Provider Tips for Medicaid Enrollment Assignment (Including Newborns)

The Medicaid Attribution Process 

Who gets enrolled:

• Member will be assigned based on the Department of Health Care Policy and Financing (HCPF) attribution and assignment policies and procedures. Member’s attribution is based on their county of residence. All newly eligible Medicaid members that reside in Denver County will be assigned to Elevate Medicaid Choice.
• All newly eligible Medicaid Members that reside in Adams, Arapahoe, and Jefferson Counties will be assigned to the appropriate RAE.

If a member “churns” or loses eligibility beyond 60 days (continuous enrollment) the State InterChange (IC) will review the member's previous 18 months claims history. If the member has claims history with a RAE provider they will be assigned to that provider. If there is no claims history, the attribution will be based on the member's county of residence as outlined above. DHMP does not have access to claims history, this must be determined by HCPF/RAE.

Newborn Assignment and Process

A Newborn's plan attribution is based on the birth mother's eligibility assignment. The newborn will be attributed to the same plan (e.g., RAE or MCO). Newborns should not be attributed to DHMP until:

• They have received their own Medicaid ID; and
• They have been discharged from the hospital

If a baby is born and goes directly to NICU or requires an extended inpatient stay at time of birth:

• Once the newborn is assigned a Medicaid ID the IC will attribute the newborn to DHMP if the mother lives in Denver County. Unfortunately, the IC cannot know if a newborn is still inpatient after being born.
• When this occurs, DHMP can request a disenrollment for the newborn based on the inpatient stay rules that do not allow a member to change their plan attribution during an inpatient stay.

Newborns that do not have their Medicaid ID assignment:

Newborns who do not have a Medicaid ID assignment cannot be verified in the Provider Portal. If you provide services and the newborn is enrolled with DHMP:

• Submit an authorization request to the Utilization Management team for review.
• The guardian of the newborn has 90 days after the date of enrollment into DHMP to transition services into the Denver Health system or to disenroll from DHMP. 
  • DHMP will review and authorize services for the newborn during the time of assignment to DHMP.
  • The member must contact Health First Colorado to request a disenrollment from DHMP.
  • If after the 90 days the member does not contact Health First Colorado and request a disenrollment, the member will be locked into DHMP until their open enrollment period and will need to obtain services through the Denver Health system.

Timeframes for Member Disenrollment

A new member may request disenrollment at any time during the initial ninety (90) days following the date of the Member’s initial enrollment with DHMP. The member can contact Health First Colorado 303 839-2120 and request to change their plan.

• This is a prospective enrollment and the new plan will not become effective until the first day of the next month after the request.
  Example: If a member's birthdate is in September, they would be eligible to change their enrollment in July and August.
• A current member can only change their plan during the open enrollment period, which is 60 days prior to the member's birth month.

Once a member is passed the initial 90 days, the member is locked in and DHMP can only request a disenroll from coverage for the following reasons:

• Member is in their open enrollment (birth month rule above).
• Member moves out of the service/residence area.
• Member was enrolled into DHMP Incorrectly due to a system issue. Examples of system issues include:
  
  --If member is new to Medicaid and is enrolled into DHMP but resides in a County outside of Denver County and the Colorado Benefit Management System (CBMS) county of residence is not Denver
  
  --The IC incorrectly assigned the member to DHMP when the member had claims experience with a RAE Primary Care Provider (PCP) within 18 months of enrollment. Please note, DHMP does not have access to claims history, this must be determined by HCPF/RAE
  
  --The IC incorrectly assigns a member of the family to a different plan than the rest of the family (e.g., the family is assigned to a RAE, but one child is assigned to DHMP)
  
  --A mismatch occurs between CBMS and the IC that results in the member being incorrectly attributed. Example: when the coverage details show CHP+ but the managed care assignment details show Medicaid or when the coverage details show Medicaid, but the managed care assignment details show CHP+ instead of Medicaid. If a mismatch is suspected or found, email the Colorado Medical Assistance Program (CMAP) for support and resolution

Refugee Exclusions

• All Refugees should be enrolled to a RAE regardless of their county of residence
• Refugee members have the option to enroll in DH based on member preference during their initial 90 days or open enrollment

Foster Care Members

• Foster Care members are not excluded from the passive enrollment process, however, the TRAILS system commonly uses Denver County as the County of residency
• Foster Care members attributed to DHMP but placed outside of the service/residence area can be disenrolled at any time and reassigned to the correct RAE