PrimeWest Health PrimeWest Health SystemSystem

Minnesota Senior Health Minnesota Senior Health OptionsOptions

MSHO ProgramMSHO Program

Effective August 1, 2005Effective August 1, 2005

What is MSHO?What is MSHO?

State-defined programState-defined programMembers have combined Medicare Members have combined Medicare

and Medicaid coverageand Medicaid coveragePrimeWest responsible for PrimeWest responsible for

adjudicating benefitsadjudicating benefitsEligibility determined by MN DHSEligibility determined by MN DHS Includes pharmacy benefit (effective Includes pharmacy benefit (effective

1/1/06)1/1/06)

Billing: Medicare Covered Billing: Medicare Covered ServicesServices

Bill using CMS guidelinesBill using CMS guidelinesCheck with PrimeWest for exceptionsCheck with PrimeWest for exceptions

All MSHO plans must waive the 3-day qualifying All MSHO plans must waive the 3-day qualifying hospital stay prior to SNF or home carehospital stay prior to SNF or home care

Reimbursement based on CMS ratesReimbursement based on CMS ratesCombined Medicare and Medicaid Combined Medicare and Medicaid

payment on one claimpayment on one claimGenerally no deductibles/coinsuranceGenerally no deductibles/coinsuranceCheck your contract for payment ratesCheck your contract for payment rates

Billing: Medicare NON-Covered Billing: Medicare NON-Covered ServicesServices

Bill using DHS guidelinesBill using DHS guidelinesReimbursement based on DHS ratesReimbursement based on DHS ratesGenerally based on MA ratesGenerally based on MA ratesSubject to State coinsurance Subject to State coinsurance

determinationsdeterminationsCheck your contract for payment Check your contract for payment

ratesrates

Coordination of Benefits Coordination of Benefits (COB)(COB)

When no secondary insurance:When no secondary insurance:No need to submit multiple claimsNo need to submit multiple claimsMedicare/Medicaid payment combined Medicare/Medicaid payment combined

into one claiminto one claimSupplemental policiesSupplemental policies

PrimeWest will recoup payment from PrimeWest will recoup payment from supplement.supplement.

CheckingChecking EligibilityEligibility

Check eligibility on all MN Health Care Plan Check eligibility on all MN Health Care Plan enrollees each month.enrollees each month.

Verify eligibility through the Electronic Verify eligibility through the Electronic Verification System (EVS) at 800-657-3613 or Verification System (EVS) at 800-657-3613 or through through ProviderInsite.orgProviderInsite.org

A member’s coverage will never be terminated in A member’s coverage will never be terminated in the middle of a month. PW coverage is not the middle of a month. PW coverage is not retroactive, but if a member is eligible during a retroactive, but if a member is eligible during a month, they will be covered throughout the whole month, they will be covered throughout the whole month. PW does not determine a member’s month. PW does not determine a member’s eligibility. This is determined by the county.eligibility. This is determined by the county.

Benefits for the Members Benefits for the Members Enrolled in MSHOEnrolled in MSHO

This is Total Coordinated Health care, This is Total Coordinated Health care, including Medicaid and Elderly Waivered including Medicaid and Elderly Waivered Services.Services.

Each member is assigned a Care Each member is assigned a Care Coordinator and a County Case Manager.Coordinator and a County Case Manager.

Minimum Yearly assessment of Minimum Yearly assessment of individual.individual.

3-day qualifying hospital stay waived to 3-day qualifying hospital stay waived to access Medicare A benefits for SNF or access Medicare A benefits for SNF or home care.home care.

Benefits for the Members Benefits for the Members Enrolled in MSHO (Continued)Enrolled in MSHO (Continued)

No limit on blood transfusionsNo limit on blood transfusionsDiabetic shoes.Diabetic shoes.Automatic enrollment into Medicare Automatic enrollment into Medicare

Part D program through PrimeWest.Part D program through PrimeWest.

AuthorizationsAuthorizations

For all members enrolled in MSHO, For all members enrolled in MSHO, PrimeWest pays the Medicare and Medicaid PrimeWest pays the Medicare and Medicaid benefit in one combined payment. If a benefit in one combined payment. If a member chooses to go to a non-contracted member chooses to go to a non-contracted provider, prior to seeing the member, the provider, prior to seeing the member, the provider must obtain a service provider must obtain a service authorization.authorization.

This authorization may be obtained by This authorization may be obtained by calling Medical Administration at (866)431-calling Medical Administration at (866)431-0803.0803.

