Eligibility, Insurance and Special Programs Frontline Education Ambulatory Business Operations

Eligibility, Insurance and Special Programs

Frontline Education

Ambulatory Business Operations

Objectives

At the end of this session you should be able to:• Understand how to verify eligibility• Understand eligibility programs and UNMH Hospitals financial

assistance programs• Become familiar with different private insurances

Agenda

Eligibility, Insurance, and Special Programs• UNM Hospitals Financial Assistance programs & FAST Lookup

Systems• Grants and Research Programs• Other eligibility programs• Medicare• Medicaid• Insurance Plan Types• Common Insurance Plans• Miscellaneous

UNIVERSITY OF New Mexico hospitals financial assistance programs

Summary of Programs Offered:• UNM Care Plan (Financial Class: 2)• Medicare/UNM Care (Financial Class: A)• UNM SCI (Financial Class: N) • Out of County Indigence Fund OOCI (Financial Class: U)• UNMH Discount Program (Financial Class: S)• Grants and Research Programs

– Breast and Cervical Caner prevention Program ‘BCC Program’

– Maternity and Family Planning; Title V and Title X– High Risk Fund– Ryan White Program

Financial assistance programs

UNM Care (Financial Class: 2)This is a special medical assistance program developed with the goal of connecting patients with primary care providers. This program is supported by Bernalillo County Property Tax Mil Levy.

• Must live in Bernalillo County and be legal residents of the U.S.• Patient will be assigned to a Primary Care Provider• Must obtain referrals to see specialists• Patients on UNM Care who are pregnant or in

need of family planning – refer to Medicaid • Can go retro to cover old bills• Able to verify through FAST Lookup System• Only covers services at UNM Hospitals and Clinics• Services will go retroactive to cover 90 days

Financial Assistance Programs

Medicare/UNM Care (Financial Class: A)This program is for Bernalillo Country residents as a secondary to Medicare.

• Must live in Bernalillo county for 90 days before referred• Used as secondary to insurance and Medicare• Able to verify eligibility in FAST lookup system

– Plan names: 001, 010, 011, 020,021– Copay $0

*Note: Always secondary Ins to Medicare

or replacement plan

Financial assistance Programs

UNM State Coverage Insurance (Financial Class: N)This is a medical assistance program developed with State Medicaid dollars that UNM participates. SCI/UNM Care Initiative-UNM CI

• Provides assistance to Adults ages 19 – 64 years (no children)• Low income adult with income up to 200% of poverty• No asset restrictions• Cannot be secondary to any other insurance, Medicare or

Medicaid coverage• Must be legal U.S. residents residing in Bernalillo Valencia, Torrance and Sandoval countiesAble to verify eligibility in FAST lookup system Only covers services at UNM Hospitals and Clinics


Out of County Indigent Fund-OOCI (Financial Class: U)This is a medical assistance program developed for State of NM residents residing outside Bernalillo County

• Patient must reside in NM but outside Bernalillo County• The services must be unavailable in the patient’s home county in

order to be seen here• OOCI patients must apply in home county first for their indigent fund• These plans would never be used at a primary care

clinic, patients will be considered Self-Pay.• Must obtain referral to be seen in specialty clinics• OOCI is secondary to home country indigence fund• Able to verify eligibility in FAST lookup system


UNM Hospitals Discount Program (Financial Class: S)This is a medical assistance program developed for patients who do not qualify for traditional financial assistance, nor do they carry third party coverage

• Expansion of Financial Assistance Program – Now includes patients who income falls below 350% of poverty

• Undocumented aliens who meet requirements may be eligible• Can qualify if outside of Bernalillo county

– services required must not be available in home county

• Allows for 45% discount to billed charges– Patients may make payment arrangements for balances owed

• Able to verify through FAST Lookup System– Plan Names: 900, 905, 910,915,920,921,930

Financial Assistance program

Pending Financial Assistance (Financial Class: S)Patients who have a schedule appointment to apply for any financial assistance program through UNMH are considered to be in a pending status

• Register as Self-Pay– Note comment section ‘pending financial assistance’

