Medicaid Managed Care Open Enrollment Extended through Dec. 15
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III. Enrollment


When the EEU makes a positive determination of eligibility, the consumer/client will be enrolled in the DSAMH LTC System within seven (7) working days of the date of written notification to the referring organization and the consumer of eligibility determination. For Medicaid recipients, the EEU will indicate the “SPI Flag” in the Medicaid Management Information System (MMIS) on the consumer’s enrollment date. The EEU will also enter each consumer in the DSAMH EEU Client Tracking System and will establish a re-determination date in the System.

EEU will coordinate with the enrollee and his/her current behavioral health services provider to effect a transfer of care to a DSAMH Long Term Care Primary Service Provider (PSP). Enrolled consumers whose DSHP behavioral health provider is also a DSAMH Long Term Care provider will have the choice of remaining with his/her current provider. Consumers who are not engaged with a behavioral health provider at the time of enrollment, or those whose provider is not funded by DSAMH, will be referred to a DSAMH Long Term Care provider. In either case, the EEU will link the consumer to a Primary Service Provider. The EEU will identify the PSP based on the consumer’s residence and will confirm the PSP’s available service capacity through the Long Term Care Service Inventory which it maintains. Consumers’ preferences regarding providers will be taken into account in this process. The EEU will not refer to a PSP which has no available service openings.

In coordinating the transfer of care, EEU staff will meet as needed to identify specific provider(s) to whom each consumer is to be referred. A designated EEU staff member will be assigned to each consumer and will call the identified provider to refer the consumer and will confirm the provider’s tentative acceptance of each consumer within one (1) working day of written eligibility determination contained in the notification letter to the referring organization and consumer. After receiving this confirmation of the provider’s tentative acceptance of the consumer, the EEU will fax the consumer’s Enrollment Application Form to the provider. The EEU will also fax the Unit’s Eligibility Determination Summary to the identified provider, if the provider had not already received the Summary during the eligibility notification process. The EEU will also notify the referring organization as to the consumer’s new primary behavioral health provider. If the provider to whom the EEU has referred the consumer believes that they are unable to appropriately serve the consumer, the provider will call the designated EEU staff member with this information. If the EEU agrees with the provider’s determination, they will identify another Long Term Care provider to serve the consumer.

The provider must make concerted efforts to locate the consumer and must arrange for an initial scheduled contact which will occur within five (5) days after the provider has accepted the consumer. The provider then completes the referral process by submitting the CRF to DSAMH within twenty four (24) hours of this first scheduled contact. Providers must call the designated EEU staff member on the day they contact the consumer to confirm this contact. If a provider has not called to confirm contact with the consumer, the designated EEU staff member will call that provider to determine the consumer’s status. If the provider has not located the consumer, the provider will outline the outreach and engagement activities they intend to undertake to effect linkage with the consumer. EEU staff will then follow up with the provider in ten (10) working days to determine whether linkage has occurred. If linkage has occurred, treatment will continue; if it hasn’t, the EEU will notify the referring organization that service linkage has not occurred and will enroll the client on an ‘inactive status’. The provider must make ongoing efforts to locate the consumer and make weekly progress reports to the designated EEU staff member . The client’s status will be re-evaluated at ninety (90) days.

If, during the outreach process, a consumer indicates that he/she does not want to receive services from the identified provider, that provider will call the designated EEU staff person with this information. The EEU staff and the provider will review the engagement activities which were undertaken and determine whether the consumer will be referred to another provider, or to another level of service.

Authorization of Substance Abuse Services

Providers accepting consumers enrolled in the LTC System must request service authorization as required by current Division policy. For LTC consumers, the Screening and Evaluation Team may accept the ASI that is submitted as part of the Enrollment Application Form and use it to confirm appropriate placement.

Authorization of Mental Health Services

The Division’s current system for authorization of Continuous Treatment Team and group home services will continue.



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