GeneralGAPQuestions-Virginia

General GAP Questions

1. What is GAP?

The Governor’s Access Plan, known as GAP, is a demonstration

program offering a targeted benefit package for Virginians who

have income less than 60% (60% plus a 5% income disregard) of

the federal poverty level

($7,657 for a single adult)

and suffer

from serious mental illness (SMI).

2. Why is GAP necessary? Without access to treatment, individuals with SMI are often

unnecessarily hospitalized, may be unable to find and sustain

employment, struggle with affordable and available housing, become

involved with the criminal justice system, and suffer with social and

interpersonal isolation. The opportunities provided through the GAP

demonstration will enable persons with SMI to access both

behavioral health and primary medical health services, enhancing the

treatment they can receive, allowing their care to be coordinated

among providers, therefore addressing the severity of their

condition. With treatment, individuals with SMI and co-occurring or

co-morbid conditions can recover and live, work, parent, learn and

participate fully in their community.

3. Who is eligible for GAP? Must meet ALL of the following eligibility requirements:

 Adult between the ages of 21 through 64 years old;

 U. S. Citizen or lawfully residing immigrant;

 Not eligible for any state or federal full benefits program

including: Medicaid, Children’s Health Insurance Program

(CHIP/FAMIS), Medicare, or Tricare;

 Resident of Virginia;

 Household income that is below 60% of the Federal Poverty

Limit (FPL) plus a 5% income disregard ($7,657 per year for a

single adult);

 Uninsured;

 Not residing in a long term care facility, mental health facility,

long-stay hospital, intermediate care facility for persons with

developmental disabilities, or penal institution; and,

 Be screened and meet DMAS criteria as of being seriously

mentally ill

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4. What services are available The array of services available under GAP includes but is not limited

under GAP? to:

 Primary medical care, medical specialty care, and pharmacy

 Diagnostic Services

o Physician’s Office

o Outpatient hospital coverage is limited to diagnostic

ultrasound, diagnostic radiology (excluding PET

scans), and EKG including stress.

 Care coordination provided solely by Magellan of Virginia

 Crisis Line

 Recovery Navigation provided solely by Magellan of Virginia

 Telemedicine

 GAP Case Management

 Crisis intervention and stabilization

 Outpatient behavioral health and substance abuse treatment

services

 Substance Abuse Intensive Outpatient Treatment (IOP)

 Psychosocial rehabilitation

 Opiod Treatment

A complete benefits chart and non-covered services list is located

on the DMAS website.

5. How does someone apply GAP eligibility is a 2 step process including a financial/non-financial

for GAP? determination and a GAP Serious Mental Illness (SMI) determination.

Individuals may start at either step to enter the GAP program.

Financial/non-financial applications are submitted to the GAP Unit at

Cover Virginia either by telephone by calling 1-855-869-8190 or TDD

1-888-221-1590 or online with the help of a GAP SMI Screener. The

use of the online application or provider assisted telephone call at

the time the GAP SMI Screening is conducted is the preferred method

of application.

6. How does someone get GAP SMI is determined through a GAP SMI Screening tool completed

screened for GAP serious by DMAS approved screening entities including the Community

mental illness criteria? Services Boards (CSB), Federally Qualified Health Centers (FQHC), and

hospitals. Individuals may call their local CSB or FQHC and request

that a screening be done or they may call Cover Virginia to submit

their application and Cover Virginia will refer them to the nearest

GAP SMI screening location.

7. If the Cover Virginia The local Department of Social Services will NOT be involved in any of

application is completed the GAP application processes. Financial/non-financial verification

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online, does the application will be conducted by Cover VA.

go to the local Department of

Social Services and will

required verification(s) be

sent to the local DSS?

8. If DSS has a backlog of Since DSS is NOT involved in the GAP application process, GAP will

Medicaid applications to not be impacted by the volume of other Medicaid benefit

process will this impact applications.

application for GAP?

