Molina Healthcare of New Mexico, Inc.

, Third Party Assessor Provider Training

Third-Party Assessments for Personal Care Options (PCO)

Provider Training February 2010 Molina Healthcare of New Mexico, Inc.

Welcome

Thank you for taking time out of your busy schedule!

Molina Healthcare of New Mexico, Inc. Third Party Assessor (Molina Healthcare TPA) Introductions
OUR MOLINA HEALTHCARE TEAM

Provider Services:
Karen Bounds, Director, Provider Services Denise Henry, Manager, Provider Services Aracely Pena, Provider Services Representative Diego Gutierrez, Provider Services Representative Launa Markel, Provider Services Representative LaDawna King, Provider Services Representative

Utilization Management:
Patty Kehoe RN, Director, Healthcare Services Gina Burttram RN, TPA Manager Kim Shipman, Supervisor, Mi Via , EMSA & PCO
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Who Is Molina?

Founded more than 20 years ago by C. David Molina, MD. Since 1980 Molina Healthcare has been a leader in providing quality healthcare to those who depend on government assistance. Our commitment to our consumers has made us a national leader in providing affordable healthcare to families and individuals. During this time, weve become one of the most experienced managed healthcare companies in the country.  Molina Healthcare Inc., is among the most experienced managed healthcare companies serving patients who have traditionally faced barriers to quality healthcareincluding individuals covered under Medicaid, the Healthy Families Program, the State Childrens Health Insurance Program (SCHIP) and other government-sponsored health insurance programs. Molina has health plans in California, Florida, Michigan, Missouri, New Mexico, Ohio, Texas, Utah and Washington as well as 21 primary care clinics located in Northern and Southern California and additional clinics in Virginia. The companys corporate headquarters are in Long Beach, California.  Serving approximately 96,000 (Salud, SCI & SCI/UNMCI) consumers in New Mexico. Serving as the Medicaid Third-Party Assessor for certain fee-for-service, home and community-based and long-term care programs.
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What We Do
Molina Healthcares mission is to serve low-income populations and those who have traditionally faced barriers to quality of health care.
Molina Healthcares Utilization Management Department:
 Performs utilization review and third-party assessment functions under the Third-Party Assessor contract with the New Mexico Human Services Department/Medical Assistance Division (HSD/MAD)  Participates in provider training sessions.  Offers customer service assistance.  Participates in development of clinically-based criteria.  Makes recommendations to HSD/MAD for enhancements to programs.  Serves as a resource to providers throughout New Mexico.
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Who To Contact
 Molina Healthcare TPA Fax Requests Monday through Friday (except holidays): 8:00 a.m. 5:00 p.m. Dedicated fax lines:
 Toll Free Fax: (866)553-9359 (866)553-9268 and (866)553-9272. Please provide specific information on waiver type (i.e. DD, Mi Via, etc.) with review request.

Molina Customer Service Check status of review requests Monday through Friday (except holidays): 8:00 a.m. 5:00 p.m.
  Telephone: (505) 348-0311 Toll Free Telephone: (866) 916-3250

ACS Verify consumer Eligibility & Claim Status

  Telephone: (505) 246-2056 Toll Free Telephone: (800) 705-4452

Molina Healthcare TPA Website UR Instructions, Training Materials & Frequently Asked Questions
 www.MolinaHealthcare.com

Personal Care Options (PCO)

Third-Party Assessor for PCO

What is Personal Care Option (PCO)?

 This is a program designed to assist Medicaid eligible consumers age 21 and older to obtain non-skilled assistance at home with activities of daily living (ADLs.) The need for assistance is reviewed by Molina Healthcare TPA using medical criteria. The applicant must meet the criteria for low or high nursing facility level of care. PCO services provide an alternative to being placed in a nursing facility.  The PCO program offers a range of services to consumers who are unable to perform some or all activities of daily living because of a disability or functional limitation(s).  POC Services include: Individualized bowel and bladder services, meal preparation and assistance, support services, hygiene/grooming, minor maintenance of assistive devices, mobility assistance, eating, assisting with self-administered medication, skin care, cognitive assistance and household services.

