Native American Salud! Managed Care Opt-In Information for Providers
When did the policy go into effect?
On January 1, 2000, the much-discussed Native American opt-in policy went into effect. Native American Medicaid recipients receive Medicaid coverage on a fee-for-service basis, unless the recipient chooses to opt-in to Salud! Under opt-in, the Native American Medicaid recipient takes an affirmative step to sign up with a Salud! Managed Care Organization (MCO).
What Determines Opt-in?
Procedurally, those Native American Medicaid recipients currently enrolled with an MCO must still finish their lock-in periods. Those who were enrolled through the auto-assignment process will move to fee-for-service coverage at the end of the lock-in period. Those who chose an MCO will be considered to have opted-in to Salud! They will still be able to opt-out during the switch enrollment period. Native Americans who are new applicants are automatically exempt from Salud! unless they opt-in.
What are some of the Implications to Managed Care Organizations?
For the MCOs, the policy change has broad implications in continuum of care. A sudden switch out of Salud! may mean an abrupt end to treatment taking place over a longer period of time. Depending on how many people fit into this situation, it requires a great deal of coordination and effort on the part of the MCOs. Additionally, this policy change will have an economic impact on the MCOs as Native Americans are no longer enrolled in Salud!
Related to the continuum of care issue faced by the MCOs are utilization and prior approval considerations for the Medical Assistance Division. Each MCO offers a package of enhanced services above and beyond those covered by Medicaid. Some services approved by the MCOs for individual clients may not be covered under fee-for-service. Consequently, Medical Assistance Division will cover those services for 30 days beyond the date of disenrollment from Salud! for Native Americans who fall under this category.
Additionally, the change will also affect MCOs in terms of capitation payments, as Native American Medicaid clients are disenrolled.
How will the change affect individual providers?
Some providers who are part of an MCO network may not be able to continue services because they are not Medicaid providers. Other providers who are part of an MCO network, and also Medicaid providers will need to submit billings directly to the Medical Assistance Division’s fiscal agent Consultec for services they provide their Native American Medicaid patients who are not enrolled with Salud!.
Specialists who are also part of Salud! MCO networks should also be aware that Native Americans not in Salud! will not need Primary Care Physician referrals.
Questions? Email us at nm_Medicaid@usa.net