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5.13.8  Enrollment and Cost Share Reports

5.13.8.1 Enrollment Reports

5.13.8.1.1 Initial Enrollment Report

5.13.8.1.2  Final Enrollment Report

5.13.8.1.3 When the IM agency should contact the CMO

5.13.8.2 Cost Share Report

5.13.8.2.1 When agencies should contact the CMO

5.13.8.1 Enrollment Reports

Two enrollment reports are created from MMIS and sent to the CMOs.  The initial enrollment report is created after adverse action and the final enrollment report is created on the last business day of the month.

 

CMOs use enrollment report information to identify the individuals that they are obligated to serve according to their contract requirements..

 

5.13.8.1.1 Initial Enrollment Report

The initial enrollment report is created after adverse action.  This report includes information on:
 

  1. New enrollees
     

  2. Continuing enrollees
     

  3. Pending enrollees (those with no eligibility on file for the next month.)
     

  4. Disenrolled enrollees (i.e. those that have disenrolled from Family Care) based on information present in MMIS.
     

For those Family Care members that do not complete a review, the disenrollment date in MMIS will be the same as the effective end date for eligibility.
 

5.13.8.1.2  Final Enrollment Report

The final enrollment report is created on the last business day of the month.  This report includes enrollment information for members that has changed since the initial enrollment report was created.

 

The final enrollment report identifies:

 

  1. New enrollees,

  2. Continuing enrollees and

  3. Disenrolled enrollees

 

Example: Joe was pending on the initial enrollment report.  Joe's Family Care eligibility was reopened after adverse action but before the last day of the month.  Joe would display on the final enrollment report as an add/reinstate.  

 

5.13.8.1.3 When the IM agency should contact the CMO/ Enrollment reports

The IM agency should notify the CMO of any changes that occur after adverse action that reopen Family Care in CARES for the next month.  (i.e. confirmation of eligibility from a review or other determination)

 

CMOs review all PENDs and may contact IM workers if they do not know why the person is losing eligibility and therefore being disenrolled.

 

For members who have moved, died or voluntarily disenrolled, the CMOs should expect a PEND or disenroll status.  However, if the CMO is not expecting the PEND or disenroll status (review overdue, assets, etc), the CMO will likely need to get more information from the IM agency to determine whether or not they should continue serving the member.

 

5.13.8.2 Cost Share Report

The cost share report is a CARES generated report created after adverse action and sent to EDS staff.  The report is zipped and password protected in an Excel file by EDS and then e-mailed to the CMO.  
 

The cost share report identifies
 

  1. Members being served by a CMO

 

and
 

  1. Any cost share or patient liability for the following three months:
     

    1. The month prior to the month in which the report is produced,

    2. The month in which the report is produced and

    3. The month following the month in which the report is produced.

 

For example, if a cost share report is created after adverse action in June it will include member cost share information for May, June and July.  


Example : Buddy disenrolls/is ineligible for FC effective 02/28/05.  Buddy would still be on the March 2005 cost share report (sent 03/18/05) with a $0 cost share.  The first month that Buddy would not appear on the cost share report would be April 2005.
 

5.13.8.2.1 When agencies should contact the CMO/Cost Share Report

IM agencies should notify the CMO of changes not captured on the current months cost share report.  These changes include:
 

  1. New enrollments with:
     

    1. A cost share or patient liability confirmed after adverse action   
       

and  
 

    1. An enrollment date in the current or following month.

 

This enrollment information may
 

• Allow the CMO to begin collecting the cost share on the first of the following month. (Depending on the CMO billing cycle.)
 

and
 

• Prevent the FC member from having to pay a two or possibly three month cost share at one time.

 

 

  1. Retroactive reductions in the cost share:

 

    1. For a period not covered in the current or next months cost share report.

 

or
 

    1. That can not be confirmed in CARES.  

 

  1. Cases which can not be correctly determined in CARES. (such as Group C spousal impoverishment case)

 

 

This page last updated in Release Number: 05-04

Release Date: 09/13/05

Effective Date: 09/13/05