KATRINA WAIVER FAQs
Eligibility
1. Is the waiver application available online? What about the eligibility information?
A: The application and general eligibility information are posted on the HHS Internet:
http://www.hhs.state.tx.us/news/release/091905_Katrina_MedicaidWaiver.shtml
2. What are the citizenship and eligibility rules for Katrina evacuees?
A: In Phase 1, citizenship and immigration status eligibility rules do not apply for Katrina
evacuees. In Phase 2, Katrina evacuees must meet the same citizenship and immigration
requirements as applicants in the regular Texas Medicaid process.
3. Can we arrange for an eligibility determination worker to come to the Vietnamese
processing site?
A: The Office of Eligibility Services is exploring options to process applications at offsite locations for populations that do not have access to local offices.
4. Has a special program type been created for this group of waiver clients (TD13,
TP40, etc.) for identification purposes?
A: Katrina evacuees will be enrolled in Type Program 55, Category 05
5. Are Katrina evacuees going to be traditional Medicaid clients or is the state going to
require them to go on a health plan?
A: All evacuees covered under the Katrina waiver will receive services through the Texas
Medicaid fee-for-service arrangement, and will not be enrolled in a Medicaid or CHIP
Managed Care health plan. In the Dallas service area, the NorthSTAR system will pay for
evacuee mental health and substance abuse services on a fee-for-service basis.
6. Do patients need to apply for coverage under the uncompensated care pool or will
they be automatically enrolled if they do not qualify for Medicaid and meet the
income requirements?
A: Staff will determine the appropriate eligibility group during the application process
and will assign clients to that category, including the uncompensated care pool.
7. Besides income and insurance status, are there other eligibility limits for patients
applying for coverage under the uncompensated care pool – such as assets?
A: There is no assets test for any of the eligibility groups.
Other Insurance and the Uncompensated Care Pool
8. Who is eligible for the Katrina waiver if an evacuee has other health insurance?
A: Katrina evacuees who have other insurance may qualify for the waiver if they are
deemed eligible for a simplified eligibility group identified in the waiver. Evacuees who
have other insurance (other than Medicare), and are not deemed eligible for a simplified
eligibility group, are not eligible to enroll in the Katrina waiver via the uncompensated
care pool.
9. What if their other health insurances are discontinued during care?
A. If their other insurance is discontinued during care, an evacuee can apply for coverage
under the waiver through January 31, 2006.
1
10. If a patient has other health insurance, but it does not cover all services within the
waiver, will Medicaid or the uncompensated care pool provide wrap around or
secondary coverage?
A: If the evacuee is covered under a simplified eligibility group, wraparound coverage
will apply. If the evacuee has other insurance (other than Medicare) they will not be
eligible to be enrolled under the uncompensated care pool and wraparound coverage will
not apply.
11. What is the procedure for retrospective review of multi-state Medicaid eligibility?
A: Katrina evacuees who are currently certified in another state may be enrolled in the
Katrina Waiver. Texas will identify the state of origin on claims submitted for
reimbursement, and CMS will pursue reimbursement from the home state.
12. If a patient is covered by Louisiana Medicaid, and is being referred to us, what
process must be followed in admitting, billing and receiving payment?
A: A Texas provider has the option of enrolling in Louisiana Medicaid as a provider, and
billing Louisiana Medicaid for services. The TMHP website (www.tmhp.com) has
contact information for providers who wish to exercise this option.
A second option is for the evacuee to apply for coverage under the Katrina waiver, and if
approved, the Texas providers would follow the established Texas Katrina waiver claims
processing guidelines.
13. If a patient is receiving medical care in Texas under the Katrina waiver, but is also
enrolled in Louisiana Medicaid, do we follow Texas or Louisiana benefits?
A: Evacuees covered under the Katrina waiver are eligible for Texas Medicaid services,
as well as the additional benefits covered under the waiver. Louisiana Medicaid benefits
do not apply to evacuees covered by the waiver.