• Collect lowest copayment amount– $5.00 for clinics– $25.00 for diagnostics

• Non-qualifying patients are considered true Self Pay patients– Please follow Financial Services policies for collections

• Patients must not have any form of insurance including; commercial, Medicare or Medicaid

Financial Assistance program

UNM Hospitals Financial Assistance ApplicationAll University of New Mexico Hospital Financial Assistance Programs can be verified through our internal Financial Assistance Application ‘FAST Lookup’

Grants and research programs

Breast and Cervical Cancer Prevention and Detection ProgramThis is a program managed by the Department of Health. Funded by the Centers for Disease Control

• Covers services directly related to screening of breast and cervical cancer

• No Residency Requirement

• Target Population– Low income women who are uninsured

or inadequately insured– Women 50+– UNM Care Women – Must be at or below 250% of poverty


BCC Grant Continued

• Does not cover treatment of breast or cervical cancer, just screening

• Women with both Medicare Part A and Part B can not participate

• Patient may also be qualified for BCC Medicaid for treatment

• Registration for BCC Grant– Use referral billing account– Guarantor number 99991978 (BCC grant)

Managed locally through a program manager:

Wendy Hine 272-1789


Maternity and Family Planning Grant Funds ProgramsTitle V & Title X cover undocumented patients on a sliding scale 0%-90% fee based upon a patient’s income and other criteria

• Only cover for certain services at M&FP sites– Occasionally covered when referred for Women’s health or

Radiology/Diagnostic services

• Program is considered payer of last resort

• When checking in to regular clinic– Patient is Self Pay, unless qualified for a

UNMH Self Pay Discount Program– DO NOT put M&I in primary insurance tab when registering

GRANTS AND RESEARCH PROGRAMS

High Risk FundThis is also a Maternity and Family Planning grant funded program • Covers

– OB– Prenatal Care– Ultrasounds

• Service through M&FP clinics– If referred covers Women’s health or Radiology/Women’s Ultrasound only

• DO NOT use for any other clinic registration

Grants and Research Programs

Ryan White ProgramThis program is managed by Health Resources and Services Administration. It was created to improve the quality and accessibility of care services received by those diagnosed with HIV/AIDS.

• This program only covers outpatient services related to HIV/AIDS

• Enrollment through Truman Street Clinic– Patient re-enrolls on an annual basis– Only for patient without any other coverage– Does not cover- Ambulance Services, Inpatient stays, ER

visits, Physical Therapy or remaining third party balances• Program is considered payer of last resort

Other eligibility Programs

State Coverage Insurance This is a medical assistance program developed with State Medicaid dollars.

• NOT the same as the UNM CI program although they are both sponsored by the State of New Mexico

• Patients can sign up for one of the three managed care organizations that are marketing the SCI program– SCI Lovelace (M73)– SCI Molina (M72)– SCI Presbyterian (M74) – not in network- requires

prior authorization to be see at UNM Hospitals

Same plan names in Cerner Registration

Other eligibility Programs

State Coverage Insurance Continues

• SCI offered to adult patients who have not voluntarily dropped insurance coverage in the past six months

• Patients enrolled must renew 45 days prior to the expiration of their coverage or they may be dis enrolled

• Able to verify coverage through Healthxnet

Other Eligibility Programs

Other County Financial AssistanceCounty funds provided to the patient through their home county

• Must apply for funds at county clerk’s office• Verification is required to be seen at UNMH

• Register as– Financial Class: W– Plan Code G40 or G41 for those

referred or approved for other county funds

• If patient has not applied, register

as self pay until they qualify for

other county assistance

• This is NOT the same as UNM financial assistance program OOCI

Other Eligibility Programs

Indian Health ServicesIndian Health Services is insurance for Native Americans living on reservation lands. Native Americans can qualify for this coverage by applying with their Contract Health Service Unit.

