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Virginia Health Care Association | Virginia Center for Assisted Living

Patient Pay Issues within the New Medicaid Eligibility System

Patient Pay Issues within the New Medicaid Eligibility System

VHCA staff has been fielding a number of calls and e-mails regarding issues with patient pay corrections not being done timely or not at all by local Departments of Social Services (LDSS). Some facilities are facing multiple months of uncollected patient pay amounts; some have even had to initiate discharge for non-payment. While timeliness of patient pay calculations has been a long-standing issue within the Medicaid program, the issue has been exacerbated by the direct linkage of patient pay on file with the Department of Medical Assistance Services (DMAS) to the claims when they are submitted.

According to DMAS, there is an issue with the new eligibility system whereby LDSS workers are unable to go back and make retroactive corrections once a patient pay has been calculated in the new eligibility system. In the past, patient pay could be corrected directly in the Medicaid Management Information System (MMIS – the claims processing system). This ability was removed with the launch of the new eligibility system for long-term care applications on September 1, 2015. Thus, as mistakes are made or as patient pay calculations need to be updated retroactively for cases processed through the new system, a bottleneck has formed.

DMAS has indicated that LDSS can, and has been, adjusting patient pay prospectively to account for this, but it can take months for a provider to catch-up on the patient pay amounts owed. Moreover, there are some residents who may not currently have the extra funds for those past amounts to be paid. To mitigate this issue, DMAS has indicated that it has suspended the conversion of the patient pay data from MMIS to the new eligibility system, which essentially allows the patient pay to remain “fixable” within the MMIS for those cases. While this suspension does not address cases already initiated under the new system since September nor would it affect new cases entered through the eligibility system going forward, it should avoid occurrences of this issue for existing cases going forward (i.e., all the people already eligible for long term care prior to September 1 should not be affected).

DMAS expects the new system to have been fixed regarding this issue by the end of May. VHCA will continue to monitor this issue and will update the membership as it progresses.