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Idaho Department of Health & Welfare
Personal Care Services (PCS)
Idaho Department of Health & Welfare
Overview
2
• Eligibility
• Prior Authorization
• Fee Schedule (Personal Care)
• Resources
Idaho Department of Health & Welfare
Eligibility
Idaho Department of Health & Welfare
Participant Eligibility
4
Why should you verify eligibility?
• To verify a participant has Medicaid coverage on actual date of service
• To review a participant’s eligibility plan, coverage codes, and healthy connections provider
Note: Medicaid card does not guarantee current Medicaid coverage.
Idaho Department of Health & Welfare
Verifying Eligibility
5
Three ways to verify eligibility:
• MACS — Medicaid Automated Customer Service 1(866)686-4272
• HIPAA compliant vendor software• Health PAS-OnLine Trading Partner
To obtain eligibility information from one of these systems, submit two pieces of identifying information from the following list:
• Medicaid ID number (ten digits)• Social Security Number (SSN) • Last Name, First Name • Date of Birth
Idaho Department of Health & Welfare
Navigating the Secure Portal
6
Idaho Department of Health & Welfare
Verifying Eligibility
7
Idaho Department of Health & Welfare
Verifying Eligibility
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Note: Two pieces of identifying information required; MID and DOB recommended.
Idaho Department of Health & Welfare
Verifying Eligibility | Patient and PCP Roster
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Idaho Department of Health & Welfare
Verifying Eligibility
10
Idaho Department of Health & Welfare
Verifying Eligibility
11
Idaho Department of Health & Welfare
Coverage
12
Medicaid offers several coverages that are aligned with health needs and include an emphasis on prevention and wellness.
Coverage codes:
• Basic Coverage• Enhanced Coverage (includes Katie Beckett)• Pregnant Women Coverage (PW)• Otherwise Ineligible Noncitizens (OINC)• Part B Premium Coverage (SLMB)• Medicare Co-insurance & Deductible (QMB)• Medicare and Medicaid • MMCP and IMPlus Coverage• INPATIENT ONLY Coverage
Idaho Department of Health & Welfare
Enhanced Coverage
13
The Medicaid Enhanced Coverage is for qualified participants with disabilities or special health needs.
• Includes all benefits in Basic Coverage, plus additional benefits:
o Nursing Facilityo Intermediate Care Facility for the Individuals
with Intellectual Disabilities (ICF/IID)o Private Duty Nursingo Home & Community Based Waiver Serviceso Service Coordination
• Many of the services in this plan have medical eligibility and prior authorization requirements
Idaho Department of Health & Welfare
Enhanced Coverage Example
14
Idaho Department of Health & Welfare
Medicare-Medicaid Coordinated Plan
15
The Medicare-Medicaid Coordinated Plan (MMCP) is for participants who:• Are 21 years old or older• Enrolled in Medicare Part A and Part B • Eligible for full Medicaid• Reside in an MMCP coverage area
The qualified participant can voluntarily enroll into MMCP, and choose their administrator.
Idaho Department of Health & Welfare
MMCP Example
16
Idaho Department of Health & Welfare
Idaho Medicaid Plus (IMPlus)
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The Idaho Medicaid Plus (IMPlus) is for participants who: • Are 21 years old or older • Enrolled in Medicare Part A and Part B • Eligible for full Medicaid • Reside in an IMPlus coverage area• Are not an excluded or exempt population
participant • Do not enroll into MMCP – Participants are
mandatorily enrolled into IMPlus, and an administrator for coverage will be assigned if one is not chosen
Idaho Department of Health & Welfare
IMPlus Example
18
Idaho Department of Health & Welfare
Claim Submission
Idaho Department of Health & Welfare
Claim Submission
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Idaho Department of Health & Welfare
Patient Roster | Submit Claim
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Idaho Department of Health & Welfare
Claim Submission
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Idaho Department of Health & Welfare
Authorizations
Idaho Department of Health & Welfare
Authorizations
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• Prior to rendering PCS services, verify that Regional Medicaid Services has issued a PA for the services you are providing
• All PCS must be provided in accordance with a written plan of care.
Idaho Department of Health & Welfare
View Authorizations
25
Idaho Department of Health & Welfare
Authorization Search
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Idaho Department of Health & Welfare
Authorization Details
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Idaho Department of Health & Welfare
Fee Schedule
Idaho Department of Health & Welfare
Fee Schedule
29
Information found on the fee schedule:
• PCS codes
• Medicaid rate
Idaho Department of Health & Welfare
Reference Material | Fee Schedules
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Idaho Department of Health & Welfare
Fee Schedule
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Idaho Department of Health & Welfare
Provider Relations Consultants
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Region 1 and the state of [email protected]
Region 2 and the state of [email protected]
Region 3 and the state of [email protected]
Region 4 and all other states [email protected]
Region 5 and the state of [email protected]
Region 6 and the state of [email protected]
Region 7 and the state of [email protected]
Idaho Department of Health & Welfare
Thank you for attending our Personal Care Services
Training.
Please take a few minutes to complete the survey that will be emailed following this presentation. This
provides us with valuable information for future trainings.