Table : ACA Impacts on Eligibility Determination ACA Requirement Section 4004 Education and outreach campaign regarding preventive benefits and obesity-related care. OM07 Audit Claim/Encounter – Table : ACA Impacts on Audit Claim/Encounter ACA Requirement Section 6507 Requires compliance with National Correct Coding Initiative (NCCI). OM16 Prepare Health Insurance Premium Payment – OM21 Prepare Member Premium Invoice – In these processes, the Commonwealth is covering the of the premium for member’s share medical coverage. The premium billing, collections, and reconciliation processes for member premiums may be handled through the HBE process/system/vendor depending on the The Division for Medicaid Services (DMS) could realize some gains Commonwealth’s solution. in efficiency by eliminating a manual Medicaid process and incorporating it into the HBE. OM20 Calculate Spend Down Amount – The Spend Down process typically covers clients with incomes slightly higher than Medicaid eligibility limits. In these cases, the HBE will offer increasing health care subsidies for health insurance coverage leading up to full Medicaid coverage. The participants would likely qualify for coverage which may eliminate the need for the Spend Down process. OM26 Manage Recovery – Table : ACA Impacts on Manage Recovery Process ACA Requirement Section 6411 The ACA requires the contracting of a Recovery Audit Contractor (RAC). 6506 This provision extends the period of time for recovery to one year from the time of discovery. PG02 Develop and Maintain Benefit Package – Table : ACA Impacts on Benefit Packages ACA Requirement Section 2001 States must create and maintain benchmark plans as well as the benefit “newly eligible” category. 2001 Beginning in 2014, benchmark and benchmark-equivalent plans must begin providing at least essential health benefits, as described in Section 1302(b).
Table : ACA Impacts on Eligibility Determination ACA Section Requirement 4004 Education and outreach campaign regarding preventive benefits and obesity-related care. OM07 – Audit Claim/Encounter Table : ACA Impacts on Audit Claim/Encounter ACA Section Requirement 6507 Requires compliance with National Correct Coding Initiative (NCCI). OM16 – Prepare Health Insurance Premium Payment OM21 – Prepare Member Premium Invoice In these processes, the Commonwealth is covering the member’s share of the premium for medical coverage. The premium billing, collections, and reconciliation processes for member premiums may be handled through the HBE process/system/vendor depending on the Commonwealth’s solution. The Division for Medicaid Services (DMS) could realize some gains in efficiency by eliminating a manual Medicaid process and incorporating it into the HBE. OM20 – Calculate Spend Down Amount The Spend Down process typically covers clients with incomes slightly higher than Medicaid eligibility limits. In these cases, the HBE will offer increasing health care subsidies for health insurance coverage leading up to full Medicaid coverage. The participants would likely qualify for coverage which may eliminate the need for the Spend Down process. OM26 – Manage Recovery Table : ACA Impacts on Manage Recovery Process ACA Section Requirement 6411 The ACA requires the contracting of a Recovery Audit Contractor (RAC). 6506 This provision extends the period of time for recovery to one year from the time of discovery. PG02 – Develop and Maintain Benefit Package Table : ACA Impacts on Benefit Packages ACA Section Requirement 2001 States must create and maintain benchmark plans as well as the “newly eligible” benefit category. 2001 Beginning in 2014, benchmark and benchmark-equivalent plans must begin providing at least essential health benefits, as described in Section 1302(b).