• Register with IHS plan code– Document the census number and tribal affiliation in the

registration

• Do not collect copayments from Native Americans

If unsure of coverage,

contact NAHS department

at 2-1612

Medicare

MedicareIs a federally administered health insurance program for eligible participants

• Who is eligible?– Those who are 65+ (A)– Social Security Disability (D)– End Stage Renal Disease (ESRD) (E)

• Medicare Part A– Inpatient stays– Automatic

• Medicare Part B– Outpatient services– Monthly premium

• Medicare Part D– Pharmacy services– Monthly premium

Medicare

Medicare Continues• Senior Plan- A senior plan is where the patient has signed over

their Medicare benefits to a Medicare Advantage Plan or other Medicare Plans (Managed Care Plan).

– Lovelace Senior Plan– Humana – Pres Senior Plan

These patients are now subject to referrals, prior authorizations, and copayments as a Medicare managed care plan enrollee.

• The only two outpatient codes to use for Medicare – Medicare – OP Only 251– Medicare – Railroad OP 255

Medicare Requirements

Medicare regulations require that all entities that bill Medicare for services or items rendered to Medicare beneficiaries must determine whether Medicare is the primary payer for those services or items.

What is MSP? Medicare Secondary Payer

Refers to Medicare benefits when Medicare is not the primary insurance.

What is MSPQ? Medicare Secondary Payer Questionnaire

A set of questions required by Medicare to help determine whether other payers may be primary to Medicare.

Since 1980, the MSP provisions have protected Medicare Trust Funds by ensuring that Medicare does not pay for services and items that certain health insurance or coverage is primarily responsible for paying.

Medicare Requirements

• Electronic form in Cerner registration To be completed on all Medicare

recipients Every outpatient visit Upon every hospital admission Every lab encounter creation

• Used as auditing tool CMS Visits

• Accident information in system must match what is on the accident tab

How do we comply with this requirement?

Medicaid

Low income

Pregnant women

Children under 19

Medicare beneficiaries

Patients on Supplemental Security Income

Temporary Assistance to Needy Families

TANF

Family planning assistance

Nursing home residents

Native Americans

Medicaid is a state health insurance program, funded by both the state and federal government that pays medical bills for eligible low-income families and individuals living in New Mexico

Who is eligible for Medicaid?

Medicaid

What do you need to know about Medicaid?

Patients can apply at any Income Support Division (ISD) Office in the county where they live

Patient seeking pregnancy or family planning service that are currently enrolled in UNM financial assistance program should apply for Medicaid

Patients that apply for Medicaid are in a ‘Pending’ status Can remain pending up to 45 days after application If they do not qualify they will be billed as self-pay

Patients that qualify for Medicaid are in a ‘Medicaid Exempt’ status 30 day period

After 30 days patient will be required to select a Salud (MCO) program With the exception of Native Americans and Nursing Home Residents who can

remain in an exempt status

Medicaid

What is a Salud Program?

Salud is the umbrella name for New Mexico managed care program.

Salud services are provided by contracted Managed Care Organizations (MCOs) to provide Medicaid services to eligible and enrolled citizens.

New Mexico MCOs Managed Care Organizations who provide Medicaid services are:

Presbyterian Salud Molina Healthcare of New Mexico (Salud) Lovelace Salud BCBS Salud

Medicaid

Other Common Medicaid Categories Category 040- Qualified Medicare Beneficiaries (QMB)

Covers the premiums, co-insurance and deductible for Medicare patients on Medicare covered services only after Medicare has paid

Category 052- Breast or Cervical Cancer Payment for services to treat Breast or Cervical Cancer Treatment

Category 035- Pregnancy and Family Planning- Covers pregnant women in families who meet certain financial

requirements

Services are limited to pregnancy-related conditions only

Also covers women age 18-50 who need family planning services related to birth control and pregnancy prevention

Medicaid

Other Common Medicaid Categories

Category 085- Emergency Medical Services for Undocumented Aliens (EMSA)

Nonqualified, undocumented, illegal, and nonimmigrant aliens who need emergency medical services may be covered

Coverage is limited to services provided under the circumstances of an immediate emergency. There are no ongoing benefits and the individual will not receive a Medicaid card.