If a provider would like to receive more information about Louisiana Medicaid services,
they may visit the LA Medicaid website at:
http://www.lamedicaid.com/provweb1/default.htm
14. If a client is currently enrolled in their home state’s Medicaid program, but is
planning to stay in Texas for the foreseeable future, can the client enroll in Texas
Medicaid to receive services while in the state? Does the client have to proactively
disenroll from their home state’s program?
A: An evacuee does not have to disenroll from their home state’s Medicaid program to be
covered under the Katrina waiver. After the 5-month evacuee coverage period, the
evacuee may apply for Texas Medicaid if they intend to reside in Texas. The current
eligibility process guidelines to Texas Medicaid and CHIP apply.
15. For the uncompensated care pool, information from HHSC states that coverage will
be for “individuals, including childless adults, up to an income limit to be identified
by HHSC, who have no other insurance, Medicaid, or SCHIP coverage.” HHSC
material implies the limit for the pool is 200 percent FPL, but there is confusion
regarding where Medicaid coverage ends and coverage under the pool begins.
Please clarify.
A: The Simplified Eligibility Groups for the Katrina Waiver are as follows:
o Children up to age 19 up to 200 percent of the federal poverty level (FPL).
o Low-income parents of these children up to 100 percent of the FPL.
2
o
o
o
Pregnant women from Louisiana and Mississippi up to 185 percent of the FPL.
Pregnant women from Alabama up to 133 percent of the FPL.
Individuals with disabilities and individuals in need of long-term care up to 300
percent of the Supplemental Security Income (SSI) level.2
Evacuees with incomes 200% FPL and below that do not qualify in one of the simplified
eligibility groups are eligible under the uncompensated care pool, provided they do not
have other insurance (does not include Medicare).
16. Will patients who are eligible for coverage under the uncompensated care pool
receive a limited benefit package?
A: Evacuees receive the same benefit package regardless if they are covered under one of
the simplified eligibility groups or in the uncompensated care pool.
17. Who will pay the claims from the uncompensated care pool– TMHP?
A: For adult outpatient substance abuse treatment claims, DSHS will pay for covered
services.
Acute Care: TMHP will process and pay all claims for acute care services
Long Term Care: Please see the DADS website for billing instructions for Phase I and II:
http://www.dads.state.tx.us/Katrina/bulletin.cfm?id=24
18. How does a physician or provider bill for services furnished to patients eligible for
the uncompensated care pool?
A: Providers must bill for services following the claims processing procedures outlined in
the Katrina Waiver claims processing documentation. This document can be found at
www.TMHP.com
or at
http://www.dshs.state.tx.us/sa/default.shtm
for services provided by adult outpatient substance abuse programs.
19. After September 30, 2005, is there a special patient ID number that should be used
when verifying eligibility or submitting claims for patients covered by the
uncompensated care pool or will the patient be issued a Medicaid number?
A: Providers must bill for services following the claims processing procedures outlined in
the Hurricane Katrina claims processing documentation. This document can be found at
www.TMHP.com
or at
http://www.dshs.state.tx.us/sa/default.shtm
for services provided by adult outpatient substance abuse programs.
20. If a physician is only submitting claims for coverage from the uncompensated care
pool, must he or she be enrolled as a Medicaid provider?
A: Yes, the provider must be enrolled in the Texas Medicaid Program in order to submit
claims to TMHP for processing. See response to question #33 for further information.
Billing/Payment
21. How long will it take to process applications? 45 days?
3
A: Applications will be processed the same day or day after, unless a physician’s
statement is required to establish disability. The additional information will need to be
provided within 10 days of the request.
22. Will the applications for long term care have to go through TIERS for retrospective
benefits?
A: No. Applicants will apply through a simplified Texas Medicaid application and will be
processed through SAVERR.
23. Will there be some form of interim Medicaid payments?
A: Interim payments are not currently available. Case-by-case consideration may be
given if a provider has significant financial hardship due to high provision of services.
