SNF Newsletter January 2025

Dear Valued Clients and Partners,


As the year comes to a close, we at Managed Care Consultants of America want to express our heartfelt gratitude for your trust and partnership over the past year. Working alongside you to navigate the ever-evolving world of managed care has been a privilege, and we are truly grateful for the opportunity to support your success.

 

Your dedication to providing exceptional care and services inspires us daily, and we’re honored to play a role in helping you achieve your goals. As we look ahead to the new year, we’re excited to continue working together to overcome challenges, seize opportunities, and make an even greater impact.

 

Thank you once again for your confidence in us. We wish you, your team, and those you serve a happy, healthy, and prosperous New Year.


Sincerely,


Destiny Quinones

President/CEO

Managed Care Consultants of America

CMS has published: Updated Part C and D Standardized and Model Notices and the Parts C and D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance effective January 1, 2025. Of significant note for providers of Medicare Advantage plans is the change to the NOMNC for Medicare Advantage (MA) members. Previously on the NOMNC, if the beneficiary or their representative missed the noon before last covered day deadline, they had to appeal directly to the MA plan. Effective January 1st, 2025, the MA beneficiaries or their representatives will submit their untimely appeal directly to the QIO just as those with FFS / Original Medicare would do.

 

There are also changes to the Detailed Notice of Non-Coverage that is produced by the MA plan when a beneficiary has already appealed and had a favorable outcome for continued skilled services. ‘If the enrollee has previously received a favorable BFCC-QIO appeal decision during the current episode of care, detail the specific change(s) in the enrollee’s condition since the previous appeal that provide the basis for this decision to terminate services.’  

 

For complete details, please visit https://www.cms.gov/medicare/forms-notices/beneficiary-notices-initiative/ffs-ma-nomnc-denc to download the new NOMNC and DENC for MA plans.

 

FYI – there may not be a MA plan listed on the NOMNC unless the plan issued it directly with their logo on it. So when the beneficiary or representative calls in, the QIO will ask who their payer is i.e. MA plan or Traditional Medicare.

OPEN ENROLLMENT REMINDER


As we approach the new year, it will bring changes for everyone, including our residents. Your residents have been bombarded by advertisements regarding Medicare open enrollment and choosing a Medicare Advantage plan. Medicare open Enrollment was October 15th to December 7th. During this timeframe, Medicare eligible people have the option to switch from Traditional Medicare to a Medicare Advantage Plan, switch Medicare Advantage Plans or change their stand-alone Part D Plan. It is important to validate all of your resident’s insurance coverage, attain their deductibles, out of pockets and new copays as of January 1st. Something to remember: all Medicare Advantage deductibles and out of pocket expenses reset on January 1st. It is also important to notate the additional Medicare Advantage Open Enrollment Period, which runs from January 1st to March 31st. This timeframe allows a member that is enrolled in a Medicare Advantage plan to: switch to a different Medicare Advantage plan, drop their Medicare Advantage plan and return to Original Medicare, or signup for a stand-alone Part D Drug Plan (if they return to Original Medicare). Medicare Open Enrollment | CMS.


Also note, that your residents covered by Medicaid and the Affordable Care Act programs also had recent open enrollments that take effect on January 1st. It is important to also validate these polices to make sure that your organization is in network or if a letter of agreement is required. Affordable Care Act polices also have an extended enrollment from December 16th until January 15th to make an election with an effective date of February 1st

 

It is a best practice to run Medicare Verifications on ALL skilled members on the 1st and 15th of the month to catch potential changes.

United Healthcare

Special Needs Plans


Last year United Healthcare sent out a reminder on their SNF admission and DISCHARGE process. Click here for the document that details the process for SNF admissions for Medicare Advantage Dual Eligibles. Medicare Advantage and D-SNP beneficiaries are managed through UHC portal. Fully Integrated Dual Eligible Applicable Integrated Plans (FIDE AIP) and Highly Integrated Dual Eligible Plans (HIDE) are managed directly by UHC. Once the patient is admitted, UHC still requires a notification within 24 hours of admission. For DISCHARGES, UHC is requesting that all patients have their DME, home health or outpatient scheduled but also that all members also have a Primary Care Provider visit scheduled for them post discharge. UHC is also requesting that upon the DISCHARGE of commercial, FIDE AIP and HIDE members, the facility notate the member’s discharge date and disposition utilizing the Prior Authorization and Notification tool at UHCprovider.com.  Medicare Advantage and D-SNP members will continue to receive the NOMNC via naviHealth; the facility is required to return the NOMNC to naviHealth via email or uploading into their portal.


For clarity, here are UHC’s definitions of Dual Eligible Applicable Integrated Plans (FIDE AIP) and Highly Integrated Dual Eligible Plans (HIDE)

A Fully Integrated Dual Eligible (FIDE) is a specific dually eligible individual who receives fully integrated Medicare and Medicaid benefits from a single managed care organization (MCO) through a Fully Integrated Dual Special Needs Plan (FIDE-SNP). FIDEs and FIDE-SNPs help streamline and declutter the often hard-to-navigate benefits and requirements that come with being dually eligible

A Highly Integrated Dual Special Needs Plan (HIDE-SNP) is an integrated care plan that combines the benefits of Medicare and Medicaid from a managed care organization (MCO) into a more unified care plan. Although less integrated than FIDE-SNPs, HIDE-SNPs still incorporate both behavioral health and Managed Long-Term Services and Supports (MLTSS) benefits into the plan here.

Educational Webinars Hosted by MCCA

January

  • NOMNC's and Appeals new changes 1/1/2025 hosted by: Chris Langebrake
  • Verifying Benefits - The Basics hosted by: Kristin Cull

February

  • Discharge Planning with the Final Rule hosted by: Nanette Johnson-Smith
  • CareCentrix Payors hosted by: Nikole Blackman



Please reach out to your liaison for invitations to join.

Paying Attention To The Details!

Housekeeping Items

  • Verify benefits every 1st and 15th of the month as a best practice
  • New employees, please let our liaisons know so we can setup training
  • Discharge Summaries should be sent to the health plans and patient's PCP upon discharge
  • Have you registered for our new portal? Register here!

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