Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth Eligibility Operations Memo 09-12 August 1, 2009 TO: MassHealth Eligibility Operations Staff FROM: Russ Kulp, Director, MassHealth Operations RE: Processing of MassHealth Applications, Reviews, and Prior Authorization Requests for Individuals Who Are Legally Blind Introduction The Massachusetts Commission for the Blind (MCB) was established in 1906 to provide services to blind residents, leading to independence and full community participation. As part of those services, the MCB/MassHealth Eligibility Unit has been processing MassHealth applications submitted to MCB by legally blind individuals and conducting eligibility reviews for legally blind MassHealth members on MassHealth Standard. Legally blind individuals who do not qualify for MassHealth Standard have been sent MassHealth applications to be completed and submitted to either the Central Processing Unit (CPU) or a MassHealth Enrollment Center (MEC). Effective December 1, 2008, MassHealth assumed responsibility for MassHealth applications, eligibility reviews, and case maintenance, including prior authorizations, for individuals who are legally blind. Individuals who are applying as legally blind, but who are not eligible for MassHealth Standard, are no longer required to complete additional applications to be determined eligible for MassHealth, Commonwealth Care, or Health Safety Net (HSN) benefits. MassHealth regulations are being revised to reflect this administrative change. This does not change the MassHealth benefits that are available to legally blind members. MassHealth Responsibilities As of December 1, 2008, MassHealth assumed responsibility for determining MassHealth eligibility for individuals who have been identified as legally blind by MCB. Additionally, MassHealth assumed responsibility for processing prior authorization requests for personal care attendant (PCA), private duty nursing (PDN), durable medical equipment (DME), and orthotic/prosthetic services for these members. (continued on next page) MassHealth Responsibilities (cont.) Central Processing Unit (CPU) Responsibilities ? Process Medical Benefit Request (MBR) applications for MCB members who are under the age of 65. MassHealth Enrollment Center (MEC) Responsibilities * Process annual ERV forms for MCB members. * Process Senior Medical Benefit Request (SMBR) and MER forms for MCB members who are o aged 65 or older; o a potential Pickle case; o a disabled adult child; o a Kaleigh Mulligan case; o seeking long-term-care services; or o residing in a nursing facility. * Attend appeals related to MassHealth eligibility and process appeal decisions. * Process Notification of Birth (NOB-1) forms for children born to a MassHealth-eligible woman with an active category 14 or 15 (MCB) case (applies to the Revere MEC only). MassHealth Prior Authorization Unit Responsibilities The prior authorization (PA) unit has assumed responsibility for processing PA requests for the following services: * private duty nursing (PDN); * personal care attendant (PCA); * durable medical equipment (DME)/oxygen; and * orthotics/prosthetics. MassHealth Customer Service (Maximus) Responsibilities Applicant and member inquiries including, but not limited to, eligibility, card replacements, prior authorizations, and managed-care information will be handled by MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people with partial or total hearing loss). MCB Responsibilities The Massachusetts Commission for the Blind continues to maintain the Central Register, which identifies people who are determined by their eye care provider to be “legally blind,” and provide social support services to MCB clients. (continued on next page) Documentation of Blindness A Certificate of Legal Blindness is required for individuals requesting MassHealth on the basis of blindness who have no prior MassHealth eligibility affiliated with MCB. If the individual has a prior eligibility segment (category 14 or 15 on MMIS), a Certificate of Legal Blindness is not required. MCB may provide a Certificate of Legal Blindness upon an individual’s request. System Implications MMIS Category 14: Category 14 identifies persons who are blind and are receiving SSI- B payments. These individuals automatically qualify for MassHealth Standard due to their SSI status. Category 14 cases are created directly on MMIS through a State Data Exchange (SDX) match from the Social Security Administration. Beginning May 2009, MCB SSI cases will be systemically converted to either category 1 (SSI for persons aged 65 or older) or category 3 (SSI for persons under age 65). The new case will include an open action reason 14 to indicate SSI-B cases. After May 2009, no new category 14 cases will be created. Category 15: Category 15 cases have historically been created by MCB staff for persons who have lost SSI-B eligibility (former category 14 cases). Upon termination of an individual’s SSI-B case, MCB staff would create a category 15 case to provide MassHealth Standard benefits for an individual identified as a Pickle, disabled adult child, Kaleigh Mulligan, or an individual seeking long- term-care services at home or in an institution. Effective December 1, 2008, no new category 15 cases are being created. Upon termination of an SSI-B case, eligibility for the individual will be determined using the MA21 and PACES (nursing facility residents only) systems. MA21 The MA21 DDU event is used to indicate if the applicant or member is legally blind. The following disability codes indicate legal blindness: * BF System Generated: indicates the individual is receiving federal benefits on the basis of blindness. The code is automatically populated as a result of the State Verification Eligibility System (SVES) match process. There is no need to request a Certificate of Blindness. (continued on next page) System Implications (cont.) ? BL Manual Data Enter Required: indicates the individual has been identified as legally blind by MCB. If the individual has submitted a Certificate of Legal Blindness or has a previous category 14 or 15 on MMIS, this code should be entered on the DDU event. Questions If you have any questions about this memo, please have your MEC designee contact the Policy Hotline.