For children currently enrolled in transitioning Waiver services, is there a different authorization period? Is it still the case, that children will be authorized for 6 months after go live for any service they are currently receiving?
The 6 month provision is for the MMCP authorizing existing Plans of Care for children in HCBS and begins when HCBS become part of the managed care benefit package, currently targeted for Oct 1, 2019.
Please clarify how long transitioning waiver children are authorized for CFTSS. Are they authorized to receive the cross-walked services for one year from initial CANS?
CFTSS are Medicaid State Plan services. Any child on Medicaid can receive these services as long as they continue to meet medical necessity. Waiver eligibility is not required for access to CFTSS.
Will Waiver HCBS Providers who bill Managed Care for cross-walked CFTSS be required to submit Plans of Care to MMCP's?
Plans of Care for Waiver children will need to be submitted to MMCPs beginning 30 days before HCBS become part of the managed care benefit package, currently targeted for July 1, 2019. Plans of Care include a list of all services the child is receiving, including CFTSS.
Plans of Care are separate than the required Treatment Plans for CFTSS. Treatment Plans for CFTSS are not required to be submitted to MMCPs, however, the information necessary to demonstrate medical necessity criteria may need to be submitted to the MMCP for concurrent authorization.
Please refer to MMCP specific authorization requirements at:
Can the Medicaid Managed Care Plan deny claims during the children's HCBS transition time period for instances in which the member has exceeded the benefit limit? Would this be permissible if plans denied these types of claims for a medical necessary review?
During the first 90 days, there is to be no utilization review conducted on Children’s HCBS (except for a new request for AT/E-Mods/V-Mods) and transitioning children are provided 180 days continuity of care. The plan should not pend or deny claims for medical necessity review during this period. If it appears the member is exceeding a benefit limit, the MCO should discuss the current HCBS Service Plan with the provider to understand the current goals, and the possibility of other covered services that might benefit the child.