9. Will GAP covered GAP benefits will only cover outpatient services, not inpatient.

individuals have both

inpatient and outpatient

psychiatric benefits?

10. Will this include GAP benefits will cover Substance Abuse Intensive Outpatient

structured Partial Day however the benefit package does not cover any partial

Treatment Programs as well hospitalization programs. Day Treatment/Partial Hospitalization is

as Substance Abuse Intensive NOT a covered service. Please see the complete list of non-covered

Outpatient Therapy? services on the GAP webpage of the DMAS website.

11. Can you confirm that ER ER services are NOT covered by the GAP benefit package. GAP

services are not covered members will be referred by Magellan to preferred indigent care

under this plan? Should a pathways for ER and hospital stays. Non-covered services will be self-GAP member be considered pay.

self-pay if they receive these

services?

12. Is there a deadline for Applications for GAP can be submitted beginning January 12, 2015

applications or can they and continue throughout the demonstration waiver.

continue throughout the

year?

13. If an individual with SMI In order to be eligible for GAP benefits the individual must be

is currently on their parents' uninsured. If an individual is insured under their parent’s health

private health plan, can they insurance they will not qualify for GAP benefits.

apply for GAP?

14. Are individuals who are in Individuals who receive Medicare benefits are not eligible for GAP.

QMB status eligible?

15. Can individuals who are Individuals receiving Plan First may apply for GAP; however, the

on Plan First through benefit plans are different and the individual should explore those

Medicaid apply for GAP? differences before making the move to GAP.

16. I deal with client’s coming GAP applications can only be submitted via telephone or the GAP SMI

out of jail and some are Screening assisted web application. There are no paper applications.

homeless. How do I find the For information on how to apply for benefits please see question #5

GAP application? Where do I above.

mail it?

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17. How long is the Once determined eligible for GAP, individuals will be enrolled for 12

enrollment period? months of continuous coverage unless they obtain full Medicaid or

Medicare, move out of the Commonwealth or turn 65 years of age.

18. Is there a paper There is no paper application. All GAP applications must be

application for the GAP? submitted either by calling Cover VA or online with the assistance of

a GAP SMI Screener.

19. How do I locate the The online application is only available via a web address that has

online GAP application? been provided to the GAP SMI Screening Entity. The online

application can only be completed with the assistance of a GAP SMI

Screener.

20. Our group cannot The SMI screening is used to determine eligibility for GAP Medicaid

perform the GAP SMI benefits. Once an individual is found eligible for benefits any

Screenings, would we be able Medicaid enrolled provider will be able to provide services.

to see GAP clients and how

would they be referred to us?

21. I see commercials about The GAP Program is not part of the Health Care Marketplace and

open enrollment for the therefore individuals do not need to enroll before open enrollment

health care marketplace. ends.

Does GAP need to enroll

before open enrollment

ends?

GAP Eligibility Determination

1. Who processes the GAP GAP applications are processed by the GAP Unit at Cover Virginia.

applications? Cover Virginia will receive telephonic and provider assisted online

applications for GAP, provide a toll free customer service line,

determine eligibility, send out member handbooks, and manage

individuals’ appeal of actions which have denied benefits.

2. How will I know if I was The individual applying for benefits will receive a notification letter

approved for GAP benefits? from Cover Virginia with a GAP Medicaid ID number and member

handbook. This letter will be mailed to the address provided on the

GAP application.

3. If approved for GAP If you are approved for the program in January 2015, your coverage

benefits when will coverage will begin on January 12, 2015 when DMAS received federal approval

begin? to operate the program.

For any other month GAP coverage will begin on the first day of the

month in which the signed application was received by Cover

Virginia.

4. Will individuals need to do Individuals will be enrolled for 12 continuous months. Prior to the

a GAP SMI screening at the end of the 12 month enrollment financial/non-financial information

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end of their initial enrollment will be reviewed. Applicants will NOT need to have another GAP SMI

period? Screening completed for the renewal.

