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July 2, 2006
 
 
 
 
MEDICAID INFORMATION RELEASE MA06-18  
 
 
TO:                 All Medicaid Providers
 
FROM:           Leslie M. Clement, Deputy Administrator
 
SUBJECT:     ELIGIBILITY AND BENEFIT PLAN COVERAGE UNDER MEDICAID MODERNIZATION
 
In July 2006, Idaho Medicaid is implementing new benefit plans to support the Medicaid Modernization initiative. 
 
NEW benefit plans, effective July 2006 include:
  1. Medicaid Basic Plan Benefits – for low-income children and adults with eligible dependent children. This plan provides complete health, prevention and wellness services for children and adults who don’t have disabilities or other special health needs.
  2. Medicaid Enhanced Plan Benefits – includes all services of Medicaid Basic Plan Benefits, plus additional services to cover the needs of participants with disabilities or special health concerns. The services in this plan include the full range of services covered by the Idaho Medicaid program.
A third plan, the Medicare/Medicaid Coordinated Plan is under development. This plan is for individuals who are also covered under Medicare. A separate information release will be issued in the future to provide details about this new plan.
 
Beginning July 2006, participants who meet eligibility requirements for Medicaid will be enrolled in either Medicaid Basic Plan Benefits or Medicaid Enhanced Plan Benefits. Plan assignment is based on health needs.
 
Children currently covered under the CHIP-B program will be transitioned to one of the new benefit plans effective July 1, 2006.  The CHIP-B benefit plan will no longer exist after this date. The new Medicaid Basic Plan and Enhanced Plan Benefits include different services than the CHIP-B Plan. These services are summarized in this information release.
 
EXISTING Medicaid programs will continue to remain in place after July, 2006: 
 
Pregnant Women Plan – limited to pregnancy related services only.
  1. Presumptive Eligibility Plan – limited to outpatient pregnancy related services only.
  2. Qualified Medicare Beneficiary Plan - limited to Medicare paid services only.
Requesting and Understanding Eligibility and Benefit Plan Information
Possession of a Medicaid identification card does not guarantee eligibility.  To ensure claims are not denied due to eligibility or benefit plan issues, verify participants’ eligibility and benefit plan on the actual date of service. Confirmation of eligibility and coverage is not available for dates in the future.
 
When an eligibility inquiry is submitted, participants who are eligible for the full range of Medicaid services will have their benefit plan reported as “Medicaid” in the eligibility response.  Participants who are not eligible for the full range of Medicaid services will have their restrictions reported according to their benefit plan.  For example: if the participant is eligible for Medicaid Basic Plan Benefits, eligibility will be reported as “benefits restricted to Medicaid Basic Plan services”.  The benefit plans for Presumptive Eligibility, Pregnant Women, and Qualified Medicare Beneficiary programs remain unchanged and the restrictions for participants on these plans will be reported accordingly.
 
You can request eligibility and benefit plan information using the same methods that are currently available. These methods include:
 
Medicaid Automated Voice Information System (MAVIS)
  • EDS Provider Electronic solution (PES) billing software
  • HIPAA-compliant point of service devices (POS)
  • HIPAA-compliant EDS tested vendor software
Medicaid Identification Cards
All participants, with the exception of Otherwise Ineligible Aliens and Presumptive Eligibility participants, will receive a white plastic identification card.  The yellow Idaho CHIP-B identification card will no longer be issued.  However, if a participant presents with the yellow Idaho CHIP-B identification card, it may still be used to verify eligibility and benefit plan information. 
 
Medicaid Services Covered under the New Benefit Plans
Coverage under Medicaid Enhanced Plan Benefits includes the full range of Medicaid services covered by the Idaho Medicaid program with exclusions and limitations described in the provider handbook.  Coverage and limitations under Medicaid Basic Plan Benefits is summarized in Table 1 below:
 
 
Table 1.  Types of Services and Medicaid Basic Plan Benefits Limitations/Exclusions
Type of Service
Covered in Medicaid Basic Plan
Basic Plan Limitations/Exclusions
(in addition to established Medicaid exclusions and limitations)
Inpatient Hospital Services
X
10 day limit for inpatient mental health services, based on a rolling year.
Outpatient Hospital Services (including Emergency Services)
X
 
Ambulatory Surgical Center Services
X
 
Physician Services
X
 
Other Practitioner Services, including Podiatrist, Optometrist, Chiropractor, Physician Assistant
X
 
Nurse Midwife Services
X
 
Certified Pediatric Nurse Practitioner or Certified Family Nurse Practitioner Services
X
 
Primary Care Case Management (Healthy Connections)
X
 
Prevention Services (includes well-baby, well-child and well-adult preventative medicine exams)
X
Adult (over age 21) preventative medicine exams are limited to one per rolling year. The year starts on the date of the initial examination. The year ends 360 days later. Prior Authorization is required for additional assessments within the same year. 1
Nutrition Services, including diabetic education and training
X
 
Laboratory and Radiological (X-Ray) Services
X
 
Prescribed Drugs
X
 
Family Planning Services
X
 
Inpatient Psychiatric Hospital Services for individuals under age 21
X
10 day limit for inpatient mental health services, based on a rolling year.
Partial Care treatment
 
Covered only in the Enhanced Plan
Psychosocial Rehabilitation
X
Limited to services provided by School Districts
Outpatient Mental Health
 
X
Mental Health Clinic providers are limited to 26 combined outpatient mental health services per participant per calendar year. The existing psychiatric service limitations also apply.  Additionally, select providers are able to perform diagnostic and evaluation services. 2
Home Health Care
X
 
Physical Therapy
X
 
Respiratory Care Services
X
 
Medical Equipment and Supplies
X
 
Prosthetic Devices
X
 
Vision Services/Eyeglasses
X
 
Speech, Hearing and Language Services
X
 
Medical and Surgical Services furnished by a dentist
X
 
Dental Services
(includes dentures)
X
 
Rural Health Clinic Services
X
 
Federally Qualified Health Center Services
X
 
Indian Health Services Facility
X
 
Independent School District Services
X
 
Medical Transportation
X
 
EPSDT/Special Services for Children
X
Medicaid Basic Plan Benefits do not cover Intensive Behavioral Intervention and Private Duty Nursing, unless provided by School Districts. A child who requires services not available under the Basic Plan may receive those services under the Enhanced Plan.
Pregnancy-Related Services
X
 
Intermediate care facility services
 
Covered only in the Enhanced Plan
Nursing Facility Services
 
Covered only in the Enhanced Plan
Personal Care Services
 
Limited to services provided by School Districts
Home and Community-Based Waiver Services
 
Covered only in the Enhanced Plan
Hospice Care
 
Covered only in the Enhanced Plan
Developmental Therapy Services
X
Developmental Disability and Rehab Mental Health providers are limited to diagnostic and evaluation services. 2
Case Management Services
X
Covered only in the Enhanced Plan
 
1 Information Release MA06-17, published in this issue of MedicAide, provides additional information about preventative medicine services.
 
2 Information Release 2006-15, published in this issue of MedicAide, provides additional information about mental health exclusions and limitations.
 
If you have questions about this information, please contact EDS at 800-685-3757 or (208) 383-4310 in the local Boise calling area.  Thank you for your continued participation in the Idaho Medicaid program.
 
LMC/cl/sw