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Jeanelle Romero PE Program Manager
PE Program
JUST Health
System & Customer Service Updates
HSD Forms & Applications
➢Short-term Medicaid coverage for eligible individuals.
➢Provides access to immediate coverage to eligible recipients.
➢Ensures assistance with submitting an application for possible ongoing Medicaid coverage.
➢Based on self-attestation.
➢MAD Certified PEDs determine eligibility.
➢ If screened correctly, applicant will most likely be approved for ongoing Medicaid coverage.
➢ Individuals may only receive one PE approval in a 12 month period (or one PE per pregnancy).
Begins on the day the PE is granted by PED.◦ Retroactive coverage not available during PE span
Ends on the last day of the following month unless ongoing Medicaid application is submitted. ◦ PE will continue until final determination has been made for ongoing
eligibility.
PE coverage ends on the last day of the month that final determination is made.
◦ If more information is needed to determine ongoing eligibility, ISD will send a Help Us Make A Decision (HUMAD) form to client.
Client must supply information within the timeframe specified on the HUMAD
PEDs are employees of participating hospitals, clinics, FQHCs, DOH, schools, IHS providers, jails, prisons and community organizations.
Two types of PEDs. ◦ 170 – Determine PE for Children and pregnant
women (clinics, FQHCs, DOH, CYFD, schools and community organizations)
◦ 171 – Determine PE for children and pregnant women but also for COEs 100 & 200 (employees of hospitals, IHS facilities and prisons and jails).
PED Certification Trainings◦ Second Tuesday of the month – full day webinar
8:30am to 4:30pm
PED Certification Trainings for Jails\Prisons◦ Two-day training at one of our HSD training labs –
trainings conducted at request
YESNM-PE Demos ◦ YES Fridays: 3rd Friday of each month
➢ NM Medicaid Web Portal • Used to check Medicaid eligibility
➢ YESNM-PE • Used exclusively by certified PEDs
• Allows PEDs to screen, grant PE and submit ongoing Medicaid applications
• After YESNM-PE screening, if PE is granted, there is a direct data feed from ASPEN to YESNM-PE
• PED is notified immediately of applicant’s MCO enrollment
• If applicant is not immediately enrolled with an MCO, a task is generated for our PE Processors to work
Click “Check Clients’ Benefits; Takes you to Linking Account page.Enter the SSN or ASPEN ID of the individual who want to view Medicaid benefits for. **Reminder, you will only be able to view Medicaid benefit’s**
After you successfully link to the client’s account, you will see their account information; the status of the case, current client contact information (mailing address, phone number, authorized representative if one exits on case); and if any HUMADs have been sent with details on what has been requested. Click on “Learn More”
You will be able to review 3 months of potential benefit issuance. If you click on the hyper-link In this example the client is not receiving any Medicaid benefits for the month of February 2018, March 2018 and or April 2018. We are still waiting for income to be received…..
You can see if an individual has been sent a HUMAD, what the HUMAD is for, when the HUMAD was sent and when it’s due. If you can get the requested documents from the individual, you can upload directly into clients case through YESNM-PE by clicking “upload”.
This individual has been approved for Medicaid. When viewing, eligibility the client’s status will always show for the current month. This screen shot shows the individual is getting Medicaid for March 2018. To get more details on that eligibility you would click “Learn More” The next screen will give you benefit details like the COE the client is receiving and the MCO. In this scenario the client has MAGI for Adults, the max co-pay is 101.00 a year and the client is enrolled with United Health Care.
Justice-Involved Utilization of State Transitioned Healthcare ◦ HSD enters into an agreement with
agency/county for data sharing
◦ HSD receives daily interface with correctional facilities to suspend rather than close Medicaid eligibility for individuals defined as inmates (per NMAC)
◦ Release information sent to HSD to reinstate benefits upon release
Currently participating counties/agencies:
CY 2017 7,324 suspensions; 5,876 reinstatements 128 Presumptive Eligibility determinations 3,285 ongoing applications filed 3,005 ongoing application approved
New Mexico Department of Corrections (all facilities)
San Juan County
Bernalillo County Sandoval County
Children Youth and Families Department (juvenile justice facilities)
Santa Fe County
Dona Ana County New Mexico Department of Health -Forensic UnitRio Arriba County
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The suspension will be viewable in the New Mexico Medicaid Portal with the original Category of Eligibility the individual is eligible for.
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➢The incarcerated individual must be approved for Medicaid and have benefits suspended for services to be covered under STMII program.
➢STMII claims may only be Medicaid-covered services for inpatient hospital stays of 24 hours or more.
➢STMII claims: the individual may be eligible for STMII multiple times a year.
➢STMII is only covered for correctional facilities that have a GSA contract with HSD. • contact MAD PE Program Staff for STMII questions
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Next Phase “Live” Spring/Summer, 2018◦ Chaves County
◦ Curry County
◦ Eddy County
◦ Roosevelt County
◦ Quay County
➢ Access to YESNM-PE is ONLY available to certified PEDs
➢ 635 Current PEDs statewide o PE Type 170: 359 o PE Type 171: 276
➢ 2,661 PEs Granted in 2017
o 2,593 PEs (or 97%) of all PEs granted had an ongoing Medicaid
application submitted
➢ 23,519 individuals have been assisted with Medicaid applications
through YESNM-PE
o 19,981 individuals (84.96%) were approved for ongoing Medicaid.
System Updates:
◦ November through December 2017 – Expanded Conduent Call Center to assist with ISD Customer Service Center calls
Medicaid Call Center 888-997-2583
ISD Customer Service 800-283-4465
◦ December 2017 – Movement of Medicaid enrollment functions to ASPEN
PE approvals feed directly into ASPEN instead of Omnicaid
Medicaid ID Cards◦ Hard-plastic, blue Medicaid ID Card no longer
issued
◦ FFS clients
Receive heavy-weight paper version of card
Request replacement cards through YESNM or the Conduent Call Center
◦ Managed Care enrollees
Only receive MCO-issued cards
Request replacement cards directly from MCOs
PED & Provider Forms◦ Current forms should always be utilized
◦ Most up to date versions of forms on the NM Medicaid Web Portal:
◦ https://nmmedicaid.portal.conduent.com/static/index.htm
◦ YESNM www.yes.state.nm.us
Apply for benefits
Renew Benefits
Request Change of MCO (if in allowable switch period)
FFS Clients may Request Replacement Medicaid ID card
◦ HSD Paper Applications
MAD 100 (Medicaid Only Application)
HSD 100 (All HSD Programs)
Available on the HSD web site http://www.hsd.state.nm.us/LookingForAssistance/apply-for-benefits.aspx
Request YES-NM demo session schedules
Request PED Training session schedules
For information on PED enrollment status
Questions regarding JUST Health
PE Program Unit ◦ Jeanelle Romero – PE Program Unit Manager
Vanessa Medina – PE Program Trainer\Auditor
Edmundo Barraza – Enrollment\Reporting Specialist
Roberta Roybal – Enrollment Specialist
Pam Champion – PE Program Auditor
◦ Kimberly Lucero – Application Processing Manager Bernice Sena – Application Processor
Esli Ornelas- Application Processor
Elaine Martinez- Application Processor
Carol Baca – Application Processor
Questions?
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