Child and Family Services Policy > Section V - Services to Children in Substitute Care > V. J. Payment for Medical and Dental Services

TITLE XIX

1.	The following clients are eligible for Title XIX:

a.	All C1, C2, C3, C4, C5, C6, C7, C8, C9 and V5 clients except those in the Mountain View Youth Development Center, Long Creek Youth Development Center, Maine Correctional Center or Maine State Prison.

b.	All V1, V2, V7 and V8 clients who are not in the home of a parent and for whom we are paying any bills.

c.	All V6 clients under eighteen who are not in the home of a parent and for whom we are paying any bills, and V6 clients over 18 receiving AFDC or eligible for the Medically Needy Program.

d.	V9 clients between eighteen and twenty-one who are found ineligible for the Medically Needy Program or for SSI, or who are eligible for AFDC-Foster Care.

2.	The following clients are not eligible for Title XIX:

a.	C1, C2, C3, C4, C5, C6, C7, C8, C9 and V5 clients committed by a court to a correctional facility.

b.	V1, V2, V8 and V6 clients under eighteen who are living with parent or parents or for whom we are not paying any bills.

c.	V6 or V9 clients over eighteen unless eligible for the Medically Needy Program, AFDC, AFDC-FC, or SSI.

3.	Entering Title XIX eligible clients on Medical Assistance System:

C and V clients who are eligible for Title XIX are entered into the Medical Assistant System centrally and issued a medical identification card monthly automatically.. Clients who will never be eligible for Title XIX are not entered into the Medical Assistance System. Changes in a client’s eligibility are made on the Medical Assistance System so only eligible clients have medical cards. Provision is also made for the mailing of the medical card to other than the person receiving the board payment.

Information from the Social Services Information System and the SWSS-048 is used to enter eligible Title XIX clients on the Medical Assistance System. To enter a child, Accounting needs:

a.	The child’s T-number or Social Security number for all openings.

b.	Any changes from T-numbers to Social Security numbers.

c.	The accurate type of living arrangement since that determines eligibility or non-eligibility of some clients.

d.	Social Security number and birthdate of the foster parent (IRS number and 01-JAN-99, if a child caring institution).

Form SWSS-048 is submitted for all board free clients and changes, and for clients whose eligibility for Title XIX changes. An example of the latter would be when a child turns 18 and is not AFDC-FC eligible, and therefore, becomes ineligible for Title XIX.

In order to send the medical identification card to other than the recipient of the board payment, Section B of Form SWSS-048 is completed related to the person to whom the medical identification card for a child eligible for Title XIX is to be mailed. For children in adoption, the Substitute Care Program Manager may be the addressee for the medical identification card. Young adults in college may be the addressee for their own medical identification cards. In instances where a child leaves a child caring facility for a short vacation, Form SWSS-048 should indicate that the medical identification card should continue to go to the child caring facility. When the address where the board payment is sent differs from the location of a child caring facility, the medical identification card is mailed to the residence address and the T-number assigned that residence is used.

4.	The Medical Identification Card:

a.	A sample of the medical identification card is shown on the following page.

The card lists all children in a foster home or a child caring facility, the medical programs for which the children are eligible, and the dates of eligibility. The foster parent is not eligible for medical care.

b.	Automatic issuance of the Medical Identification card:

The medical identification cards will be mailed the first of each month starting the month after which the child comes into care. The computer prints the cards on the 25th of each month for the following month and they are mailed out so they would be received by the first of the month. This emphasizes the importance of prompt entries on the Social Services Information System and submission of the forms SWSS-048 in order to keep these mailings current. It is equally important to submit closings, since delays may make us liable for medical bills for which the client is ineligible.

c.	Hand issuance of Medical Identification cards:

Medical identification cards may be hand issued on MCMA50 when a child first comes into care and again when a child moves from one foster home to another in the middle of the month. In all other instances, the medical identification cards are to be issued by the computer.

The information to be typed on the card is the child’s name (last name first), Social Security number - or T number if a Social Security number has not yet been assigned - birthdate, program MM, and program eligibility dates. The initial eligibility dates are the date of opening on a C or V program through the end of the month for new openings.

PAYMENT FOR MEDICAL/DENTAL CARE FOR YOUTHS WHO WERE IN THE CUSTODY OF THE DEPARTMENT OF HUMAN SERVICES AT THE TIME OF THEIR COMMITMENT TO MOUNTAIN VIEW YOUTH DEVELOPMENT CENTER AND LONG CREEK YOUTH DEVELOPMENT CENTER

As part of the agreement negotiated between the Department of Human Services and the Mountain View Youth Development Center, Long Creek Youth Development Center the Department of Human Services agreed to pay for Medicaid reimbursable services according to the policy of the Medicaid Program when these services are not available from or provided by Mountain View Youth Development Center and Long Creek Youth Development Center staff. Following are the conditions under which the Department of Human Services will pay and the procedures to be followed.