The provider must submit information that specifies the reason for the financial hardship,
what amount of interim payment they would propose, and the impact of not receiving an
interim payment on the provision of services in the community.
24. When can we expect payment?
A: Acute Care: Claims will be processed and finalized no later than 60 days from the date
of submission to TMHP.
Long Term Care: Please see the DADS website for billing instructions for Phase I and II:
http://www.dads.state.tx.us/Katrina/bulletin.cfm?id=24. Payments will be made to
providers 7 to 9 business days after the claim is submitted.
Adult outpatient substance abuse claims will be paid within 10 days
25. For inpatient and outpatient hospital services rendered to out of state evacuees, will
HHSC consider paying Texas Medicaid rates without applying the 15% outpatient
hospital discount and without the 2.5% inpatient hospital discount?
A: Claims processed and paid under the Katrina Waiver are subject to all current
reimbursement methodologies.
26. There are about 15,000-20,000 Asian (mostly Vietnamese) Katrina evacuees in
Houston. Do you have any plans for language assistance services to meet the
demand?
A: This is not a covered service under the Texas Medicaid state plan, therefore is not a
reimbursable benefit under the waiver.
27. How do you handle a claim where you do not have a zip code?
A: Claims that are submitted to TMHP for processing must have the zip code on the
claim or it will be denied. TMHP will provide a crosswalk of the disaster counties and
their appropriate zip codes on the TMHP website.
28. If a patient was a visitor in New Orleans, therefore did not live in the disaster
county, but was evacuated and treated in our facility, how do we bill Katrina
Waiver without a disaster zip code?
A: For an evacuee to be eligible they must be a resident of a disaster county or parish. For
example, a resident of a disaster county/parish who had to be evacuated while being
treated at Tulane Hospital would be covered under the Katrina waiver. However, a person
who was a resident of a non-disaster county/parish and was evacuated while being treated
at Tulane Hospital, would not be covered under the Katrina waiver.
4
The Katrina waiver defines an evacuee as “an individual who is a resident of the
emergency area affected by a National Disaster as declared by the President of the United
States pursuant to the National Emergencies Act of the Robert T. Stafford Disaster Relief
and Emergency Assistance Act, and has been displaced from his of her home by the
emergency.”
29. If an evacuee enters an inpatient hospital during Phase 1 of the waiver and
the stay extends beyond 9/30/05 (into Phase 2), how does the provider bill
TMHP for these services? (e.g., Does the provider need to submit two
separate bills for the single stay, using Phase 2 criteria and verification of
Medicaid eligibility for the second bill or will the entire stay be billed/paid
under Phase 1 criteria?)
A: Use Phase 1 criteria for the entire stay. If the client's stay in the hospital extends past
9/30/05, the facility may utilize the "000000001" Medicaid ID number for claims
submission for the entire length of stay. If the client is admitted after 10/01/05, the
facility must obtain a valid Medicaid ID number for the client prior to billing or the
claim will deny.
Hospital Transfer
30. Will there be special consideration for those patients transferred to receiving
hospitals and then transferred back to the original hospital? How will those
hospitals that took the patients be reimbursed?
A: When more than one hospital provides care for the same client, the hospital
providing the most significant amount of care receives consideration for a full
DRG payment. The other hospitals are paid a per diem rate based on the lesser of
the mean length of stay for the DRG or eligible days in the facility. The DRG
modifier PT on the Remittance and Status Report indicates per diem pricing
related to a client transfer. Services must be medically necessary and are subject
to the Texas Medicaid Program's utilization review requirements.
Client transfers within the same facility are considered one continuous stay and receive
only one DRG payment. Medicaid does not recognize specialty units within the same
hospital as separate entities; therefore, these transfers must be billed as one admission
under the Texas Provider Identifier. Admissions billed inappropriately are identified and
denied during the utilization review process and may result in intensified review.
If a provider has experienced significant financial hardship in serving transferred patients,
an appeal can be submitted for claims denied and these appeals will be reviewed.
