Secondary Payer Concerns
During our meeting a few weeks ago with Doug Elwell, Illinois Medicaid Administrator, about the following issue and here is his suggestion about next steps:
Effective October 1, 2019, IL Medicaid will begin to follow the federal regulation that states that IL Medicaid will only pay for prescriptions written by an IL Medicaid enrolled provider. If a prescription was written by a non-Medicaid doctor, IL Medicaid will no longer pay for this prescription.
This leaves families with several options:
1) Change to a doctor that is enrolled with IL Medicaid.
– As we are aware, there is a lack of available IL Medicaid enrolled doctors.
– Many IL Medicaid doctors are not seeing new patients.
– It is very difficult for individuals with an Intellectual and Developmental disability or Autism to change to a new doctor.
– To find a doctor who is currently enrolled with traditional IL Medicaid, you may call: 800-226-0768
2) The current non-Medicaid doctor can enroll with IL Medicaid.
– A physician can register in Impact to become a Medicaid enrolled provider.
– After Medicaid enrollment, this doctor can choose to accept Medicaid patients or choose not to see Medicaid patients but his/her prescriptions will be paid by IL Medicaid for patients eligible for IL Medicaid.
A thanks to Sherri Schneider, The Arc board president, who participated in the discussion with the Administrator and helped with this language.
Electronic Visit Verification Update
We have been tracking CMS’s roll out of electronic visit verification for homebased services. As I highlight last week, in our meeting with Medicaid Administrator Doug Elwell, we talked about EVV engagement with stakeholders. He acknowledged that Illinois was behind and had submitted for an extension with CMS (reporting today at the HCBS conference that 12 states submitted for extensions from CMS). He would expect stakeholder meetings and input in September/October. That being said, earlier this month, CMS released responses to key questions that will impact people receiving homebased services. Importantly enough, CMS clarified that shared living/adult foster care/host home models were NOT included in the application since many states were interpreting they were. Also, EVV requirements DO NOT apply when the caregiver providing the services and the beneficiary live together. We understand that California was thinking about a system that they believed would better protect privacy by allowing location documenting to be designated as “home” or “community” rather than the exact address/GPS location. CMS in answering question #3 shares that this is acceptable for services partially rendered in the home but also community. We also heard states like California were pondering the allowance of web based timesheets where the EVV requirements of location, service rendered, etc. could be entered at any time through that portal. The answer in #4 affirms that web-based electronic timesheets alone are not sufficient for ensuring EVV compliance. I hope this was helpful!
CIB: Electronic Visit Verification
Frequently Asked Questions – June 2019
1) Do EVV requirements apply if the individual receiving personal care or home health
care lives with the caregiver providing the service?
No, EVV requirements do not apply when the caregiver providing the service and the beneficiary live together. PCS or HHCS rendered by an individual living in the residence does not constitute an “in-home visit”. However, states are encouraged to apply appropriate oversight to services provided in these circumstances to curb fraud, waste and abuse. Additionally, states may choose to implement EVV in these instances, particularly when using discrete units of reimbursement, such as on an hourly basis.
2) Do EVV requirements apply to the component of home health services authorizing the
provision of medical supplies, equipment or appliances?
No, EVV requirements do not apply to this component of the home health benefit. The
delivery, set-up, and/or instruction on the use of medical supplies, equipment or appliances do not constitute an “in-home visit.”
3) If a personal care or home health care service is provided both in the home and in the
community during the same visit, is that service subject to EVV requirements?
EVV is only required for the portion of the service rendered in the home; however, states
may choose to require more information to control fraud, waste, and abuse. EVV methods states can use for capturing services rendered partially in the home may include:
a) Capturing the specific location where the service starts and stops, regardless if that
location is in the home or community.
b) Using the terms “home” and/ or “community” as the designation in the EVV system for location. The location data element transmitted to the state is indicated as either “home” or “community” depending on the location of the check-in/out. The specific community location (e.g., coordinates, address, etc.) would not be transmitted.
c) Capturing only the specific home location, but the start and stop times for the full
service unit. For example, if a service visit starts in the community and ends in the
home, the caregiver would check in from the community to note the visit’s start time
(without recording location), check in again when they enter the home to begin
recording the location, and then check out when they leave the home to note the
visit’s end time. Methods b) and c) above are presented as options for alleviating privacy concerns regarding tracking of community locations while ensuring that the location of any portion of a service delivered in the home is recorded. States may select the approach that best aligns with their systems and program integrity goals. CMS takes no position on which option should be selected by a state, or on the technological implications for implementing methods b) or c).
4) Are web-based electronic timesheets with dual verification a permissible form of
No. Most states’ EVV systems use GPS and/or landlines to capture the location of PCS and HHCS. As an alternative, stakeholders proposed the use of web-based timesheets in which the time and location of service delivery is entered by the caregiver and authenticated by the beneficiary. However, web-based timesheets alone do not provide the state with auditable confirmation of the data entered by the provider and approved by the individual. Consequently such a system would not be sufficient for electronically verifying the six data elements required by section 1903(l)(5)(A) of the Act for PCS or HHCS services rendered during an in-home visit.
5) Who can I reach out to with additional questions?
Please email EVV@cms.hhs.gov with questions or concerns
Secondary Payer Concerns