Claim SubmissionClaim Submission Member’s ID number for Part A, B, or D is their Member’s ID number for Part A, B, or D is their

PrimeWest ID number.PrimeWest ID number.

Claims for Covered Services rendered to MSHO Claims for Covered Services rendered to MSHO members should be submitted to and received by members should be submitted to and received by PrimeWest PrimeWest no later than one-hundred and eighty no later than one-hundred and eighty (180) days from the date of service.(180) days from the date of service.

Claims should be sent to PrimeWest Health Claims should be sent to PrimeWest Health System at:System at:

822 South 3822 South 3rdrd St., Ste 150 St., Ste 150Minneapolis, MN 55415Minneapolis, MN 55415

180 day benefit180 day benefit

180 day benefit: (Nursing Home Residents) 180 day benefit: (Nursing Home Residents)

Any PrimeWest Health System enrollee admitted Any PrimeWest Health System enrollee admitted to a nursing home from the community is entitled to a nursing home from the community is entitled to 180 days of care paid for by PrimeWest. After to 180 days of care paid for by PrimeWest. After the initial 180 days, billing for nursing facility care the initial 180 days, billing for nursing facility care should be submitted to the Minnesota should be submitted to the Minnesota Department of Human Services (DHS).Department of Human Services (DHS).

If a PrimeWest Health System enrollee is If a PrimeWest Health System enrollee is currently residing in the nursing home at the time currently residing in the nursing home at the time they enroll in MSHO or MSC, they are NOT they enroll in MSHO or MSC, they are NOT entitled to the 180 day benefit.entitled to the 180 day benefit.

180 Day Benefit (cont.)180 Day Benefit (cont.)

Medicare SNF days.Medicare SNF days. PrimeWest is responsible for services covered PrimeWest is responsible for services covered

under the Medicare Advantage Special Needs under the Medicare Advantage Special Needs Population (SNP) benefit regardless of whether Population (SNP) benefit regardless of whether NF liability is indicated on the State’s Medical NF liability is indicated on the State’s Medical Assistance file.Assistance file.

Medicare SNF days for the Enrollee incurred Medicare SNF days for the Enrollee incurred prior to the begin date of the 180-day NF prior to the begin date of the 180-day NF benefit do not count toward the 180 day benefit do not count toward the 180 day benefit. This section does not apply to the 90-benefit. This section does not apply to the 90-day NF benefit.day NF benefit.

180 Day Benefit (cont.)180 Day Benefit (cont.)Swing BedsSwing Beds

These include Medicare SNF days and These include Medicare SNF days and Medicaid room and board days provided Medicaid room and board days provided in swing beds that meet all other in swing beds that meet all other requirements for use of swing beds, requirements for use of swing beds, including claims processing procedures including claims processing procedures and Minnesota Department of Health and Minnesota Department of Health approval.approval.

180 Day Benefit (cont’d)180 Day Benefit (cont’d)Swing BedsSwing Beds

PrimeWest Health System must be PrimeWest Health System must be notified when a member is in a Swing notified when a member is in a Swing Bed. Use the appropriate notification Bed. Use the appropriate notification form based on the member’s form based on the member’s enrollment.enrollment.MSHO members-MSHO notification formMSHO members-MSHO notification formPMAP members – PMAP formPMAP members – PMAP form

HospiceHospice

When MSHO member chooses to enroll in When MSHO member chooses to enroll in hospice, they remain in MSHO; but Medicare hospice, they remain in MSHO; but Medicare assumes direct responsibility for all Part A & B assumes direct responsibility for all Part A & B services for that member, including but not services for that member, including but not limited to the hospice services.limited to the hospice services.

Institutional SNF or NF days that accrue during a Institutional SNF or NF days that accrue during a hospice election period do not cound toward the hospice election period do not cound toward the 180 day SNF/NF benefit period.180 day SNF/NF benefit period.

Institutional room & board for these days is paid Institutional room & board for these days is paid by the State on a fee-for-service basis (DHS by the State on a fee-for-service basis (DHS contract section 4.22.1 C-4)contract section 4.22.1 C-4)

Days accrued in the hospice setting do not count Days accrued in the hospice setting do not count toward the 180 day SNF/NF benefit.toward the 180 day SNF/NF benefit.

Hospice (cont.)Hospice (cont.)

Essentially a hospice member is still Essentially a hospice member is still officially enrolled in MSHO, but the officially enrolled in MSHO, but the coverage reverts to a status more coverage reverts to a status more like Minnesota Senior Care (MSC), like Minnesota Senior Care (MSC), with PrimeWest responsible only for with PrimeWest responsible only for the Medicaid-covered services not the Medicaid-covered services not covered by Medicare.covered by Medicare.