TMHP
31. How do we file the issued modifiers, condition and occurrence codes?
A: Providers may submit Medicare crossover claims to TMHP with all valid Medicare
modifiers, condition and occurrence codes. These claims will process and pay as usual.
32. What field does THMP want the Social Security # in?
A: The Social Security number should be put in the “Other Insurance” field.
Expedited Provider
5
33. If a physician or provider enrolls in Medicaid using the expedited enrollment form,
is the performing provider member time limited or valid for a full year?
A: If a provider enrolls into the Texas Medicaid Program utilizing the abbreviated and
expedited provider enrollment form located on the TMHP website, the provider’s
enrollment period will only be valid through January 31, 2006. If a provider believes that
he/she will be providing services for a longer period of time, then the provider should
complete the regular Texas Medicaid provider application. This regular application can
be found at www.tmhp.com or by calling 1-800-925-9126, Option 2.
34. Will expedited enrollment for providers apply to Phase 2?
A: The abbreviated and expedited provider enrollment form applies to both phase 1 and
phase 2. See response to question #32 for further information.
35. How do we bill for volunteer physicians assigned to our clinic for the Phase 1
waiver? Are you asking us to get TPI’s for those physicians?
A: If a facility utilized the services of “volunteer” providers, the facility must enroll the
provider(s) into the program as a performing provider in order for the claim to be
considered for payment. The facility may use either the abbreviated and expedited
provider enrollment form or the regular provider enrollment form. See response to
question #32 for further information.
Miscellaneous
36. Home health services provided to Katrina evacuees both prior to 10/1 and after, but
were not provided by a Medicare-certified home health agency – can they be billed
and paid?
A: Acute Care: To enroll in the Title XIX Texas Medicaid Program, home health services
providers must be certified by Medicare and complete the Texas Medicaid Provider
Enrollment Application. Enrolled providers of durable medical equipment (DME) and/or
expendable medical supplies will be issued a Durable Medical Equipment-Home Health
Services (DMEH) Texas Provider Identifier (TPI) that is specific to home health
providers. If the home health agency is only providing comprehensive care program
services (those services for clients under the age of 21 years), then Medicare certification
is not a requirement prior to enrollment in the Texas Medicaid Program. The home
health agency must have a valid and current license within the state of Texas.
A: Long Term Care: Yes. LTC providers do not require Medicare Certification.
However, LTC providers must be enrolled Texas Medicaid providers to receive payment.
If they are not an enrolled Texas Medicaid provider, the provider will be enrolled through
an expedited process.
37. What is the billing process for an adult in an IMD?
A: Providers will follow a process similar to that followed for billing children’s
freestanding psychiatric services to TMHP. The provider must request an authorization
number from TMHP in order to file the claim. For services provided during Phase 1 of
the waiver and services provided to individuals who become Medicaid eligible after
admission or discharge, the authorization number must be obtained before billing for the
service. For services provided to individuals during Phase 2 who have a Medicaid
number at the point of service, the regular TMHP time frames for seeking authorization
for admission and continued stay apply.
6
38. Will an extension be granted for 1115 evacuees that were started on psychiatric
medication in which barriers prevented Medicaid enrollment within the 5-month
time frame?
A: Extensions for treatment will be handled on a case-by-case basis through prior
authorization. Eligibility will not be extended.
39. For benefits rendered to an evacuee, but not historically covered at that POS or by
that provider type – who does a provider look to for payment?
A: There are three options.
1. The provider may contact their local government entity to negotiate with FEMA for
reimbursement of services.
2. If the provider has sufficient information from the patient to bill under the Katrina
Waiver, the provider may do so under Phase I, if the services were provided during
that time period.
3. The provider normally providing the service can bill for the service and reimburse the
provider who provided the service. For example, if a hospital provides vendor drugs
to a busload of nursing home customers, the nursing home would bill vendor drug
then reimburse the hospital.
7