medicaid treatment act (mta) client eligibility ... · mta application and copies of appropriate...

Implemented: October 2001 Reviewed/revised: 2003, 2004, 2006, 2007, 2008, 2011, 2012, 2014, 6/2016, 12/2017

MEDICAID TREATMENT ACT (MTA) CLIENT ELIGIBILITY & ENROLLMENT PROCEDURE

Siegl, E.J. (DCH) [email protected]

TABLE OF CONTENTS

I. Introduction ............................................................................................................................................. 2

II. BCCCNP Medicaid Treatment Act Eligibility Criteria ................................................................................2

III. Classification of BCCCNP MTA Clients .....................................................................................................2

IV. New Client Enrollment in MTA............................................................................................................... 3

V. Arranging For Cancer Treatment of MTA Clients .................................................................................... 4

VI. Duration/Termination of Medicaid Coverage for MTA Clients............................................................... 4

VII. Yearly Redetermination of BCCCNP MTA Eligibility............................................................................... 5

VIII. BCCCNP MTA Hearing/Appeal Rights................................................................................................... 6

IX. MDHHS BCCCNP MTA Contact Staff ...................................................................................................... 7

X. References ……………………………….............................................................................................................7

APPENDICIES

A. MTA Patient Navigation Form................................................................................................................. 9

B. MTA Eligibility / Application Checklist ...................................................................................................11

C. MTA Citizenship / Identity Documentation Requirements.....................................................................13

D. MTA Application……………………................................................................................................................15

E. MTA Release of Information (ROI)……………………. ....................................................................................17

F. MTA Breast & Cervical Treatment Start / End Dates……………….................................................................19

G. MTA Client Redetermination of Continued Breast or Cervical Cancer Treatment....................................26

H. Client Status Memo…………………………….....................................................................................................28

I. INTRODUCTION

Women who meet the BCCCNP eligibility criteria as described in section II, are eligible to enroll in the BCCCNP Medicaid Treatment Act (MTA) program. Women will receive full Medicaid benefits (beyond those required for breast or cervical cancer treatment) as long as they continue to meet BCCCNP and MTA eligibility criteria.

II. ELIGIBILITY CRITERIA

Women meeting the following criteria may be eligible to enroll in the BCCCNP MTA program.

Age 21‐641

Income < 250% Federal Poverty Level1 (FPL) Current Michigan resident1

US citizen/legal resident, registered alien or refugee as defined by the Michigan Department of Health andHuman Services4

Diagnosed with a NEW or RECURRING breast or cervical cancer or cervical pre‐cancerous lesion (CIN II)requiring treatment2

Non‐citizens are ineligible for BCCCNP MTA; they are eligible for Emergency Services Only (ESO).

For these clients and others who are DENIED MTA coverage, the BCCCNP Coordinator / Designee will assist them in obtaining cancer treatment through appropriate providers.

Insurance Requirements1

Uninsured (No health insurance) Underinsured (Insurance meets the criteria described below as non‐creditable)

EFFECTIVE 12/5/2017: Pre‐approval for underinsured clients is required PRIOR to client enrollment into BCCCNP MTA by the BCCCNP Director or Nurse Consultant.

Non‐Creditable4 insurance coverage is defined as: Health insurance that contains a pre‐existing condition exclusion, which either excludes treatment of breast or cervical cancer, or covers limited services, but not treatment for breast or cervical cancer. (§2701(c) of the Public Health Services Act, 42 U.S.C. §300gg(c) ) An insurance deductible of > $1500 must be met prior to receiving services reimbursed by the insurance.

Special Considerations: Clients enrolled in Medicare Part A and B, or who are eligible but choose NOT to enroll in Part B: are NOT

ELIGIBLE for BCCCNP MTA. Clients enrolled in private insurance: are NOT ELIGIBLE for BCCCNP MTA if they have received treatment and

had any treatment services reimbursed by their insurance. Clients enrolled in Michigan’s Healthy Michigan Plan (HPM) or another type of Medicaid: ARE eligible to

transfer to BCCCNP MTA at any point during their cancer treatment.

III. CLASSIFICATION OF BCCCNP MTA CLIENTS

A. NEW clients diagnosed with breast/cervical cancer enrolled in BCCCNP. (I.e. BCCCNP funds paid for at least ONE service prior to client diagnosis)

Client classified as CASELOAD client Complete data in MBCIS as per policy

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DO NOT ENTER DATA in Patient Navigation databaseB. NEW clients diagnosed with breast/cervical cancer OUTSIDE BCCCNP (I.e. not currently enrolled in the BCCCN program)

Client classified as MTA Navigation Client Complete data on MTA Navigation form and submit to MDHHS for data entry. (Appendix A)

C. Renewing MTA clients still actively receiving treatment or care related to a breast/cervical cancer diagnosis. Client classified as MTA Navigation Client Complete data on MTA Navigation form and submit to MDHHS for data entry. (Appendix A)

IV. NEW CLIENT ENROLLMENT IN MTA

BCCCNP Coordinator or designated Local Health Department Program Staff will:

√ OBTAIN the client’s pathology report to confirm a breast or cervical cancer or cervical pre‐cancerous condition(CIN II).