An “emergency” is defined as a medical condition, including labor and delivery, manifested by acute symptoms that require immediate medical attention. Without immediate medical attention, the health of the individual would be placed at serious risk.

Medicaid

Cerner Registrations

Guidelines Pending Medicaid

• FC: P Plan Code: 021 Medicaid Exempt

• FC: M Plan Code: M90 Medicaid QMB

• FC: M Plan Code: M93 Medicaid EMSA

• FC: M Plan Code: M25

Do not use the 10 digit Medicaid ID/policy number Please use the appropriate policy number or social security

number

IMPORTANTEligibility verification for

Medicaid patients is required each Month.

Please document effective dates in Cerner

Insurance Tab

Commercial insurance

Health insurance can be broken down into two broad categories.

Traditional and Managed Care Within those categories, there are four basic types of plans

Health Maintenance Organization (HMO)

Point of Service Plans (POS)

Preferred Provider Organization (PPO)

Traditional Indemnity (Fee-For-Service)

No one type of health care plan

is better than the other. It

really depends on the needs

and preferences of an individual


What is the descriptions of the four basic Insurance Plan Types?

Health Maintenance Organization (HMO)

Any person or company that arranges basic health care services to enrollees on a prepaid basis

By choosing an HMO Plan

Paying for your coverage in advance

Monthly premium

Requires the selection of a Primary Care Physician (PCP)

Must go through PCP for specialty referral

Majority of HMO Plans require co-payments (Office Visit, Specialist Services, Hospital

Stay)


Point of Service Plans (POS)

POS plans are HMO’s that allow you to control your own health care, rather than insisting on referrals from your primary care physician.

By choosing POS you have three ‘point of service’ choices

Go through your primary care physician, and receive coverage under HMO guidelines

Get your care through a PPO provider and receive coverage under PPO’s in-network rules

Choose the services of a healthcare professional outside of the HMO or PPO networks, and receive coverage under out-of-network rules


Preferred Provider Organization (PPO)

PPOs are network of doctors, hospitals, and other healthcare providers. PPO’s give you the option to seek services outside of the network.

By choosing an PPO Plan

In-network/out-of-network option

Increased out of pocket cost for care outside of network

Requires the selection of a Primary Care Physician (PCP)

Self-referral to specialists


Traditional Indemnity (Fee-For- Service)

These plans are the least restrictive types of insurance plan. One has complete autonomy when it comes to choosing doctors, hospitals and other health care providers.

By choosing an Indemnity Plan

Reimbursement as expenses occur

Member pays 100% of charges up to annual deductible

Following deductible, plan pays a percentage of covered charges

When out of pocket maximum is met, the plan pays 100% of charges

Common Insurance Plans

• BCBS• Lovelace• Presbyterian• Tricare• Humana• United• Molina• Amerigroup• Evercare

Common insurance plans

Blue Cross Blue Shield BCBS Association affiliated independently licensed providing a network of both independent MDs and multi-specialty groups. BCBS directly and indirectly provides health coverage to over 99 million people throughout the United States

Provides assistance to individuals and families No referral required Able to verify though HealthXnet Health Plans include HMO, PPO and

individual Plans


Blue Cross Blue Shield

UNM Hospitals Employee plan BCBS UH Employee in Cerner Group Number N11003 Policy numbers begin with YIU

BCBS of New Mexico formatting

“R” 8 numeric 3 Upper case letters 9 numeric 9 numeric 12 alpha/numeric

Group numbers are required for BCBS

registrations

Common Insurance plans

Common Blue Cross and Blue Shield errors Incorrect BCBS Policy Number

Missing BCBS Group Number


Lovelace Health PlanArdent purchased and affiliated healthcare company. When registering a patient, select the financial class and plan code that corresponds with the correct plan type.

Provides assistance to individuals and families No referral required Able to verify though Healthxnet Plans range from HMO, POS Medicare supplemental “Gap” plan


Lovelace Health Plan

UNM employees who have Lovelace should be registered with the plan code of K92 UNM Lovelace employee

All Lovelace policy numbers will start with ‘LH’ and “L0”

Group numbers are required for Lovelace registrations


Common Lovelace Health Plan errors Incorrect Policy Number


Presbyterian Health PlanPresbyterian Health Plan is one of New Mexico's largest health plans. Almost 400,000 New Mexicans are enrolled in an PHS plan.

