What Exactly is a Medicaid Single Case Agreement?
Medicaid Single Case Agreements (MACSAs) are a tool under Medicaid to make exceptions to the Medicaid provider enrollment process. Under Medicaid, if a health care provider wants to bill for services under the program, it needs to enroll in Medicaid as a participating provider. However, there is a process through MACSAs for a contracted health care provider that has failed to enroll in the Medicaid program to nonetheless bill for services. The purpose of a MACSA is to avoid a disruption of care and financial hardship on both the provider and the Medicaid enrollee. A MACSA may only be entered into for the purpose of addressing a disruption of care and hardship to the Medicaid enrollee. In the absence of a MACSA, the provider will not get reimbursed by Medicaid. For example, if a cardiologist had a contract with a hospital to see Medicaid patients who were patients at that hospital and had not enrolled in Medicaid, the cardiologist would need to make arrangements to bill the Medicaid program to keep seeing those patients covered by Medicaid. The cardiologist could then enter into a MACSA or two with Medicaid , one covering their professional services and one covering the facility fees, for the duration of the hospital contract.
A MACSA must be entered into with Medicaid and be in effect before reimbursement can occur. A MACSA can be entered into only for a limited duration of time and can be subject to termination by Medicaid after giving 30 days written notice to the provider. The MACSA must be one authorized by the Medicaid program, which include:
A MACSA does not require that the health care provider gets enrolled as a participating provider. That is, the health care provider may continue to be an "out of network" provider with respect to participating Medicaid providers and not be formally enrolled in Medicaid and thus not be permitted to bill Medicaid for other services. However, in negotiating MACSA’s, health care providers should be aware that in New York State, the New York Attorney General has publicly stated that the failure to enroll in the Medicaid program may jeopardize their Medicaid enrollment if, at some later point, the health care provider applies to become a Medicaid provider.
When are Single Case Agreements Applicable?
As discussed above, when a Provider is out of network with the applicable Medicaid Managed Care Organization, but the Provider seeks compensation for treatment of a Medicaid beneficiary, it would be necessary to enter into a Single Case Agreement.
Single Case Agreements are used in limited circumstances and only when there really is no other option available. A Single Case Agreement should NOT be used: (1) for a Provider who is looking for an opportunity to negotiate better rates; (2) for a provider who is looking for better reimbursement rates from one plan than from another plan; (3) for a provider who is looking to participate in the Medicaid program with the latest state of the art treatment modality; (4) for a provider who is looking to serve patients with special needs without being included in the provider network; (5) for a provider who is noticing a decline in patients and does not meet the volume requirement to be accepted onto the Provider network; (6) for a provider who is looking to off-set losses from poor reimbursement for the same treatment provided to non-Medicaid patients; (7) for a provider who is entitled to retroactive-rate adjustments but has not properly asserted their right to collect the rate increase.
In each of the above instances, the proper procedure would be to file an adjustment to the provider’s Reimbursement Methodology or to request to be added to the network. For the most part, Providers are compelled to apply to the plan for participation in the network if they want to be compensated for the services supplied rather than wait for the opportunity to have the State Department of Health or the plan’s Medical Director address a request for a Single Case Agreement. If you are not in the network, the State Department of Health will most likely send your request back to the plan for a determination on participation and reimbursement.
How to Secure a Single Case Agreement
In order to obtain a Medicaid Single Case Agreement, the insurance provider (or provider representative) must submit a written request to the local County Department of Human Services Office. The Single Case Agreement request form can be downloaded from the Medicaid Provider Enrollment website. Form ML-0080 (9/4/19) is the request for MA Single Case Agreement (SCA) or Exception for Out of Network Provider. You will also need Attachment B of form J-700, Medical Assistance Provider Enrollment, which can be downloaded from the Medicaid Provider Enrollment website. Form ML-0039 (1/26/16) is the request for ML-0080 – Single Case Agreement (SCA) or Exception Status for Out-of-Network Providers for payments made through managed care organizations under the II. General Information section of the J-700 form. The form J-700 must be signed by the appropriate provider and then sent to the county office.
Once the case is submitted by the office to DHS, you generally receive a response within 5 business days denying or accepting the exception request. Consider appealing if it is denied and be sure to sign all forms as you go to show that you approved the request.
Advantages and Disadvantages of Single Case Agreements
Single Case Agreements, while offering several advantages, may not be the best option for every provider or patient. Understanding the resultant benefits and challenges helps both providers and administrators make appropriate decisions.
Benefits to Providers
There are several advantages to Single Case Agreements for providers. Typically, these Letters of Agreement are signed under special circumstances between a Medicaid managed care plans and out-of-network providers (or sometimes between two managed care plans). Some of the most common reasons these agreements are signed include:
Challenges to Providers
There are also challenges that need to be considered when using these Letters of Agreement. One major challenge is the payor is not obligated to formally define the nature of the services provided or the length of the patient’s stay in an inpatient care facility. This makes it difficult for the provider to get reimbursement for services already delivered if the services do not meet the expectation of the managed care plan. There is also the risk of lengthy appeals – in the end the provider could be required to provide services without any payment from the managed care plan.
Benefits to Patients
For patients, the greatest benefit of a Single Case Agreement is the ability to receive in-network providers that are part of the level of care they required. The Letter of Agreement may lead to better continuity of care compared to the alternatives, particularly for long-term services.
Challenges to Patients
Patients may experience several potential challenges with Single Case Agreements such as the inability to go to the same provider for certain services during a transition period. There can also be a delay in receiving the necessary services, or the level of care may not be exactly what the patient needs or expects. For example, a patient may be transferred but their needs were not completely meet in the new facility, or they may have been transferred to a provider that does not use the methods or treatments they desire. However, rates for the services provided under a Single Case Agreement may be confusing and vary from one address to another, leading to unanticipated charges. This makes early enrollment and coordination key for patients, so they can be aware of the potential challenges associated with this Agreement.
