement is not yet effective.
l Certain people, including newborns, who are added to a managed care household. These people may be eligible on a FFS basis for one or more months before they can be enrolled in managed care for the next available month.