5. Can individuals appeal if Individuals who are determined to not meet the eligibility

they are determined not requirements will be notified of appeal rights in writing to the

eligible for GAP benefits? address provided on the GAP application.

6. How long does Cover Cover Virginia will have 45 days to make an eligibility decision after

Virginia have to make a receiving the GAP application either by phone or through the

decision after the GAP provider assisted web application.

application is completed?

7. What if an individual If an individual applies to Cover Virginia and does not have a GAP SMI

applies to Cover Virginia but Screening completed, the individual will be referred to either their

doesn’t do a GAP SMI local CSB or FQHC to have a GAP SMI Screening completed.

Screening? Individuals must have a GAP SMI Screening conducted as soon as

possible following the submission of a GAP application to Cover VA.

If there is no GAP screening completed by the end of the 45 days that

Cover Virginia has to process the application, the eligibility will be

denied.

8. How long after being If an individual has a GAP SMI Screening conducted prior to

screened for GAP SMI can an submitting an application to Cover VA that screening will remain on

individual wait before file for 12 months awaiting the Cover VA application.

applying to Cover Virginia?

9. What is the definition of a Inpatient hospitalization is not a covered service under GAP. If an

'resident' of a State Mental individual is hospitalized in a state facility it is recommended that

Health Facility? Will patients applying for GAP benefits be part of the discharge planning if the

in State Mental health individual does not meet the full Medicaid eligibility criteria.

facilities be eligible for this

program? If an individual has GAP benefits when they go into the state facility

they will NOT lose their coverage as a GAP enrollee, however the

hospital stay is not a covered benefit.

10. What does it mean that Retro eligibility for Medicaid Fee-for-Service can begin as early as the

there is no retro eligibility for first day of the third month prior to the month of application. For

the GAP program? GAP there is NO retro eligibility. Individuals approved for GAP will

have eligibility begin on the first day of the month the signed

application was received by Cover VA with the exception of January

2015. For GAP applications received in January 2015, eligibility will

begin on January 12, 2015.

11. How soon after eligibility Eligibility will show in the Medicaid ARS system in real time as

is determined will a provider applications are approved. This information is being conveyed to

be able to check eligibility? Magellan from DMAS in a daily file and will be available in the

Magellan system within 24 hours of eligibility determination.

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12. What if my client is For homeless individuals you may use the address where the

homeless? What address do individual usually receives mail, (CSB, family home, authorized rep,

we put on his application? etc.). If the SMI screening entity is where the individual receives their

mail, that address may be used.

13. What do the GAP ID cards The Cover Virginia GAP webpage, /,

look like? How long before has a sample ID card.

the individual receives the

card once they are found The individual should receive their ID card within 7-10 business days

eligible? of eligibility notification.

14. What impact does a Having a criminal history does not impact an individual’s eligibility for

criminal record have on a GAP. However, if the person is in Jail or prison, they are not eligible

person’s eligibility for GAP? for GAP.

Behavioral Health Covered Services (Authorizations, Units, & Limitations)

1. Does GAP cover regular Medication management is a covered benefit as is telemedicine.

Medication Management Telemedicine is covered by GAP under the current Medicaid fee-for-services as well as Telemed service rates and requirements as defined in policy.

Medication Management

Services?

2. Does GAP cover active case GAP benefits will cover a new form of case management called GAP

management as well? Case Management (GCM). This new service is slightly different from

Mental Health Targeted Case Management. A detailed description of

GCM is located in the GAP Provider Supplemental Manual which was

posted to the DMAS web portal in January 2015. The DMAS web

portal may be found at

/wps/portal

3. Will the number of units The number of units available for all current medical and behavioral

available be different for health services are identical to the current fee-for-service units.

covered medical and

behavioral health services?