Option because consumers have an option of two different service delivery models:
 Consumer-Delegated  Consumer-Directed

Consumer-Delegated:
 This model is ideal for consumers who do not want to or are not able to direct their own care.

The Consumer:
 Delegates the delivery of services to the Medicaid approved provider PCO Agency.

PCO Agency Is Responsible for:

 Advertising and recruiting prospective attendants, interviewing, hiring, firing and training according to program regulation. (See MAD Regulation 8.315.4.11, Section B)  Quality assurance and is expected to closely monitor the consumers services through monthly supervisory home visits.  PCO Directory: http://www.nmaging.state.nm.us/PCO_Program.html
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Consumer-Directed:
 This model is ideal for consumers want to and are able to direct their own care.

The Consumer:
 Advertises and recruits prospective attendant(s), interviews, hires, fires and trains according to program regulation. (See MAD Regulation 8.3154.10, Section A for specifics on Consumer Directed Personal Care)

PCO Agency Is Responsible for:

 Working with the consumer and acting as the fiscal intermediary.  PCO Directory: http://www.nmaging.state.nm.us/PCO_Program.html

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Consumer Eligibility Requirements

 Must have full Medicaid benefits  Must be 21 years of age and over
 If not yet 21, submit a Medical Assessment Form (MAD 075) 90 days prior to the birthday of turning 21.

 Must meet the medical criteria requirements.

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Molina Healthcare TPA Process for New PCO Consumers Not in CoLTS:
 Consumer calls Molina Healthcare TPA at 1-866916-3250.  Consumer receives packet in the mail with Molina Healthcare TPAs contact information/instructions & a blank MAD 075.  Consumer takes MAD 075 to physician to complete; mails/faxes MAD 075 to Molina Healthcare TPA.  Molina Healthcare TPA staff review the MAD 075 for completeness.
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Molina Healthcare TPA Process for New PCO Consumers Not in CoLTS-cont.
 If the MAD 075 is incomplete, Molina Healthcare TPA will fax it back to the physician indicating what sections need to be completed.  If the MAD 075 indicates that the consumer meets initial criteria, Molina Healthcare TPA will assign an independent assessor to perform an in-home assessment.

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Molina Healthcare TPA Process for New PCO Consumers Not in CoLTS-cont.
 If the MAD 075 indicates consumer does not meet criteria, Molina Healthcare TPA will issue a denial letter to the consumer (and send a copy to PCO agency, if known).  At the in-home assessment, the assessor explains the program and both service delivery models to consumer.

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Molina Healthcare TPA Process for New PCO Consumers Not in CoLTS-cont.
 Molina Healthcare TPA staff reviews the results of the independent assessment to determine if the consumer meets nursing facility level of care (LOC).  If the consumer does meet the level of care, Molina Healthcare TPA will issue an eligibility letter to the consumer and will fax back to the PCO agency the MAD 075 approving a 75 day temporary authorization.
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Molina Healthcare TPA Process for New PCO Consumers Not in CoLTS-cont.
 The MAD 075 will include the authorization number from Omnicaid, the time period, and Units/Hrs approved (dependent on whether delegated or directed).  If the consumer does not meet LOC, Molina Healthcare TPA will issue a denial letter to the consumer (and send a copy to PCO agency, if known).
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Molina Healthcare TPA Process for New PCO Consumers In CoLTS

 MCO sends MAD 075 and in-home assessment to Molina Healthcare TPA.  Molina Healthcare TPA reviews submission of the assessment and MAD 075 and determines LOC.
 If the consumer does not meet LOC, Molina Healthcare TPA will issue a denial letter to the MCO, consumer (and PCO agency, if known).  If the consumer does meet LOC, Molina Healthcare TPA notifies MCO of approval by faxing MAD 075 with the authorization number and LOC span.

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Molina Healthcare TPA Process for New PCO Consumers In CoLTS-cont.