Benefits and Challenges for the Medicaid Managed Care Plan
Medicaid Managed Care Plans have the benefit of controlling out-of-network costs. These agreements can also help them avoid network disruptions, particularly for those who are already vulnerable. Single Case Agreements also allow Medicaid Managed Care Plans to negotiate rates with providers. The downside to the managed care plans, though, is the risk of being subjected to rate review by regulatory agencies. They also face risks because their providers are not formally trained on the Medicaid guidelines.
Legal and Financial Aspects
A Single Case Agreement could have significant legal and financial implications that must be navigated. The Single Case Agreement expressly creates an exception to a Medicaid Managed Care Organization’s ("MCO’s") obligation to allow a beneficiary to utilize their out-of-network provider. However, the MCO is not obligated to pay at the same rates or reimburse for the same services in the Medicaid fee-for-service space, or for a higher rate, unless expressly set forth in the amendment. This is especially critical when an MCO has a higher reimbursement rate for medical services than the Medicaid fee-for-service program. This often causes tension because the provider expects to be paid at the higher rate while the MCO expects to be reimbursed at the lower rate.
Moreover, an MCO can reject the operator-initiated request of a provider to treat a particular patient despite the existence of an active Single Case Agreement . The MCO is identifying that a claims dispute is present. For those providers that are focused on collections, a complicated mediation process may not be conducive to resolving the dispute. Regardless of the provider having filed a claims dispute, contracting responsibilities, licensure and scope of practice issues and federal anti-kickback laws, are all implicated. And, as such, facility billing would have to be paid by an MCO under the contract in the state Medicaid program, as opposed to the Medicare program in the same manner that any other facility, or MCO which directly bills for its services would be paid. In fact, the provider will expect that Medicaid will provide direct payment for services as well. Thus, failing to properly advise a provider of the options available and issue 855 forms that inform providers of the application process for NPI numbers could create more problems than it solves.
Practical Applications and Case Studies
The impact of Medicaid Single Case Agreements can best be understood through real-world applications. Consider the following scenarios:
Patient A is a 14-year-old with spina bifida who requires a specially modified wheelchair. Her parents live in County B, which typically does not cover her specialized equipment needs. Her close friends live in County C, which does cover the equipment in question. When the HMO for Patients A’s friends reach out to the HMO that covers Patient A to request coverage under Medicaid’s Out-of-County Services Plan, Patient A’s Managed Care Organization is startled by this request, and refuses to cover the requested wheelchair. However, after legal intervention, County A’s MCO is compelled to cover the specialized wheelchair despite their usual policy denying such costly and specific requests.
Patient B is a 25-year-old diagnosed with cystic fibrosis. At 3 a.m. on the morning of May 22, Patient B had a dental emergency that required immediate attention. Patient B presented at the Emergency Room for evaluation and treatment. Then, urinalysis testing revealed that Patient B also had a urinary tract infection. On the same date, patient needed blood work.
On May 23rd and 24th, Patient B was admitted to the hospital for evaluation, and given antibiotics for his common urinary tract infection. These services included lab tests, medications, urinary catheter placement and a limited MRI.
Later, Patient B was stepped down, and sent home with extensive instructions for follow up care. But Patient B’s high medical bills result in ‘financial hardship’ and a co-pay which he cannot handle. After discussing the situation with a financial services specialist, Patient B was assisted in getting a Medicaid Single Case Agreement.
In the case of Patient B, because his MCO would not cover the hospitalization, a Medi-cal Single Case Agreement was obtained. Medi-cal allowed for payment to be made for the hospitalization due to a change in his health condition, which was not addressed prior to admission to the hospital.
Cases such as these emphasize the necessity for healthcare professionals to familiarize themselves with the process of a Medicaid Single Case Agreement. While these tools for bridging the gap between Managed Care Organizations and the coverage of services are not the answer to every situation, these are an important consideration and an integral part of patient-centered healthcare.
Looking Ahead: The Future of Medicaid Agreements
As with any aspect of health care, there are trends in Medicaid single case agreement use. The most common clinical treatments for which single case agreements are used are movement disorders, cardiology (particularly cardiac imaging, nuclear medicine, and cardiac catheterization), and psychiatry. In some communities, certain centers become known for their expertise in specific areas, and these centers can sometimes be seen as the clear and only choice for a given specialty. When this occurs, the provider may have a significant patient base with a particular specialty need that needs treatment but does not have the resources to meet those needs.
For many of these providers, single case agreements can be a way to contract with a state Medicaid program for patients who typically would not be covered by its fee-for-service Medicaid program because it does not participate in that program’s network. In other cases, single case agreements are used as a mechanism for coverage for a specific patient when that patient is not otherwise within the network .
This area is very much evolving, as single case agreements, along with value-based care initiatives such as bundled payments and site-neutral payments, are holding both Medicaid programs and providers accountable in new ways for their quality and efficiency. "Closed networks" like managed care programs, which bring providers together under a single plan so all participants are accountable to the plan and potentially subject to financial penalties for outlier performance, will continue to flourish and will result in more creative approaches to single case agreements.
We will also foresee more innovation in the use of technology and apps to identify qualified providers and facilitate the use of single case agreements. Currently, providers are limited in their ability to assess network adequacy, and state Medicaid agencies are limited in their ability to determine the willingness of a given provider to accept a single case agreement or the timeliness with which that provider will respond to a request. App-based technologies for network adequacy determination and tracking for single case agreements will serve to make the use of single case agreements far simpler.