4. What are the differences Psychosocial Rehab Services (PSR) requirements for GAP members

for Psychosocial Rehab for will mirror the new fee-for-service regulations. Changes include that

individuals receiving GAP the service specific provider intake can no longer be completed by a

benefits? QMHP and that an ISP completed by a QMHP must be reviewed and

approved by an LMHP (including supervisees and residents) within

the 30 days following admission to services.

5. What are the differences Crisis Intervention requirements for GAP members mirror the new

for Crisis Intervention for fee-for-service regulations. QMHPs are not permitted to render Crisis

individuals receiving GAP Intervention services.

benefits?

6. What are the differences Crisis Stabilization requirements for GAP members mirror the new

for Crisis Stabilization for fee-for-service regulations. Changes include that a QMHP-C cannot

individuals receiving GAP render Crisis Stabilization to GAP members. QMHPs are also not

benefits? permitted to conduct the service specific provider intake.

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The individual service plan (ISP) must be developed or revised within

three (3) calendar days of admission to this service.

Service Authorization through Magellan is required for Crisis

Stabilization for individuals enrolled in GAP.

7. Will Gap Case Yes, GAP Case Management (GCM) requires service registration.

Management require a Registration methods mirror current mental health case

registration much like management registration through Magellan of Virginia.

Medicaid?

8. Will there be different SRA The current Magellan SRAs and TRF forms will be used for GAP

forms for GAP (such as Crisis beneficiaries. Crisis Stabilization services require service

Intervention, Psychosocial authorization for GAP members and a new SRA isavailable on the

Rehab, Outpatient Therapy, Magellan website.

etc.)?

9. Are there differences in Any enrolled Medicaid provider that is credentialed with Magellan

who can provide behavioral may provide GAP behavioral health services.

health services under GAP

services?

10. What is the difference Registration is a method of informing Magellan that an individual is

between registration and receiving a service and requires the completion of an online

authorization? questionnaire that gathers basic member information. Registrations

may be submitted after services have already begun.

Service authorization is a process by which a provider submits a form

with service specific eligibility requirement questions which will help

Magellan determine whether the individual meets the medical

necessity criteria to receive the service that is being requested.

Service authorization is required prior to services being provided.

This is the current practice though Magellan for behavioral health

services.

11. Is GAP Care Coordination No. GAP Care Coordination services are only provided by Magellan

a billable service by and are not Medicaid reimbursable service.

providers?

12. Is GAP Recovery No. GAP Recovery Navigation services are only provided by Magellan

Navigation (Peer Supports) a and are not Medicaid reimbursable services.

billable service by providers?

13. How much time do we Crisis Stabilization must be authorized no later than one business day

have to get the Authorization following the admission. It is recommended that authorization be

for Crisis Stabilization? submitted prior to admission if possible, however since admissions

may happen after business hours, on holidays, or weekends

additional time has been allotted.

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14. Can administrative staff Administrative staff may upload clinical documentation into the

submit the GAP SRAs to Magellan system. This is the same procedure currently allowed.

Magellan, or will clinical staff

need to submit the SRAs?

15. If a GAP client is GAP case management is billed on a monthly basis. Which tier of

approved for High intensity case management is billed is determined by the case management

case management and they activity of that month. It is anticipated that most GAP members will

can't make a face to face go back and forth between intensity depending on the circumstances

contact for a particular that month.

month, can we bill for the

Regular intensity instead? Is

it possible that a client can go

back and forth within

intensities?

16. What are the All codes, rates, and service authorization will be the same as the

Psychosocial billing CPT current fee-for-service process. Please refer to Chapter V of the

codes and rates? How are Community Mental Health Rehabilitative Services Manual for these.

these services approved and

authorized?

17. What are the GAP Case Management entities (the CSB) will be required to have

requirements for the case monthly contact with Magellan care managers for recipients of GCM.

manager to contact the Magellan and the VACSB have jointly developed a process that is

Magellan care manager? both efficient and effective to ensure a high quality of collaboration

and coordination with a low level of labor intensity. This process

classifies clinical needs into three categories:

Critical, Urgent, and

Stable. Please note that care coordination between CSB case

managers and Magellan GAP care managers is required for

the critical and urgent status. It is not required when GAP

members are stable. Each Status is defined by the sentinel

events that would indicate the need for care coordination and

gives the time frames within which the coordination must

occur.

