DEPARTMENT OF HEALTH SERVICES
Division of Public Health
F-00221A (04/2018)
Family care / partnership / pace / IRIS
Change routing - instructions
Section A—Member Information
The information in this section should match the information in ForwardHealth. If there has been a change in contact information, check the box at the bottom of the section and supply documentation to IM.
Section B—Changes that may Affect Medicaid Eligibility and/or Long-Term Care Enrollment
This section is completed when any of the potential reasons for a change in eligibility or enrollment for a member or participant is discovered. Income Maintenance (IM) determines whether the information actually affects eligibility or enrollment. IM must process the reported change (s) within 10 days of receipt. The MCO or ICA should verify the results of the reported change in CARES and FHiC 14 days after submission. The result should be documented in the box marked ‘MCO/ICA AGENCY USE’. If the reported change results in a disenrollment for the customer/participant, the MCO or ICA will route the entire form to the ADRC to perform disenrollment counseling.
Section C—Change in Living Arrangement (To or From an Institutional Setting)
The MCO or ICA enters the facility information, date of admission to the facility and/or the date of discharge, if known, and marks the appropriate checkbox for the expected length of stay for an institutional admission.If the stay is expected to be more than 30 days, provide a physician’s statement that the person is likely to return to the home or apartment within six months.For all nursing home admissions or discharges, the MCO/ICA should follow their internal process for making a referral or sending an update to the Money Follows the Person (MFP) program.
Any MCO member or IRIS participant who enters an Institute for Mental Disease (IMD) or is incarcerated must be disenrolled from the program because these are ineligible Medicaid settings. Services can continue to be provided to a member of an IMD if they are under age 21 or over age 65. A 21-year-old resident of an IMD may also continue to receive services if the individual was a resident of the IMD immediately prior to turning 21 and continues to be an IMD resident after turning 21.For IRIS participants, a nursing home isconsidered an ineligible setting and will result in disenrollment.
Section D—Change of Address
It is not necessary to complete a disenrollment form for individuals who choose to remain enrolled with the same MCO/ICA and move between counties or if the individual moves to another county due to an MCO/ICA placement. If the person voluntarily moves to another county, the ADRC will end the current enrollment and enter a new enrollment using the new MCO ID in FHiC.The ADRC may need to select other and enter the correct MCO ID. Income maintenance will be responsible for updating the special managed care program code and the transfer of Medicaid eligibility. If individual is an MFP participant, theMCO/ICA should follow their internal process for sending an update to the MFP program regarding the change in living arrangement.The MCO/ICA may refer the customer to the receiving ADRC or county waiver agency for information and assistance regarding other available programs if they are interested.
Section E—Form Completed By
The MCO or ICA completes this section with their own name, contact information, and faxes the form along with supporting verifications to the appropriate IM processing unit. For members/participants residing in Milwaukee and Menominee counties, fax to the Milwaukee Document Processing Unit at 1-888-409-1979. For members/participants residingoutside of Milwaukee and Menominee counties, fax to the Central Document Processing Unit at 1-855-293-1822.
Section F—ADRC Information
The ADRC must offer disenrollment counseling to all MCO members and IRIS participants who are disenrolling from the program, including a disenrollment due to the loss of Medicaid eligibility. If the individual is in an IMD under age 65, incarcerated, has passed away, or moved out of state, disenrollment counseling cannot be performed. Complete the information regarding the ADRC and the date the form was received.Please include a detailed note in the client-tracking database including; whether the customer has been disenrolled or will have their disenrollment pending, if the individual wishes to remain enrolled,and the outcome of disenrollment counseling.
STATE OF WISCONSIN
DEPARTMENT OF HEALTH SERVICES
Division of Public Health
F-00221A (04/2018) /
Family care / partnership / pace / IRIS
Change routing
Pages 2and 3 are to be completed by theManaged Care Organization (MCO)or IRIS ConsultantAgency (ICA), with a copy sent to theincome maintenance (IM) agency and ADRC.
