Adding Managed Care Enrollment Exemptions

 Clients required to be in a managed care or
coordinated care plan for physical health
 Clients exempt from managed care or
coordinated care enrollment for physical health
 The exemption process & exemption codes
 The exemption process for clients with Third
Party Liability (TPL)
 How to enter an exemption in the MMIS
 FCHP: Fully Capitated Health Plan
 PCO: Physician Care Organization
 CDO: Chemical Dependency Organization
(available in Deschutes County only)
 MCO: Managed Care Organization
 CCO: Coordinated Care Organization
 MHO: Mental Health Organization
 PHP: Prepaid Health Plan
 PMP: Primary Medical Provider
Identifying clients
required to be in an
MCO or CCO plan for physical
Who Must be Enrolled in an MCO
or CCO Plan?
 Non-Medicare clients who live in mandatory enrollment
areas are required to enroll in an MCO or CCO plan
unless they are eligible for an exemption.
 If the client is eligible for an exemption, an appropriate
exemption must be entered in the MMIS.
 If the client does not meet the exemption criteria, they
will be auto enrolled in an MCO or CCO plan (if one is
Medicare Clients and Physical
Health Managed Care
 Medicare OHP Plus clients have the option to
enroll in an MCO or CCO plan for physical health
or to remain fee for service.
Medicare Clients and Physical
Health Managed Care
 Medicare OHP Plus clients must be choice
 The Medicaid MCO or CCO plan the client
chooses may have a corresponding Medicare
Advantage plan (may be Special Needs plan).
Medicare Clients and Physical
Health Managed Care
 Before CCO implementation - To be enrolled
in a managed care plan, the client had to enroll
into the Medicare Advantage plan offered by the
MCO or the managed care plan would request
the member to be disenrolled.
Medicare Clients and Physical
Health Managed Care
 After CCO Implementation - Effective August
1, 2012, with CCO implementation, a CCO cannot
ask for disenrollment if the member was enrolled
in a Medicare Advantage Plan that wasn’t specific
to the CCO (OAR 410-141-3060).
Managed Care for Dental and
Mental Health
 Local branch staff cannot add exemptions for dental
or mental health.
 All clients with OHP Standard and Plus are required
to enroll in dental and mental health plans. This
includes both Medicare and non-Medicare clients.
 If the worker does not enroll them, the MMIS
will auto enroll clients in areas of the state
where plans are open for enrollment.
Identifying clients
exempt from MCO or
CCO enrollment for physical
Managed Care Exemptions
 Workers have a select group of exemption
reasons they can use to exempt a client from
MCO or CCO enrollment.
 If you are setting up a new case through UCMS,
please refer to the following guide: “The New
PHP Enrollment Screens” at the URL below.
Managed Care Exemptions
FCHP and PCO enrollment types:
 When entering an exemption, be sure to add it to
both FCHP & PCO even if the client lives outside an
area serviced by the PCO.
 This prevents auto enrollment if a client moves to an
area serviced by Kaiser, or in the event the PCO
expands their service area to where the client
currently lives. Kaiser is the only PCO at this time.
Managed Care Exemptions
For Medicare OHP Plus clients choosing to
remain fee for service:
 Due to a system limitation, you will need to enter
a Medical Medicare Choice exemption for them
until MMIS programming is changed to bypass
Medicare clients.
 Use the Medical Medicare Choice exemption
code instead of Continuity of Care.
Managed Care Exemptions
End Stage Renal Disease (ESRD)
 Only Client Enrollment Services (CES) can add
an exemption for a client with ESRD.
 Local branch offices do not have authority to add
an ESRD exemption.
 Failure to follow this protocol may result in
losing access to the MMIS exemption panels.
Exemption Codes
Exemption Codes
 Access to Care. This code can only be added by
 Access to Care is Monitored by CMS. Contractually,
MCOs and CCOs are obligated to provide specialty
care. If they do not have a provider available in their
service area, they must allow the client to go out of
area for specialty treatment. The plans reimburse the
specialist for providing the service.
Exemption Codes
Access to Care, cont…
 If care cannot be coordinated, DMAP DSU/CES will
disenroll the client and exempt the client for Access to
 If you feel there is an access issue, contact CES or a
DMAP PHP Coordinator.
Exemption Codes
 Continuity of Care – This code should only be used
when a client’s health will be harmed by a move into
an MCO or CCO plan. Use of this code requires
documentation in the case file from the physician
regarding the client’s need.
Example: A client requires long-term services from a
primary physician for a complicated medical condition
and the physician does not participate with any MCO
or CCO plan in the client’s area. This code is not used
for Medicare clients who choose not to enroll.
Exemption Codes
 Client is Hospitalized – This code is used if the client is
in the hospital when their MCO or CCO enrollment
would have begun if they hadn’t been hospitalized. The
client will be fee for service until their discharge from the
hospital. Upon discharge, the client will be enrolled in a
 Hearing Scheduled – Enrollment is delayed.