Please see Magellan’s webpage for the full description and required

contacts and time frames:

/media/1000441/03-06-15_gap_care_coordination_requirements_-_effective_immediately_email_blast_for_website_.pdf for a provider

announcement that was posted March 16, 2015 and was effective as

of that date.

18. Will retro service Retro service authorizations and registrations will be accepted by

authorizations and Magellan. Providers must submit registration or authorization

registrations be accepted by requests within 30 days of the GAP eligibility determination. Start

Magellan? dates cannot be prior to the date that GAP eligibility began.

REMINDER: There is no retro eligibility in GAP. Individuals approved

for GAP will have eligibility begin on the first day of the month the

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signed application was received by Cover VA with the exception of

January 2015. For GAP applications received in January 2015,

eligibility will begin on January 12, 2015.

19. When can you start GAP This may be better responded to via a scenario:

case management for an An individual has been receiving MH TCM from the CSB for some

individual who has been time (no Medicaid billing). The GAP application and SMI screening are

receiving Mental Health submitted. MH TCM continues while the submissions are being

Targeted Case Management? reviewed. The CSB learns that the individual is approved for GAP as of

the first of the month. A Retro Registration for GAP case

management must be submitted within 30 days of the date the

individual became GAP eligible in order for the CSB to bill GAP for the

earlier case management activities that same month. If no case

management services were provided in that month prior to the GAP

eligibility, then a GAP case management registration is required

within 2 days of starting GAP case management.

20. When can you start GAP Once the CSB learns that the individual is approved for GAP, a

case management for an Registration for GAP case management is required within 2 days of

individual who has not been starting GAP case management. If a CSB provides GAP case

known to the CSB? management prior to confirmation of GAP eligibility, the CSB

assumes the financial risk. Please see # 18 and 19 regarding retro

registration.

21. What is the expectation When transitioning individuals who are currently receiving non-for assessments and ISPs Medicaid reimbursed mental health case management all

when an individual is already Department of Behavioral Health and Developmental Services

open to targeted case (DBHDS) licensing regulations must be adhered to. Please consult

management and is your licensing specialist to ensure that your agency remains in

transitioning to GAP case compliance with DBHDS regulations regarding targeted case

management? management.

For DMAS purposes, if an individual is already open to the agency for

mental health case management when they are found eligible for

GAP benefits, the existing mental health case management

assessment and ISP must be modified within the first 30 days

following the registration for GAP Case Management with

Magellan. At a minimum this modification must reflect any changes

within the 30 days leading up to the transition, including the

individual obtaining GAP benefits and necessary medical and

behavioral health follow up due to having health care coverage. The

modification must be attached as an addendum to the existing

assessment and ISP and completed by a minimum of a qualified GAP

case manager. This modification does not take the place of any

annual assessment updates required by DBHDS, nor does it replace

any quarterly reports as required by DBHDS. Providers also have the

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option of closing the individual to mental health case management

and opening them to GAP case management and following all

timeline requirements as outlined in the GAP Supplemental

Manual. Please note that in these cases where MHCM is closed and

GAP CM is opened, the same procedures currently followed for

documentation of retro registrations for mental health case

management would apply for documentation with retro registration

of GAP case management.

22. My client was found GAP GAP case management services may only be provided the CSBs. You

eligible and their SMI may make a referral to the CSB. Both Cover Virginia and Magellan can

screening was not completed help you locate a nearby CSB. Intake processes may differ from CSB

by the CSB. How do they now to CSB.

get GAP case management

services?

