December 2015 – Please be aware that FSSA is no longer making the temporary determination that an applicant may meet the medically frail/state plan category based on the health questions at the time of application. The MCE is making this determination subsequent to the application approval. This will be based on a health assessment and/or the MCE will use claim or pharmacy information to run through a “scoring” tool. The MCE’s are also required to do a reassessment on the medically frail at least every 12 months. The state will be able to automatically make a member medically frail/eligible for state plan based on SSI/DI determination and Scott County/Ryan White HIV project. ICES is supposed to send this information to the MCE. Members that are eligible for low income parent/caretaker, Transitional Medicaid, or low income 19/20 year old dependent are eligible for the state plan which is not based on the health assessment.
Because the HIP State Plan is most appropriate for some of our patients/consumers based on meeting medically frail criteria and a delay in enrolling them can adversely affect their covered services, please continue to complete the health questions even when the state application on line drops it projected sometime this month.
If anyone answers yes to any of the health questions please contact the patient’s elected MCE as soon as they are conditionally approved. Ask the MCE what documentation is needed to support their medical condition so they can accurately determine if they meet the medically frail category. Being proactive, especially for our Behavioral health patients will improve their access to MRO services. This may include their treatment plan so obtain authorization for medical records for these patients at the time you are meeting with them. The trigger is a YES answer to any of the questions on the health assessment. You can also familiarize yourself with the conditions that may qualify a patient/consumer for medically frail/state plan.