 End Stage Renal Disease (ESRD) – Only entered by
DMAP. Contact CES to have the exemption added.
Exemption Codes
 Medical Medicare Choice – This code should only be
used in the following circumstances.
 the client has chosen a Medicare Advantage plan, or
 the client has chosen a Medicare Part D plan that does
not coordinate with the managed care plans available
where they live, or
 the only managed care plans available require the client
to be enrolled in a Medicare Advantage plan not of their
Exemption Codes
 Other – APD/AAA workers should not use this code for
exemptions from physical health plans.
 If you believe that a client needs the “Other” exemption,
send a request to Dr. Tina Kitchin at
[email protected] or via fax at (503) 373-7823.
 Case workers requesting this exemption should request
documentation from the client’s physician.
Exemption Codes
 Proof of Indian Heritage – Exemptions are no longer
required for Native Americans or tribal members. This
group must opt-in if they wish to be enrolled in an MCO
or CCO plan. The worker codes the client’s medical
eligibility with the HNA Case Descriptor, which excludes
the client from the auto enrollment process for all plan
types. The worker must manually enroll the tribal
member into their chosen plan.
Exemption Codes
 Religious Consideration – This code is rarely used. An
example might be if the client’s religion only allows them
to be seen by a female physician and the MCO or CCO
plan does not have any female physicians available.
 Surgery Scheduled for Client – Use this code when a
surgery is already scheduled and the provider does not
participate with any of the available plans. After the postsurgery period has passed, the client must be enrolled in
an MCO or CCO plan.
Exemption Codes
 Rehabilitation/Inpatient/Facility – This code should
be used for clients in the Blue Mountain Recovery
Center, the Oregon State Hospital, or for those clients in
a nursing facility who meet both of the following
The client needs to use the facility’s in-house physician.
The physician is not a member of an MCO or CCO plan.
Exemption Procedures
Exemption Procedures
 Exemptions for physical health are for temporary
situations and cannot exceed one year from the date of
 Exemptions must be reviewed annually at the time of
eligibility re-determination.
 Retroactive exemptions cannot be done by local office
staff. Send retro exemption requests to CES.
Exemption Procedures
 If the client is already enrolled in a physical health plan, the
enrollment must be ended before you can add an exemption.
Contact CES for any questions about enrollment issues.
Adding an exemption does not automatically disenroll a client
from an MCO or CCO plan.
Note: The Health Insurance Group (HIG) takes care of
disenrollments for TPL exemptions.
Exemption Procedures
 The exemption start date cannot be earlier than the
first day of the next new month.
 Unless approved by DMAP, the MCO or CCO
enrollment will end the last day of the current
month. You can then add the exemption to begin on
the first of the next new month.
Exemption Procedures
 If you need the disenrollment to occur earlier than the
last day of the month, contact CES.
 Retroactive disenrollments impact capitation payments,
enrollment history, and services that have already been
delivered. These disenrollments must be done by CES.
 If you want to end an exemption and enroll a client in a
physical health plan, you must end the exemption with a
date that is prior to the new enrollment beginning.
Exemptions for TPL
TPL Exemptions
 Case workers should not add or end TPL exemptions.
When HIG receives information that a client has TPL,
HIG enters the exemption. HIG then verifies and records
the status of the TPL in the MMIS.
 If the client reports changes to their private health
insurance situation, send a completed form “MSC
0415H” to HIG. (Use form DHS 0156 for emergencies.)
 HIG will verify the status of the policy and will update
the exemption as appropriate.
TPL Exemptions, cont…
 If the client is enrolled in an MCO or CCO plan, HIG will
process the disenrollment effective at the end of the
month in which the TPL is added.
 If the client already has a TPL or ESRD exemption, do
not change it to another code type. TPL exemptions can
only be ended by HIG. ESRD exemptions can only be
ended by CES.
TPL Exemptions, cont…
 When in doubt, check with CES or HIG before changing
an existing exemption code.
 HIG only handles exemptions for TPL. If the exemption
is related to third party insurance, contact HIG.
 For all other exemption reasons, contact CES.
New CCO Exemption Codes
With the inception of CCOs,
the Managed Care Special
Conditions panel in the MMIS
will now display additional
exemption codes for the new
CCO plan types.
New CCO Exemption Codes
CCO exemptions:
 A - EXQ - Mental / Physical / Dental
 B - EXR - Mental / Physical
 C - EXS - Physical / Dental
 D - EXT - Physical
 E - EXU - Mental
How to enter a managed
care exemption in the
Health Insurance Group (HIG)
Phone: 503-378-6233
Fax: 503-373-0358
Email: [email protected]
For assistance with exemptions or MCO & CCO
enrollments and disenrollments, please contact
Client Enrollment Services.
Client Enrollment Services (CES)
[email protected]
Questions about MMIS Training
Bob Costa
MMIS Training Manager
Oregon Health Authority
[email protected]

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