Can children's providers continue to provide services on a fee for service basis after the children's system transition?
Yes, services will continue to be provided on a fee for service basis for children who are not enrolled in a Medicaid Managed Care Plan (MMCP). However, services must be billed to the MMCP for children enrolled in managed care.
What types of children will need to remain Fee for Service during the transition?
Many children will remain Fee for Service because they are exempt or excluded from Medicaid managed care for reasons that are not impacted by this transition, such as children with comprehensive Third Party Health Insurance and children who are Native American. Children who will be mandatorily enrolled in Medicaid managed care as part of this transition are children who are only exempt due to 1915c waiver enrollment or who are excluded because they are in the care of a voluntary foster care agency (VFCA).
The July 2019 State HCBS billing guidance explains that State designation as a children's HCBS provider is not required for vehicle modification, environmental modification and adaptive and assistive equipment providers. Therefore are these providers and services not applicable to the remedial process?
Consistent with the April 1, 2019, transition, if the FFS authorization process for AT/EMods/ V-Mods has already begun prior to 10/1/19 (meaning the Description and Cost Projection Form has been provided to the LDSS), the process is to be completed through the FFS delivery system.
MCOs are responsible for new requests for these services for eligible enrollees 10/1/19 and forward. New requests for AT/E-Mods/VMods are subject to MCO prior authorization requirements starting 10/1/19, including review for medical necessity of the service.
Are we moving towards a Per-Month-Per-Member (PMPM) environment or a Fee-for-Service (FFS) environment?
We are moving towards a PMPM environment. Managed Care Organizations (MCOs) receive a fixed monthly payment for each member which covers a defined set of services, or benefits. Please refer to slide 16, "How Managed Care is Paid," found here.