30.5 Partnership Enrollment/Disenrollment and Intercounty Moves

30.5.1 Enrollments

30.5.1.1 SSI Recipients

30.5.2 Disenrollment

30.5.2.1 Adverse Action Disenrollment

30.5.2.2 Voluntary Disenrollment

30.5.2.3 Death Of A Partnership Participant & Disenrollment

30.5.2.4 Non-Payment Of Cost Share & Disenrollment

30.5.3 Re-enrollment In Partnership

30.5.3.1 Request For Retroactive Enrollment

30.5.4 InterCounty Moves

30.5.1 Enrollments

The enrollment date is always the date that the memberA recipient of Medicaid; formerly referred to as a "client." is enrolled in the MCOManaged Care Organization . The Resource Center worker provides the IM worker with this information.

Because the Partnership Program is voluntary, the enrollment date is a mutually agreed upon date chosen by the participant and the ADRCAging and Disability Resource Center , provided that the participant meets all other eligibility requirements on that date. The ADRC will provide this enrollment date to the Economic Support (ES) worker. It is possible that the client may be eligible for regular MA using the non-Partnership (waiver) eligibility criteria for the 3-month period prior to their month of application as well as the portion of the month prior to enrollment date. This potential backdated eligibility should be examined as it is for any other MA applicantA person who has submitted a request for coverage for whom no decision has been made regarding eligibility . Unlike other Home Based Community Waiver cases, The Management Group (TMG) has no oversight or approval responsibilities for Partnership.

30.5.1.1 SSI Recipients

A full Medicaid application or review is not necessary for an SSISupplemental Security Income. A program based on financial need operated by the Social Security Administration that provides monthly income to low income people who are age 65 or older, blind, or disabled. recipient who asks to enroll in Partnership, and is not applying for FoodShare. The ADRC will supply the IM worker with the following information:

Name.
Residence Address.
Mailing Address.
SSN (and MAID number if different).
Sex.
Primary Language (English or Spanish).
Guardian/Power of Attorney Name and Address.
Date of Birth.
Race (Optional)
Citizenship Status (Alien registration number, if not a citizen).
Disability Status (if not age 65 or older).
All information necessary to complete the Community Waiver, Medical Expense, and the Medical Coverage pages
Has this individual transferred any assets in the last 36 months or created a trust in the last 60 months? (If so, the eligibility worker needs to contact the applicant and ascertain if divestment has occurred).

They may use the "Model Agency Referral Form” to provide this information. Workers can contact members as needed for additional information.

30.5.2 Disenrollment

Disenrollment from the MCO may occur for a variety of reasons. Some of the more common

reasons for disenrollment include the loss of Medicaid eligibility, a change in functional eligibility,

a move out of the MCO’s service area, or simply that the member expresses a desire to

disenroll.

30.5.2.1 ADRC Approved Disenrollments

Certain disenrollments, listed below, can only be approved by the Aging and Disability Resource Center or by the Department of Health Services (DHS) Office of Family Care Expansion (OFCE).

Member Requested Disenrollments. When a member requests to be disenrolled from the MCO for any reason, the Aging and Disability Resource Center (ADRC) will send the completed disenrollment form to both the IM Agency, as well as the MCO. The IM Agency should accept and process member requested disenrollments only when the associated disenrollment form is submitted by the ADRC. Disenrollment forms indicating the member requested to be disenrolled that have been submitted by the MCO should be returned unprocessed to the MCO, along with the completed ’Unprocessed Disenrollment Request Form [F-00009 (12/08)].

Note: There is one exception to the above. Because Dane County does not yet have an ADRC, Dane is the only county where member requested disenrollments may, until further notice, be accepted directly from the MCO (i.e., Care Wisconsin) - with a signed disenrollment form.