Medical/Dental Services Covered:

1.	Only those services not available from/provided by Mountain View Youth Development Center and Long Creek Youth Development Center staff.

This is to be determined and verified by Mountain View Youth Development Center and Long Creek Youth Development Center staff before any request for payment is made to the Department of Human Services.

2.	Services delivered by providers participating in the Medicaid Program.

In the selection of a provider by Mountain View Youth Development Center and Long Creek Youth Development Center, Mountain View Youth Development Center and Long Creek Youth Development Center staff is to determine whether the provider participates in the Medicaid Program. Department of Human Services will assume responsibility for payments only if the provider participates in and bills according to the Medicaid policy.

Approval for Payment:

Emergency Medical/Dental Services

These are services provided to diagnose and/or treat a condition which Mountain View Youth Development Center and Long Creek Youth Development Center staff did not suspect or know to exist 24 hours before services were delivered.

Payment for emergency services does not need prior approval by the Department of Human Services. However, the Department must be notified within 24 hours of the initiation of emergency medical/dental services. If notification is not received within this time frame, the situation will not be considered an emergency and prior approval provisions apply. Notification may be given to Children’s Emergency Services after hours.

Non-Emergency Medical/Dental Services

These are services to diagnose and/or give treatment identified as needed by Mountain View Youth Development Center and Long Creek Youth Development Center staff at least 24 hours before these services are initiated.

Payment for non-emergency services must be approved by the Department of Human Services prior to the delivery of the services. No payment will be made by the Department of Human Services if not approved in accordance with Department of Human Services policy and procedures and with this agreement.

Those services which are Medicaid reimbursable may be approved by the substitute care caseworker for the youth or his/her supervisor. This approval is contingent, upon the determination that the service is reimbursable according to Medicaid policy, including prior approval by the Bureau of Medical Services, should prior approval be required of the provider under Medicaid Program policy.

2.	For services which are never reimbursable under Medicaid, payment must be authorized in accordance with policy and procedures for payment of medical, dental and eye care from child welfare funds.

Approval/denial for payment will be given to Mountain View Youth Development Center and Long Creek Youth Development Center in writing by the substitute care caseworker.

Fees:

Payment by Department of Human Services for any and all medical/dental/health services will be made at the rates established by the Medicaid Program.

Billing Procedures:

Outpatient Services

The Mountain View Youth Development Center and Long Creek Youth Development Center advises the provider to submit the bill on Medicaid billing forms to the Department of Human Services, Attention: the youth’s substitute care caseworker at the address of the appropriate regional office.

After verifying that any required approval was given according to Department of Human Services policy and procedures, the substitute care caseworker submits the bill and a G16-A form to the Regional Budget Officer for processing. The G16-A is to read "At Mountain View Youth Development Center and Long Creek Youth Development Center /Not Medicaid Eligible."

Inpatient Services

If the youth is admitted for inpatient services, the facility is to be advised by the Mountain View Youth Development Center and Long Creek Youth Development Center to bill the Department of Human Services for its services in accordance with Medicaid policy and to be given the youth’s medical identification number. When notified of the admission, the substitute care caseworker for the youth will submit form SWSS-048 giving the hospital as the youth’s residence and will activate his eligibility for Medicaid. This change is effective the date of admission. When the youth is discharged back to Mountain View Youth Development Center and Long Creek Youth Development Center, the form SWSS-048 is again submitted to reflect the change in residence and loss of Medicaid eligibility.

The chart below summarizes the responsibilities of Mountain View Youth Development Center and Department of Human Services staff relative to medical/dental/health services to be paid by Department of Human Services:

Mountain View Youth Dev. Center Long Creek Youth Dev. Center	DHS
1. Medical/dental: staff identifies the need for further diagnosis and/or treatment.
2. Selects service provider and determines whether provider participates in Medicaid Program and whether the service is Medicaid reimbursable.
3. Notifies DHS of any emergency services within 24 hours of initiation of services.
4. Assistant Superintendent (or designee) requests approval for payment for non-emergency services from DHS prior to the delivery of the service.	1. Substitute care caseworker or supervisor approves payment of services which would be Medicaid reimbursable if the youth were not at MYC and seeks Central Office approval for other services requested.
5. After receiving approval, notifies provider of billing procedures.	2. Substitute care caseworker or supervisor gives approval/denial for outpatient services.
	3. Approval/denial of inpatient services is directly subject to Medicaid policy and procedures; a written statement from the substitute care caseworker to the Maine Youth Center is not required for inpatient services. However, substitute care casework initiates changes in order that inpatient services are covered directly by Medicaid.
	4. Processes bills in accordance with policy and procedures.