500           OVERVIEW OF AGED, DISABLED AND LONG TERM CARE MEDICAID

The Alaska Department of Health administers the Medicaid program in accordance with federal and state laws and regulations.  The Medicaid program is authorized under Title XIX and Title XXI of the Social Security Act and the Code of Federal Regulations, Title 42 Part 435 and Title 45 Part 233.  

Alaska joined the Medicaid program in September 1972.  New services and eligible groups have been added to the program since that time by the Legislature.  The Medicaid program in Alaska is authorized under Alaska Statutes 47.07.010 - 47.07.900 and the Alaska Administrative Code, Title 7 Chapter 100 through chapter 160.

Medicaid is jointly financed by the federal government and the state.  Certain groups of individuals and services are required by federal law; while other optional groups of individuals and services are selected by the state.

The Division of Public Assistance (DPA) processes Medicaid applications and determines eligibility.

The Division of Health Care Services (DHCS) oversees the processing of Medicaid claims, payment to health care providers, and overall fiscal responsibilities of the Medicaid program. DHCS contracts with Health Management Systems (HMS) to handle the day-to-day processing of medical claims and payments.

The Division of Senior and Disabilities Services (DSDS) determines the Level of Care for Home and Community Based waiver services.

500 A.      APPLICABLE ELIGIBILITY CATEGORIES

This manual contains Medicaid eligibility policy for the following Adult Public Assistance (APA) related eligibility categories:

• Supplemental Security Income (SSI) Recipient
• APAAdult Public Assistance Recipient
• SSISupplemental Security Income Eligible - Not Receiving Cash Payments
• APAAdult Public Assistance Eligible - Not Receiving Cash Payments (Refused Cash)
• Expanded Refused Cash -- APAAdult Public Assistance ineligible due to countable income over the appropriate need/payment standard but below the Expanded Refused Cash income limit shown in ADLTC MS 530(C)
• SSISupplemental Security Income or APAAdult Public Assistance Ineligibles for Reasons Prohibited by Medicaid
• Working Disabled Medicaid Buy-In
• Special Long Term Care
• Disabled Children at Home (TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248)
• ”Pickle People”
• ”Section 1619(b)” Eligible
• SSISupplemental Security Income Disabled Children
• Disabled Widow(er)

Individuals receiving APAAdult Public Assistance and SSISupplemental Security Income are automatically eligible for Medicaid.

Individuals who meet the categorical requirements of APAAdult Public Assistance-related Medicaid, but require an institutional living arrangement or home and community based care may be eligible for Medicaid under the Special Long Term Care category.

In addition, Alaska has the Medicare Savings Programs that help pay Medicare costs, but do not offer regular Medicaid coverage:

• Qualified Medicare Beneficiary (QMB);
• Qualified Disabled and Working Individuals (QDWI);
• Specified Low Income Medicare Beneficiary (SLMB); and
• Specified Low Income Medicare Beneficiary Plus (SLMB Plus).

Please refer to ADLTC MS 580 for additional information.

Note:

If the individual has not yet received a favorable disability determination but states they are seeking a determination, process under MAGIModified Adjusted Gross Income Medicaid rules. If the individual does not pass under MAGIModified Adjusted Gross Income rules, refer the application to the FFMFederally Facilitated Marketplace.

500 B.      MEDICAID COVERED SERVICES

Payment for Medicaid services will only be made to enrolled providers.  It is the responsibility of the recipient to find out if the medical provider is enrolled with Alaska Medicaid before receiving the service.  

The Division of Health Care Services (DHCS) publishes and distributes the Alaska Medicaid Recipient Services booklet for all Medicaid recipients.  This booklet gives detailed information about what medical services are covered by the Alaska Medicaid program and how to use those services.  Many services require a prior-authorization by the medical provider before payment can be made by the Medicaid Program.  

Any services received by a recipient that are not covered by Medicaid, or were not prior authorized when required, are the responsibility of the recipient.

Note:

The Alaska Medicaid Recipient Services booklet is available on the DHCSDivision of Health Care Services web site at https://health.alaska.gov/dhcs/Documents/PDF/Recipient-Handbook.pdf. 

500 C.      MEDICAL SERVICES RECEIVED OUT-OF-STATE

Medical services may be received out-of-state if those services are not available in Alaska as long as the service is prior authorized and the health care provider is enrolled in the Alaska Medicaid program.   Services received without prior authorization because of an emergency or because the recipient’s health would be endangered if required to return to Alaska to receive medical care may also be covered if the provider subsequently enrolls in the Medicaid program.

A recipient living in a community with convenient road access to a Canadian medical provider and no access to a U.S. medical provider other than by chartered airplane may receive medical care in the Canadian community.  Medicaid will reimburse covered services provided by Canadian providers if one of the following conditions is met:

1. The services were provided because of a medical emergency.  A medical emergency exists when a recipient has a severe, life threatening, or potentially disabling condition that requires intervention within minutes or hours; or

2. The State of Alaska has agreed that the needed health care services are more readily available in Canada at equal or less cost.  

All other services received out-of-state must be prior authorized by Affiliated Computer Services to be covered by Medicaid.

500 D.      FREEDOM OF CHOICE OF PROVIDERS

Medicaid recipients are free to choose their own health care provider(s), as long as that provider is enrolled with the Alaska Medicaid program, with the following exceptions:

1. When a recipient is placed in the Care Management Program; or

2. When a recipient must use a non-enrolled provider during an emergency, but that provider subsequently enrolls in the Medicaid program.

500 E.      FREEDOM OF CHOICE RESTRICTION - CARE MANAGEMENT PROGRAM

The state’s fiscal agent, Affiliated Computer Systems (ACS), administers the Medicaid Lock-In program.    ACSAffiliated Computer Systems may restrict a recipient's choice of providers if they find that the recipient has used a medical service at a frequency or in an amount that is considered improper, excessive, or unusual.  This restriction is imposed by placing a recipient into the Care Management Program.  

When this occurs, ACSAffiliated Computer Systems will notify the recipient of the finding and assign the individual a provider who will be the only provider available for the services identified by ACSAffiliated Computer Systems .  Once placed in the Care Management Program, the recipient may not receive medical services from another enrolled provider without first getting a written referral from their care management provider except in the case of a life threatening or potentially disabling emergency.

The recipient has a right to a fair hearing to contest this finding.  Recipients may request a fair hearing by contacting either their caseworker or the Medicaid Recipient Helpline toll free at 1-800-780-9972 (both inside and outside Anchorage area).  A Fair Hearing Representative from the Division of Health Care Services will then contact the recipient regarding this request.

When an individual is placed into the Care Management Program, ACSAffiliated Computer Systems staff will enter a "PC" code for that individual on the EISEligibility Information System Medical Resource (MERE) screen.  DPADivision of Public Assistance will authorize the benefit in the normal manner, and EISEligibility Information System will show a benefit issued.  The Recipient Identification card (coupons) for the individual will be mailed separately by ACSAffiliated Computer Systems , usually within three days of the system issuance.

DPADivision of Public Assistance is unable to issue or print manual coupons for a Care Management Program recipient, but may contact ACSAffiliated Computer Systems at 907-644-6842 or by email at Jason.Ball@acs-inc.com to request coupons on behalf of the recipient.

500 F.      CONFIDENTIALITY

Refer to Administrative Manual Section 100-3.

500 G.      HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)

Health or medical information that the Department of Health may have is protected under the Health Insurance Portability and Accountability Act (HIPAA) of 1996.  This federal law provides individuals with certain rights about how health information is used and disclosed.  Refer to Administrative Procedures Manual Section 100-8 for HIPAA policy.