180 Day Benefit (cont.)180 Day Benefit (cont.) Medicaid NF daysMedicaid NF days

These may include Medicaid leave days. Leave These may include Medicaid leave days. Leave days must be for hospital or therapeutic leave days must be for hospital or therapeutic leave of an Enrollee who has not been discharged of an Enrollee who has not been discharged from a long term care facility.from a long term care facility.

According to current MA standards, payments According to current MA standards, payments for hospital leave days are limited to 18 for hospital leave days are limited to 18 consecutive days for each separate and consecutive days for each separate and distinct episode of Medically Necessary distinct episode of Medically Necessary hospitalization, and payments for therapeutic hospitalization, and payments for therapeutic leave days are limited to 36 leave days per leave days are limited to 36 leave days per calendar year.calendar year.

Respite days do not count towards the Respite days do not count towards the Medicaid or Medicare Benefit Period.Medicaid or Medicare Benefit Period.

180 Day Benefit (cont.)180 Day Benefit (cont.)

If a PrimeWest enrollee is in the If a PrimeWest enrollee is in the middle of their 180 day benefit and middle of their 180 day benefit and they enroll in MSHO, this benefit they enroll in MSHO, this benefit ends. DHS is responsible for this ends. DHS is responsible for this member’s nursing care.member’s nursing care.

180 Day Benefit Cont.180 Day Benefit Cont.

New AdmissionNew Admission: Example: New : Example: New admit on 12-29-05 (currently does admit on 12-29-05 (currently does not have PrimeWest). 1/1/06 person not have PrimeWest). 1/1/06 person signs up for PrimeWest/MSHO – This signs up for PrimeWest/MSHO – This resident is NOT entitled to the 180 resident is NOT entitled to the 180 day benefit, as he/she was residing in day benefit, as he/she was residing in the nursing facility at the time of the nursing facility at the time of enrollment.enrollment.

100 Medicare Days100 Medicare Days MSHO enrollees are entitled up to 100 MSHO enrollees are entitled up to 100

days of Medicare coverage if the Medicare days of Medicare coverage if the Medicare qualifications have been met.qualifications have been met.

The nursing facility should notify The nursing facility should notify PrimeWest Health System of when the PrimeWest Health System of when the resident became a Medicare skilled level resident became a Medicare skilled level of care using the MSHO notification form.of care using the MSHO notification form.

Once the 100 days of Medicare coverage Once the 100 days of Medicare coverage are used, the person is not entitled to are used, the person is not entitled to another 100 days, unless there has been a another 100 days, unless there has been a 60 day break from the Medicare skilled 60 day break from the Medicare skilled level.level.

100 Medicare Days (cont)100 Medicare Days (cont)

Claims for the Medicare days for an MSHO Claims for the Medicare days for an MSHO enrollee would be sent to PrimeWest.enrollee would be sent to PrimeWest.

A resident is entitled to the 100 Medicare A resident is entitled to the 100 Medicare days no matter how long they have been a days no matter how long they have been a resident at the nursing facility, as long as resident at the nursing facility, as long as they meet the requirements of a skilled they meet the requirements of a skilled level of care.level of care.

If a resident remains at a Medicare skilled If a resident remains at a Medicare skilled level and has used up their 100 days, they level and has used up their 100 days, they are NOT entitled to an additional 100 days.are NOT entitled to an additional 100 days.

MSHO Notification FormMSHO Notification Form

This form is used ONLY for PrimeWest MSHO This form is used ONLY for PrimeWest MSHO members. Use this form to notify PrimeWest members. Use this form to notify PrimeWest and MHP of Medicare days used and and MHP of Medicare days used and notification of the 180 day benefit. This form notification of the 180 day benefit. This form must be faxed to both PrimeWest and MHP. must be faxed to both PrimeWest and MHP. The The only time this form is sent to the Stateonly time this form is sent to the State is is to notify them of the end of the 180 day to notify them of the end of the 180 day benefit.benefit.

This form can be found on our website: This form can be found on our website: www.primewest.orgwww.primewest.org (Partners & Providers>Resources>SNF (Partners & Providers>Resources>SNF

Notification Form)Notification Form) Instructions for completing this Instructions for completing this form are also on the website.form are also on the website.

PMAP FormPMAP Form

This form is a notification form for all PMAP This form is a notification form for all PMAP members that are NOT enrolled in MSHO.members that are NOT enrolled in MSHO.