 MCO assigns number of hours and sends authorization information to PCO Agency and consumer.  PCO Agency develops service plan with the consumer.

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Coming Soon
 The completed MAD 075 will be sent to Molina Healthcare TPA by the MCO.  Molina Healthcare TPA will return the MAD 075 form if received directly from a PCO agency for a consumer enrolled with an MCO.

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Annual Re-assessments

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Re-assessment Process
 Consumer receives a letter from the MCO contact with information and blank MAD 075.  Consumer mails/faxes completed MAD 075 to MCO to review within 30 days of receiving MAD 075.  MCO contacts consumer to schedule in-home assessment.  MCO conducts in-home assessment.  MCO sends MAD 075 and assessment to Molina Healthcare TPA.
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Re-assessment Process-cont.
 Molina Healthcare TPA reviews submission of the assessment and MAD 075 and determines LOC.
 If the consumer does not meet LOC, Molina Healthcare TPA will issue a denial letter to the MCO, consumer and PCO agency.  If the consumer does meet LOC, Molina Healthcare TPA notifies MCO of approval by faxing MAD 075 with the authorization number and LOC span.
 MCO authorizes services and informs the PCO Agency and consumer.  PCO Agency receives prior authorization from the MCO and uses the information received to create a service plan with the consumer.

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Re-review Reconsideration Fair Hearing

Re-review
 The request must be received by Molina Healthcare TPA within 10 calendar days from the date on the denial letter. No additional medical/clinical information is required.  For non-CoLTS consumers, the request must be made by the physician.  For CoLTS enrollees, the request must be made by the MCO.  Molina Healthcare TPA has 15 days to reply to the Rereview request.

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Reconsideration
 The request must be received by Molina Healthcare TPA within 30 calendar days from the date of the initial or re-review denial.  The request must have additional medical/clinical information (that is different from the initial information submitted) in order to meet the requirements for the reconsideration.
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Fair Hearing
 This request is administered through the HSD Fair Hearings Bureau.  This is the appeal process that an applicant or recipient may utilize either after the re-review and reconsideration processes have been exhausted, or in lieu of the re-review or reconsideration process.  Consumer has 13 days from date of denial letter to notify Molina Healthcare TPA of request for continuation of care.
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Continuation of Benefits


If you are now receiving services that have been denied, in order to continue to receive the same Medicaid services while the hearing process goes forward, the request for a Fair Hearing must be received by the HSD Hearings Bureau, your local Income Support Division office or the Medical Assistance Division no later than the close of business on the thirteenth (13th) calendar day from the date on this notice. If you ask for a hearing within the thirteen (13) calendar days and continue to receive the same Medicaid services but the final hearing decision favors HSD or the contractor, you will have to repay HSD for the cost of those services (8.352.2.13 (B) (2) NMAC).
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FAQS
Q. What information should I have ready when I call Molina Healthcare TPA Customer Services regarding status of a prior authorization request? A. You will need to provide:
 Recipient number, name and date of birth;  Your provider name and number or NPI;  The date the request was sent to us; and  Item(s) or service(s) requested.

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FAQS Cont.
Q. How will I be notified when my request for prior approval has been completed? A. The form you submitted for the Prior Approval Review Request will be faxed back to you with Molina Healthcare TPAs PA number. Q. Can a consumer in a nursing home transfer to Medicaid Personal Care Options via Community Integration? A. Yes, if they are eligible for full Medicaid and have received a community integration allocation.

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FAQS Cont.
Q. If a consumer is not 21 years of age what alternatives are there? A. The New Mexico Medicaid program (Medicaid) pays for medically necessary personal care services furnished to eligible recipients under 21 years of age as part of the Early and periodic Screening, Diagnostic and Treatment (EPSDT) program. (NMAC 8.323.2 EPSDT PERSONAL CARE SERVICES)

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FAQS Cont.
Q. If a consumer is receiving Medicare can they receive Medicaid Personal Care? A. Yes, if they are on an eligible full Medicaid Category Q. Can a Personal Care Attendant be the consumers spouse? A. No

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THANK YOU!

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