MCO Requested Disenrollments. MCOs are required to contact the Department’s Office of Family Care Expansion (OFCE) to obtain prior approval for any of the following types of disenrollment and to determine the actual disenrollment date. If the disenrollment request is approved, an OFCE representative will email the completed disenrollment form to both the MCO as well as the CARES Coordinator in the Income Maintenance agency to which the member’s case has been assigned. The text of the email will explain the disenrollment reason as well as a contact name and telephone number. The CARES Coordinator should then assure that the disenrollment is processed by the IM worker.

Disenrollment requests for any of the following reasons received from the MCO (i.e., not

emailed to the CARES Coordinator by an OFCE representative) should be returned

unprocessed to the MCO along with the completed Unprocessed Disenrollment Request

Form [F-00009 (12/08)].

Loss of Contact Disenrollments. When a member is no longer accepting services and the MCO has been unable to contact the member for 30 days or more, the member may be disenrolled due to loss of contact, but only with prior approval from the Department.
The MCO Cannot Assure the Member’s Health/Safety. If the member accepts services under an approved plan of care, but refuses to allow care manager contacts, the member may be disenrolled, but only with prior approval from the Department.
The Member Has Jeopardized the Health/Safety of Others. If the member has committed or threatened acts that jeopardize the health or safety of MCO staff, contractors, or others, the member may be disenrolled, but only with prior approval from the Department.

30.5.2.2 Adverse Action Disenrollment

CARES populates the date when there is ineligibility for PACE/Partnership. It is not worker enterable. The date will be an end of month date according to adverse action logic, except when the member dies. In this case, the disenrollment date is the date of death.

When ES removes the Partnership program type from the Community Waivers Page, the Partnership AG will close with an effective date related to adverse action. If the disenrollment date on the disenrollment form is earlier than the adverse action closure date, the ES worker should fax the form to the DHCF Enrollment Specialist at 608-261-7793.

It is important to have the correct disenrollment date on file at ForwardHealth interChange. Providers verify eligibility each time a MA recipient has an appointment. The recipient’s services may be delayed if the provider verifies through ForwardHealth interChange that the person is enrolled in PACE or Partnership when in actuality the disenrollment date on file at ForwardHealth interChange does not match the date on the disenrollment form. Do not use a manual F-10110 form to send a mid-month disenrollment date. Medicaid will continue under Partnership waiver medical status code according to adverse action logic.

If disenrollment is to occur prior to the date set according to adverse action logic, fax the paper disenrollment form to the DHCF Enrollment Specialist at (608) 261-7793. The request will then be forwarded to HP Enterprise Services for entry in ForwardHealth interChange.

30.5.2.3 Death Of A Partnership Participant & Disenrollment

If a PACE or Partnership member dies, ES workers need to enter the date of death on the Permanent Demographics page in CWW, run eligibility, and confirm. The date of death as well as the PACE or Partnership disenrollment will then be transmitted to ForwardHealth interChange. The PACE or Partnership disenrollment date on ForwardHealth interChange will be the member’s date of death. It is not necessary to send a disenrollment form to DHS/DHCAA when the member dies midmonth or prior to the disenrollment date populated in CARES. Keep the disenrollment form for ES records.

30.5.2.4 Non-Payment Of Cost Share & Disenrollment

When ES is informed in writing by the MCO that an enrollee has not met the cost share obligation for past months’ services, the member will be disenrolled.

ES should:

enter "N" to the question "Are you meeting your cost share/spend down obligation?" on the Managed Care section of the Community Waiver page in CWW,
run eligibility, and
confirm.

This will end the PACE or Partnership enrollment according to adverse action logic. A CARES notice will be sent to the recipient informing them of the termination of eligibility. ES should file the written notice of non-payment.

30.5.3 Re-enrollment In Partnership

Partnership enrollees who lose Medicaid eligibility, reapply and again are found eligible for Medicaid may be re- enrolled in Partnership for up to three calendar months prior to the Medicaid application month, only if all of the following conditions are met:

The person (or his/her representative) requests backdated Medicaid.
The person is determined to have met Medicaid financial and non-financial requirements in the month(s) being considered for re-enrollment in Partnership.
The person is determined to have been functionally eligible for Partnership in the month(s) being considered for re-enrollment in Partnership.
The person is determined to have received services, in addition to care management, under the Partnership (MCO) plan of care during the month(s) being considered for re-enrollment in Partnership.