A. MEMBER INFORMATION
Name – First / MI / Last
Street Address / City / Zip Code
Name of Contact Person Guardian SpouseConservatorPOA Other:
Street Address / City / Zip Code
County of Residence / County of Responsibility / Phone Number
- -
Member/Guardian Cell Phone Number
- - / Member/Guardian Fax Number
- -
Date of Birth / Member ID No. (as shown in ForwardHealth) / Member Target Group (FE, ID/DD, PD)
FE ID/DD PD
Long Term Care (LTC) Program
Family Care Partnership
PACE IRIS / Name of Managed Care Organization (MCO) / IRIS Consultant Agency (ICA)
Change in contact information – documentation attached
B. CHANGES THAT MAY AFFECT MEDICAID ELIGIBILITY AND/OR LONG TERM CARE ENROLLMENT
Please indicate the type of change, provide details in the Additional Information sectionbelow, and submit any available verification.
Death – Date:
Change of address - Complete Section D
Change in living arrangement (institutional setting or incarceration) - Complete Section C
Failure to pay cost share / spenddown or failure to meet spenddown
Failure to complete annual long term care functional screen
Increase in assets
Increase / decrease in income
Increase / decrease in medical / remedial and/or MA card coverable expenses
Increase / decrease in shelter expenses
Change in marital status
Change in Health Insurance (coverage, premiums, start and end dates, Medicare)
Increase / decrease in level of care on the long term care functional screen (route to ADRC ONLY)
Failure to complete Medicaid recertification (route to ADRC ONLY)
Other:
PACE / Partnership ONLY:
Disenrollment from the MCO’s PACE plan
Disenrollment from the MCO’s Medicare Part D Plan
Refusal to select a primary care provider in the MCO’s network
ADDITIONAL INFORMATION
Pages 2 and 3 are to be completed by the Managed Care Organization (MCO) or IRIS Consultant Agency (ICA), with a copy sent to the Income Maintenance (IM) agency and ADRC.
C. Change in living arrangement (To or From an Institutional Setting or Correctional Facility)
Note: Services are not covered for IMD residents between the ages of 21 and 64 years of age, except that services may be provided to a 21-year-old resident of an IMD if the person was a resident immediately prior to turning 21 and continues to be a resident after turning 21.All incarcerations over 24 hoursMUST be disenrolled regardless of length of stay.
Name of Institution or Correctional Facility / Phone Number
- -
Address of Facility
Date of Admission
Institutional stayis expected to be:
Less than 30 days
30+ days (provide physician’s statement to IM)
Unknown / Date of Discharge/Release
Note to MCO / ICA: For all nursing home admissions or discharges, follow internal process for making a referral or sending an update to the MFP program.
D. CHANGE OF ADDRESS
Reason:
VoluntaryMCO Placement / Note to MCO / ICA: If individual is an MFP participant, follow internal process for sending an update to the MFP program regarding change in living arrangement.
Type of Residence individual was living in:
Nursing HomeAFH CBRF
Own home/apartment RCAC Hospital / Type of Residence individual moved to:
Nursing HomeAFH CBRF
Own home/apartment RCAC Hospital
Type of Move: Continuing with Current MCO/ICA
Move within MCO/ICAgeographic service region
Effective date:
Move outside of MCO/ICA geographic service region
Effective date:
Move out of State
Effective date of disenrollment:
Facility Name (if applicable)
New Address (Street, City, State, Zip Code) / Phone Number
- -
Date of Move / County Moving From / County Moving To
E. FORM COMPLETED BY
Name – MCO / ICA Worker / Date Completed and Faxed to IM and ADRC
Email Address / Phone Number
- - / Fax Number
- -
MCO/ICA AGENCY USE: Please check the appropriate boxes, complete details, and route entire form to ADRC if reported change results in disenrollment.
No Change in Eligibility / Enrollment
Change in Cost Share/Patient Liability Amount:
New Amount:Effective Date:
Loss of Functional Eligibility
Loss of Financial Eligibility
MCO No Longer Providing Services Effective Date:
Comments/Additional Information:
Family care / partnership / pace / IRIS
Change routing
This section to be completed by the Aging and Disability Resource Center (ADRC) only.
F. ADRC INFORMATION
ADRC of / County / Date Form Received
Name – ADRC Worker / Date Completed
Phone Number
- - / Email Address
ADRC enters the following information in the notes of the Client Tracking Database:
- Customers status at the time the form is received
- The outcome of disenrollment counseling
- Customer preferences regarding continued enrollment
- ADRC ability to assist the customer to remain enrolled or re-enroll