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Molina-Medicare-Complete-Care Molina Medicare Complete Care Molina Medicare Complete Care Overview What it is: Molina Medicare Complete Care (HMO SNP) is a Medicare Advantage Prescription Drug Special Needs Plan. All Members of Molina Medicare Complete Care (HMO SNP) are full benefit dual eligible (e.g., they receive both Medicare and Medicaid. CMS rules state that these Members may enroll or disenroll throughout the year. What are some specific things your office should know about Molina Medicare Complete Care: • Cultural Competency Molina is committed to reducing health care disparities. Training employees, Providers and their staffs, and quality monitoring are the cornerstones of successful culturally competent service delivery. Molina integrates Cultural Competency training into the overall Provider training and quality monitoring programs. An integrated quality approach intends to enhance the way people think about our Members, service delivery and program development so that cultural competency becomes a part of everyday thinking. • Molina Special Needs Plan Model of Care Molina operates Medicare Dual Eligible Special Needs Plans (SNP) for Members who are fully eligible for both Medicare and Medicaid. In accordance with CMS regulations, Molina has a SNP Model of Care that outlines Molina’s efforts to meet the needs of the dual eligible SNP members. This population has a higher burden of multiple chronic illnesses and sub-populations of frail/disabled Members than other Medicare Managed Care Plan types. The Molina Dual Eligible Special Needs Plan Model of Care addresses the needs of all sub-populations found in the Molina Medicare SNP. • Model of Care Training Molina will issue a written request to Providers annually to participate in Model of Care training. All Molina Providers have access to SNP Model of Care training via the Molina website. • Member Care Plan To better coordinate the Molina member Care Plan with the Primary Care Physician, a faxed copy of the individual Care Plan will be sent to the Primary Care Physician office for all assigned Molina Medicare and Molina MI Health Link members. The Primary Care Physician is a critical member of the Interdisciplinary Care Team (ICT). An Attestation Form will accompany the faxed ICP. This will need to be reviewed and your agreement or updates will need to be documented. Once complete, the Attestation Form, along with any changes, will need to be returned via fax or mail. The Primary Care Physician’s signature is required and without other changes, indicates agreement to the Care Plan established by the Care Manager, the member/caregiver, and other members of the ICT. • Quality of Provider Office Sites Molina has a process to ensure that the offices of all Providers meet its office-site standards. Molina continually monitors Member complaints/grievances for all office sites to determine the need of an office site visit and will conduct office site visits within sixty (60) calendar days. Molina assesses the quality, safety and accessibility of office sites where care is delivered against standards and thresholds. A standard survey form is completed at the time of each visit. This form includes the Office Site Review Guidelines and the Medical Record Keeping Practice Guidelines and the thresholds for acceptable performance against the criteria. This includes an assessment of Physical Accessibility, Physical Appearance, Adequacy of Waiting and Examining Room Space and Adequacy of Medical/Treatment Record Keeping. • Medicare STAR Ratings – The Affordable Care Act With the passage of the Affordable Care Act, the health care industry will be subject to greater scrutiny wherever taxpayer dollars are involved. One method of oversight is Medicare “STAR Ratings.” STAR ratings are not new, but in the current regulatory climate, value-based payment will be receiving more focus. STAR Ratings are a system of measurements CMS uses to determine how well physicians and health plans are providing care to Medicare Members. The provider role in this rating is in the responses received through survey questions that ask your patients to “…rate your satisfaction with your personal doctor” and “…rate your satisfaction with getting needed appointments.” • Balance Billing Providers contracted with Molina cannot bill the Member for any covered benefits. The Provider is responsible for verifying eligibility and obtaining approval for those services that require prior authorization. Providers may not charge Members fees for covered services beyond copayments or coinsurance. Providers agree that under no circumstance shall a Member be liable to the Provider for any sums owed by Molina to the Provider. Members who are dually eligible for Medicare and Medicaid shall not be held liable for Medicare Part A and B cost sharing when the State or another payer such as a Medicaid Managed Care Plan is responsible for paying such amounts. Balance billing a Medicare and/or Medicaid Member for Medicare and/or Medicaid covered services is prohibited by Law. This includes asking the Member to pay the difference between the discounted and negotiated fees, and the Provider’s usual and customary fees. • Termination of Provider Services (SNF, HH, CORF)/Issuance of Notice of Medicare Non- Coverage (NOMNC) and Detailed Explanation of Non-Coverage (DENC) – When a termination of authorized coverage of a Member’s admission to a skilled nursing facility (SNF) or coverage of home health agencies (HHA) or comprehensive outpatient rehabilitation facility (CORF) services occurs, the Member must receive a written notice two (2) calendar days or two (2) visits prior to the proposed termination of services. Molina or the delegated Medical Group must coordinate with the SNF, HHA or CORF Provider to ensure timely delivery of the written notice, using the approved NOMNC, which is available on our website and attached to this document. Delivery of the notice is not valid unless all elements are present and Member or authorized representative signs and dates the notice to document receipt. A full and complete explanation of the requirements and process can be found in the Medicare Provider Manual. For more detailed information on Molina Medicare Complete Care, please visit the provider manual located on our website. https://www.molinahealthcare.com/providers/common/medicare/PDF/provider-manual-mi.pdf Thank you for serving Molina members. 880 West Long Lake Road - Suite 600 - Troy, MI 48098 - Phone 248.729.0905 .
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