The local income maintenance (IM) agency is not authorized to re-enroll anyone in Partnership earlier than the first of the month, three months prior to the application month.

Example 1: Richard was enrolled in Partnership until he lost his Medicaid eligibility on January 31, 2007. On May 11, 2007, he filed a new application for Medicaid with the county income maintenance agency, requesting backdated eligibility. Richard’s IM worker determines that:

He met Medicaid financial and non-financial requirements in February, March and April; and
He was functionally eligible for Partnership in each of those three months; and
In each of those three months, he received services under a plan of care developed by the Partnership MCO.

Richard may be re-enrolled in Partnership back to February 1, 2007 covering the entire three month period.

Example 2: Elizabeth was enrolled in Partnership until she lost her Medicaid eligibility on January 31, 2007. On May 11, 2007, she filed a new application for Medicaid with the county income maintenance agency requesting backdated eligibility. Elizabeth’s IM worker determines that:

She met non-waiver EBD Medicaid financial and non-financial requirements in February, March and April.
She was functionally eligible for Partnership in April, but not in February or March.
In each of those three months, she received services under the MCO’s plan of care.

Elizabeth may be re-enrolled in Partnership only back to April 1, 2007. Her non-waiver EBD Medicaid eligibility may, however, be backdated to February 1, 2007.

Example 3: Andrew was enrolled in Partnership until he lost his Medicaid eligibility on December 31, 2006. On May 11, 2007, he filed a new application for Medicaid with the county income maintenance agency requesting backdated eligibility to January. Andrew’s IM worker determines that:

The month of January 2007 may not be considered for Partnership re-enrollment or a Medicaid backdate because it is more than three calendar months prior to the application month; and
Andrew met Medicaid financial and non-financial requirements in February, March and April; and
He was functionally eligible for Partnership in February, March and April; and
In each of those three months, he received services under a plan of care developed by the Partnership MCO.

Andrew may be re-enrolled in Partnership to February 1, 2007, covering the period from February through April.

30.5.3.1 Request For Retroactive Enrollment

PACE or Partnership members that lose MA eligibility and regain it within three calendar months may be retroactively enrolled into the respective program following the Medicaid backdating policies.

Example 4: Kelly was enrolled in the Partnership program until she lost Medicaid eligibility on January 31, 2001. On May 11, 2001, she re-applied at the county. The ES should contact the Partnership agency to ask if she received services from the agency since February 1, 2001. If the program states she had, ES will re-enroll her in Partnership if she is found to be eligible for Medicaid.

30.5.4 InterCounty Moves

When a FC enrollee moves permanently to a non-MCO county, s/he can remain enrolled in the MCO only if the Resource Center worker informs IM that the following three conditions are met:

S/he is eligible for COP or waiver services.
After moving to the new county, the enrollee resides in a long-term care facility ( Nursing Home, CBRFcommunity-based residential facility. A place in which five or more unrelated adults live and where they receive care, treatment, or services, but not nursing care on any permanent basis, in addition to board and room , or AFH ).
The enrollee’s placement in the long-term care facility is done under and pursuant to a plan of care approved by the MCO.

A single MCO may serve multiple counties. A FC member may:

move from one FC county to another served by the same MCO and
wish to remain enrolled in FC in the new county and
wish to continue to be served by the same MCO

Disenrollment from the MCO would not be necessary under these circumstances. Disenrollment from the MCO would be necessary only if the member changed MCOs, changed programs (e.g., from FC to Partnership) or ended services.

This page last updated in Release Number: 10-03

Release Date: 11/15/10

Effective Date: 11/15/10