Our staff includes experienced former Medicaid employees that have expertise in all facets of the eligibility and systems rules and processes, and we are able to provide complete revenue cycle management from each admission through the private pay and Medicaid process, monitoring private insurance, NAMI collection, billing and re-billing, and ensuring continuous Medicaid coverage.
We have had a great success rate in obtaining Medicaid approvals for difficult applications for many nursing home clients for over 15 years.
Many of our case management services are included in our services for MEDSŪ clients, but are also available to clients who do not wish to submit electronically with our system, including monitoring of your submissions, following-up/tracking status of cases, and ensuring Medicaid systems are updated correctly for billing.
We can also provide assistance in the following areas:
- Working with the resident and nursing home to obtain required resource documentation for the 5 year look-back period
- Pre-screening the Medicaid application and submitting it timely with the correct documents in an orderly format, facilitating review by the Medicaid workers
- Assistance with completion of MAP-2159i forms
- Responding to requests for information
- Attending Medicaid conferences and fair hearings
When a member is authorized for long term care in a nursing home, Form 2159i must be completed by both the plan and the nursing home and submitted to the NYC Medicaid office along with the Medicaid Conversion form, income, residence and other documentation including five years of banking. It's important for the form to be completed timely, so the Conversion Package can be submitted to Medicaid and a long term care decision can be made. It is the plan's interest to find out if the member is eligible and ePACES updated with an N1 code or is ineligible for excess resources or transfer of assets as soon as possible.
Medicaid Conversion Process
According to NYS and HRA policy for prohibited transfers, "Payments made to nursing home are recouped by plan. Consumer is responsible for cost of care during penalty period." Firstly, this decision needs to be made timely by Medicaid to mitigate the plan's loss if the member is ineligible. Secondly, this decision needs to be sent timely to the plan to initiate recoupment. Thirdly, there is a logical flaw in the process that does not consider the member's refusal to supply banking information. In this situation, Medicaid will reject the conversion but not inform the plan to recoup.
Once the 2159i is sent to the nursing home, the plan has no knowledge of when the conversion was submitted to Medicaid, the status at Medicaid, and even the decision by Medicaid. The plan learns of the approval when the member appears on the plan's DOH Long Term Care Roster. This roster is generated by manual entry of an N1 code by a Medicaid worker into the NYS EMEVS, separate from the data entry done to approve the Conversion. Our experience with our nursing homes is that it is not uncommon for the N1 code to not be entered and the member never appearing on the Long Term Roster. Likewise, if a conversion is submitted to MAP without the 2159i, it will be evaluated for long term care eligibility, and if approved, will not be updated with the N1 code. If the conversion is rejected for failure to provide resources documentation, the notification process to the plan will not be updated.
Eligibility Notification Process
HRA has set up a website portal that plans can access to receive copies of eligibility notices that are mailed to the Medicaid recipient. The portal is manually updated by a data entry worker via paper copies of notices given to him from Medicaid workers when the workers determine that the applicant is enrolled in a managed care plan. This is not a tight process and we have found that most of the eligibility notices that we have received on MEDS for our nursing homes that have members needing long term conversions were not received by our plan clients via the portal.
Nursing Home Discharges
It is the responsibility of the nursing home to submit a discharge notice to Medicaid when a resident is discharged home and needs to be converted to a community case and the NAMI changed to surplus income. This process should also remove the N1 code, which in turn, will remove the member from the long term care roster. Failure to process the discharge properly could affect the member's community eligibility for services not covered by the plan, as well as prevent a Medicaid card from being generated or the previous card re-activated.
Tracking Medicaid Eligibility Via Batch ePACES Inquiry
RES provides the capability to process the entire plan membership through ePACES inquiry and produce the responses in a spreadsheet or CSV export that includes all the response fields viewable on the ePACES screen. This will immediately identify closed Medicaid cases, re-opening of Medicaid cases in the plan, plan transfers, etc. It can be run weekly and also include the last day of the previous month for comparison.