• Use this form to notify PrimeWest and MHP Use this form to notify PrimeWest and MHP of any admission or change in RUG level.of any admission or change in RUG level.

• Use this form to notify the State at the end Use this form to notify the State at the end of the 180 day benefit.of the 180 day benefit.

This form must be faxed to MHP and This form must be faxed to MHP and PRIMEWEST. This form can be found on PRIMEWEST. This form can be found on the DHS website.the DHS website.

1503 Form1503 Form

Unless you are completing an Unless you are completing an original 1503 form, this form DOES original 1503 form, this form DOES NOT need to be signed by a NOT need to be signed by a physician. It can be signed by an RN, physician. It can be signed by an RN, or Director of Nurses.or Director of Nurses.

The SNF must complete and submit The SNF must complete and submit to the county financial worker in a to the county financial worker in a timely manner.timely manner.

Medicare Reimbursement Medicare Reimbursement Program (MREP)Program (MREP)

At this time, this is still in place.At this time, this is still in place.

Continue to file these as you have Continue to file these as you have before MSHO.before MSHO.

As the entire State goes to MSHO, As the entire State goes to MSHO, this may eventually be discontinued.this may eventually be discontinued.

BillingBilling

210 Bill – 210 Bill – No need for this as PrimeWest No need for this as PrimeWest Health System is paying both portions of Health System is paying both portions of the claim. the claim. The 60 day break in spell of illness will be The 60 day break in spell of illness will be

tracked by the MSHO Notification Form.tracked by the MSHO Notification Form. Demand Bill – Demand Bill – The member is entitled to The member is entitled to

receive one if they request it.receive one if they request it. Medicare Denials – Medicare Denials – These are still in These are still in

place. Follow same guidelines as in the place. Follow same guidelines as in the past.past.

Durable Medical Equipment (DME) Durable Medical Equipment (DME) SuppliesSupplies

When ordering DME supplies for your When ordering DME supplies for your residents, the vendor you order the residents, the vendor you order the supplies from may not be contracted supplies from may not be contracted with PrimeWest.with PrimeWest.

To assure that this vendor will be To assure that this vendor will be reimbursed for these supplies, we reimbursed for these supplies, we encourage you to call Medical encourage you to call Medical Administration for a service Administration for a service authorization for the item.authorization for the item.

Durable Medical Equipment Durable Medical Equipment (cont.)(cont.)

Medical Administration at (866)431-Medical Administration at (866)431-0803.0803.

Needs to be done each time an Needs to be done each time an item/supply is ordered for this MSHO item/supply is ordered for this MSHO member.member.

If the vendor is interested in contracting If the vendor is interested in contracting with PrimeWest Health Systemwith PrimeWest Health SystemRobin Zimmerman, Credentialing Specialist Robin Zimmerman, Credentialing Specialist

(320)335-5213.(320)335-5213.

““Bad Debt” ReconciliationBad Debt” Reconciliation

PrimeWest is not part of this processPrimeWest is not part of this processWe are not a fiscal intermediaryWe are not a fiscal intermediaryWe are a public program that receives We are a public program that receives

funds from the State and CMS to cover funds from the State and CMS to cover only the medical services of our only the medical services of our members.members.

We do not receive extra funds from CMS We do not receive extra funds from CMS to reimburse this.to reimburse this.

Concerns regarding this need to be Concerns regarding this need to be addressed directly with CMS.addressed directly with CMS.

Other helpful informationOther helpful information

PrimeWest Web site:PrimeWest Web site:www.primewest.orgwww.primewest.org

Check frequently for timely updatesCheck frequently for timely updates

Administrative manualAdministrative manual

Prime PointersPrime Pointers

Pharmacy LinkPharmacy Link

Provider InsiteProvider Insite

CredentialingCredentialing

This presentationThis presentation

Much more!Much more!

Questions?Questions?

Contact numbers:Contact numbers:1-866-431-0802 (Provider Services)1-866-431-0802 (Provider Services)1-866-431-0803 (Medical Admin-Service 1-866-431-0803 (Medical Admin-Service

Auth)Auth)1-866-431-0801 (Member Services)1-866-431-0801 (Member Services)Provider Relations:Provider Relations:

Kathleen LowdenKathleen Lowden 320-335-5224320-335-5224Becky WalshBecky Walsh 320-335-5214320-335-5214Marcie VickermanMarcie Vickerman 320-335-5222320-335-5222

See hand out for additional contacts.See hand out for additional contacts.

Thank-you!!Thank-you!!