Answers about Nursing Home Clients and Members with Both Medicare and Medicaid
What is an MCO?
Managed Care Organizations (MCOs), like UnitedHealthcare Community Plan, provide health care services to members through doctors, hospitals and other health care providers through contract agreements. The MCO also provides non-medical services based on the benefit package.
Do I get to choose my MCO?
Yes, you can choose your MCO upon initial enrollment in a health plan or during the open enrollment period each May. You will default to an MCO if you do not choose.
How do I change my health plan?
You may change your health plan at any time during the first 90 days after your initial enrollment in a health plan. You can also change your health plan during the open enrollment period in May.
Will I get a different Medicaid card?
No, but you will have an additional card. After you choose your MCO, you will get a card from them. p>
Can I stay in my nursing home?
Will this change my patient pay amount to the Nursing Home?
No, you will continue to pay the Nursing Home your patient pay amount.
Will I get my $44.00 per month personal needs allowance?
Will my Medicare premium still be paid by the State?
Will I have to change doctors?
It will be important for you to speak with the Health Benefits Manager when you choose your plan to ensure your primary care provider (PCP) is enrolled with your plan.
What about prescriptions?
You will continue to use your Part D provider and your state-issued Medicaid card when you fill prescriptions.
Who will coordinate and manage my case and service?
Your MCO care coordinator will manage your care.
Will there still be income protection for dental, medical equipment, etc.?
Will I still be able to take my family member out overnight?
Will there still be a 7 day bed hold?
What do I need to tell the doctor’s office when I go for my office visit?
Tell them you have a new insurance card. Give them your Medicare card, state-issued Medicaid card and your new MCO member ID card.
Will I still have to do redeterminations?
Who do I call about problems or questions?
Enrollment and General Questions: Call the Health Benefit Manager Billing: Call your MCO Changes in income or expenses: Call your Division of Medicaid & Medical Assistance (DMMA) Financial Senior Social Worker
Who do I call about appeals?
If your MCO denies a service and you disagree, you may call your MCO about an appeal. Your member handbook tells you all about appeals and hearings.
Answers to questions about Delaware Division of Services for Aging and Adults with Physical Disabilities (DSAAPD)
What is an MCO?
Managed Care Organizations (MCOs), like UnitedHealthcare Community Plan, provide health care services to members through doctors, hospitals and other health care providers through contract agreements. The MCO also provides non-medical services based on the benefit package.
Who has to enroll?
Clients currently on the Elderly and Disabled Medicaid Waiver, including Assisted Living and AIDS waiver, must participate. Also included are nursing facility recipients and those who are Community Full Dual eligible (clients who receive both Medicare & Medicaid).
Who will be my Care Coordinator? Will that person come see me or do I have to go to an office somewhere? Who do I call if there is a problem? If I call, will I get to talk to a real person or a machine?
You will be assigned a Care Coordinator from the MCO. The Care Coordinator will routinely visit you, review your care plan and discuss any changes in your situation. The Care Coordinator will also assist you with accessing additional social services. You will receive a phone number to call to contact your Care Coordinator.
Will the Medicaid agency make home visits?
DMMA may make some home visits to conduct quality assurance reviews of the MCOs.
What if I have Medicare and Medicaid but do not have health issues that make me eligible for Long Term Care Medicaid? What services will I be eligible for and will I have a Care Coordinator?
Your benefits will remain the same. You will be eligible for Acute Care Services, in-patient hospitalization, outpatient visits, behavioral health, limited case management, limited durable medical equipment, and 30-day institutional care if Medicare approved.
Will I have to change doctors, the hospital I usually go to or the drug store?
No, as long as these providers contract with the MCO you selected.
Will I be able to stay in “XYZ” Assisted Living Center or nursing home?
Yes, as long as these providers contract with the MCO you selected.
Will I have to get a physician order for everything before an MCO will approve the bill?
The Health Benefits Manager or your selected MCO will answer this question for you.
What about the medical equipment I have now? Is somebody going to come take it? Can I get new equipment??
It is not likely your current medical equipment will be taken. Your new MCO Care Coordinator will review your equipment needs.
If I have issues with my MCO, what can I do?
Check your member handbook for information on the appeal process. Then call your MCO. You can also appeal your concerns to the DMMA.
What is the appeal process?
The MCOs are required to have internal appeals processes for members and providers. A DMMA staff person sits on all MCO client appeals as a voting member. In addition, clients will continue to have the ability to appeal any negative action taken by the MCO via the State Appeal process.
Will Medicaid provide training to all agencies on subjects such as Care Plans?
The MCO would be responsible for providing training to their contractors.
What will the audit process be and how frequently will it occur? Who will perform audits?
The DMMA will retain oversight of the MCOs. The MCOs will also be responsible for overseeing and auditing any of their contractors.
Who will be responsible for the initial needs assessment/determination/Level of Care (LOC), the on-going LOC and the re-determination of LOC's?
DMMA staff will continue to perform the initial level of care determination and redeterminations for Nursing Facility clients only. The MCOs will perform redeterminations of LOC for community-based clients.
Will different levels of care be accommodated under the new program?
The level of care determination will remain the same for community-based clients.
Because different waivers used to require different levels of care, will services/units of service and/or reimbursement be assigned according to level of care?
Services will be authorized based on the unique needs of the client. It is up to the MCOs to establish their reimbursement methodology for their providers.
Will I be able to contact the Ombudsman and Adult Protective Services Units to make referrals and discuss concerns?
Yes. They will be working very closely with the MCOs.
What do I do if I want to change my MCO?
You need to call the Health Benefits Manager who will advise you of this process. You will be allowed the opportunity to change your MCO during an annual open enrollment period in May. You will be notified in a mailing from your health benefits manager on how to make this change