23. My client is “AWOL” and I GAP does not require this notification. However, it is a good practice.

cannot locate them. I have If the individual does arise in another setting, Magellan’s care

notified the local CSB coordination can be beneficial to both the individual as well as the

emergency services. Do I serving provider.

need to notify Magellan?

Medical Covered Services (Authorizations, Units, & Limitations)

1. Does GAP cover regular Medication management is a covered benefit as is telemedicine.

Medication Management Telemedicine is covered by GAP under the current Medicaid fee-for-services as well as Telemed service rates and requirements as defined in policy.

Medication Management

Services?

2. Who can provide medical Any current Medicaid enrolled provider.

services under GAP benefits?

3. What are the billing CPT CPT codes and reimbursement rates for GAP benefits are identical to

codes and rates? the current fee-for-service codes and rates for all covered medical

services. That can be found on the DMAS website.

4. How are these services Medical services requiring service authorization will continue to have

approved and authorized? services authorized through KEPRO. Current fee-for-service

authorization timeliness rules will apply for GAP beneficiaries.

5. My client tried to make an For medical services that GAP does not cover, providers are

appointment with a PCP but encouraged to continue to use the current indigent care resources in

was turned away as the PCP their local communities. DMAS is compiling a list of those entities

said GAP didn’t cover medical that have asked to be on the list. You may contact a Magellan GAP

services. What alternatives care manager at 1-800-424-4046 for referrals from that “preferred

are there for my client? pathways” list.

DMAS is implementing an outreach campaign for medical and

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pharmacy providers to better communicate the covered benefits

plan.

6. My client was charged a GAP does not require members to pay a co-pay. The DMAS claims

co-pay for their prescription. system has been updated to reflect this. DMAS is communicating

I thought GAP didn’t include with pharmacy providers about this update and the no copay

copays? allowance.

7. How can I help my client Go to the DMAS Provider Portal

find a Medicaid website: /wps/portal

medical/pharmacy provider. Click on the “Provider Services” button

On the drop down menu, click on “DMAS Provider Services”

On the next webpage, under the “Quick Links” box, click on “Search

for Providers”

You may also contact a Magellan GAP Care Manager at 1-800-424-4046.

GAP Claims/Billing

1. Where can I find A separate frequently asked questions document has been created

information regarding claims for GAP SMI Screening entities and posted to the DMAS and Magellan

and billing for the GAP SMI websites. Please refer to that document.

Screening H0032 UB and

H0032 UC?

2. What are the All reimbursement rates will be the same as the current Medicaid

reimbursement rates for fee-for-service rates.

medical, diagnostic, lab,

DME, and pharmacy services?

3. What are the Reimbursement rates remain the same as the current Medicaid fee-reimbursement rates for for-service rates.

behavioral health services

such as Psychosocial Rehab,

Crisis Intervention, Crisis

Stabilization, and Substance

Abuse IOP?

4. Should behavioral health GAP is using a hybrid payment structure identical to the current

claims for all GAP member Medicaid fee-for-service reimbursement system. Behavioral health

services be submitted to claims need to be submitted to Magellan and Medical claims to the

Magellan? DMAS contractor, Xerox.

5. Where can I get a provider The Magellan provider handbook can be located on the Magellan

handbook? website at this weblink: /for-providers-va/ . Questions about the

handbook or Magellan procedures can be directed to

**************************************.

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Additional information regarding the GAP demonstration waiver can be located on the DMAS website

at /Content_pgs/. Trainings can also be found on the Magellan

of Virginia website at /for-providers-va/.

The GAP Supplemental Provider Manual was posted to DMAS web portal in

January 2015. Providers are strongly encouraged to read the manual in its

entirety.

Please encourage potential GAP members, GAP members, families and

advocates to join a conference call dedicated to listen to their questions,

recommendations and concerns about GAP.

Fridays 11AM-12 noon

Call in Number: 1-866-842-5779

Conference code: 7439901269

Magellan GAP Care Managers for Members: 1-800-424-4279

Magellan help for Providers: 1-800-424-4046

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