Provides assistance to individual and families No referral required Able to verify though Healthxnet Plans ranging from HMO, POS and ASO (Administrative

Services only) and more


Presbyterian Health Plan

Any Presbyterian hospital employee seen here is considered out of network

Presbyterian Senior plan HMO is also out of network here unless a retiree from UNM

Presbyterian SCI plan is out of network

Presbyterian HMO, PPO and other plans are in network

Commons insurance plans

Common Presbyterian Health Plan errors Incorrect Policy Format


TricareTricare is the Department of Defense managed care program for active duty military, active duty families, retirees, and their families

Formerly known as Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)

Referral Required Plans ranging from Tricare Prime, Tricare Standard, and Tricare

for Life


Tricare

Tricare Prime

Similar to HMO Beneficiaries enroll, no enrollment fee (active duty/dependents),

annual fee & $12.00 copayment (retirees) Card issued (Military ID)

Tricare Standard Similar to indemnity plan – cost sharing (no card issued)

Tricare for Life- Extended healthcare benefits

Uniformed services retirees, their spouses and survivors Secondary to Medicare Plan code C71 ‘Tricare for Life’


Tricare Registration

Insurance currently found under plan name of Tricare/Champus in Cerner

Group Name and # field: Active Duty or Retired followed by branch of service

Policy #: Always the sponsor’s social security number

Commons insurance plans

Humana Insurance PlanHumana is an American managed health care company that manages health insurance.

New Medicare Plan Will have co-pays No referral required


Humana

Humana Plans have two choices for registrations Humana commercial plan – I08 Medicare/Senior Plans – K08

Healthxnet will show which plan to register under Common Humana errors

Incorrect Policy Format


United Healthcare

UNMH became contracted with United Healthcare on 02/01/2004.

Plans include: Choice, Choice Plus, Select Plus, Options PPO and Managed Indemnity

No referral required


United Healthcare

Nationwide insurance plans

Other United Programs Evercare – Now called United Healthcare Community Plan Secure Horizons

Policy number is nine numeric

Group number is required on registrations

Referrals and Prior Authorization

INSURANCES MATRIX REFERRALS/PRIOR AUTHORIZATION

REFERRALS NEEDED FOR SPECIALTY VISITS

AUTHORIZATION NEEDED FOR SPECIALTY VISITS

AUTHORIZATIONS NEEDED FOR PRIMARY CARE CLINICS

LOVELACE SALUD LOVELACE SCI MOLINA SALUD MOLINA SCI MOLINA MEDICARE

OPTIONS PRESBYTERIAN SALUD IHS AMERIGROUP MEDICAID AETNA-POS PLANS CIGNA HEALTH PLAN-WHEN

PCP IS LISTED IN HEALTH X NET

OOCI-MUST HAVE SPECIALTIY CLINIC LISTED IN FAST WHERE PATIENT IS SCHEDULED

UNM SCI WORK COMP

PRESBYTERIAN SENIOR HMO PRESBYTERIAN EMPLOYEES PRESBYTERIAN SCI TRICARE VA HOSPITAL TOTAL COMMUNITY CARE CMS WORKMANS COMP ( NEEDS

CLAIM # ) ALL OUT OF STATE

MEDICAIDS AETNA HMO (not

contracted)

PRESBYTERIAN SENIOR HMO PLAN

PRESBYTERIAN SCI PRESBYTERIAN EMPLOYEES AETNA HMO (NOT

CONTRACTED)

Verification of Insurance

• Health X Net – www.healthxnet.com• Financial Assistance – FAST lookup• Insurance company websites• ACS – 246-2219• Copy of Insurance Card• Call Insurance Company

http://www.healthxnet.com/

Questions?

Documents

Eligibility, Insurance and Special Programs Frontline Education Ambulatory Business Operations