√ EXPLAIN MTA program requirements to the client prior to her signing the BCCCNP MTA application.Explanation should include the following:

BCCCNP MTA eligibility criteriao BCCCNP MTA is s different program from other Medicaid programs and has different eligiblity

criteria for enrollment.

Duration of MTA insurance coverage based on cancer diagnosis and treatment

Procedure for yearly review (redetermination) of client eligibility Criteria for termination of BCCCNP MTA

Completion of BCCCNP MTA Application: BCCCNP Coordinator or designated Local Health Department Program Staff will:

√ REVIEW: BCCCNP MTA Eligibility/Application Check list to determine information required for clientenrollment into BCCCNP MTA. (Appendix B)

√ OBTAIN:

Citizenship/identify documentation as requested by the Michigan Department of Health and HumanServices. (Appendix C)

Check the appropriate boxes on the form confrming both copies have been obtained. Client signature on Form DCH‐1088, Michigan Department of Community Health Medicaid Breast and

Cervical Cancer Prevention and Treatment Program. (Appendix D)

Client signature on BCCCNP MTA Release of Information Form. (Appendix E)

√ ENTER BCCCNP MTA BEGIN/END DATES

The BCCCNP Coordinator/Designee determines the MTA start date for Medicaid coverage based on the date when the client was diagnosed with breast or cervical cancer and is scheduled to begin treatment. (Appendix F)

“Treatment Begin Date” – the first day of the month in which client eligibility is determined.

“Treatment End Date” (For CIN 2 and CIN 3/CIS clients) – the last day of the month after treatment hasended.

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√ SIGN: MTA Application verifying that the client meets all eligibilty criteria for the BCCCNP MTA.

ONLY approved state or county employees are authorized to witness and sign Medicaid applications.o Signing the BCCCNP MTA application by non–BCCCNP agency staff will invalidate the application

and delay processing for Medicaid coverage.

√ FAX (DO NOT MAIL) MTA application and copies of appropriate citizenship/ identification documentation toMichele Barton, Medicaid Quality Analyst, at fax number 517‐373‐9305.

DO NOT fax client’s pathology report

√ FILE ORIGINAL MTA application, citizenship/identification documentation and a copy of the pathology reportconfirming breast/cervical cancer or cervical pre‐cancerous condition in the client’s chart at the BCCCNP agency.

BCCCNP MTA applications MUST be retained for 7 years.

V. ARRANGING FOR CANCER TREATMENT OF MTA CLIENTS

A. BCCCNP Coordinator or designated Local Health Department Program staff will:

√ ASSIST client in:

Identifying/contacting appropriate Medicaid enrolled provider(s) (surgeons, medical oncologists and/orradiation oncologists) willing to accept the client as a patient for breast or cervical cancer treatment.

Arranging for transportation to treatment (if needed). Identifying/contacting community resources and/or breast cancer nurse navigators in arranging for

additional support as needed for treatment.

√ CONTACT client’s provider of MTA begin date and end date (if applicable).

VI. DURATION/TERMINATION OF MEDICAID COVERAGE FOR BCCCNP MTA WOMEN

A. Client is eligible to receive BCCCNP MTA coverage as long as she continues to:

1. MEET BCCCNP age, income, insurance eligibility requirements1,2 AND2. Is currently receiving breast or cervical cancer treatment OR3. Is currently receiving follow‐up care to monitor the effectiveness of treatment or care for

a side effect related to treatment according to the woman’s health care provider.3

B. Breast or cervical cancer treatment5,6,7 is defined as the following:

Breast or cervical cancer surgical procedures. Provision of chemotherapy/hormonal therapy/endocrine therapy to treat the breast or cervical cancer. Provision of radiation therapy to treat the breast or cervical cancer.

Treatment of side effects relating to the type of breast or cervical cancer therapy received by thewoman.

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Duration of MTA Treatment Length of treatment depends on the type of cancer diagnosed. (Appendix G)

MTA Coverage Termination MTA coverage will be terminated at any time if the client:

Turns 65 Reports income over 250% FPL Has obtained creditable insurance that covers cancer treatment

Is eligible for Medicare A/B Has completed breast/cervical cancer treatment and has returned to surveillance monitoring

Cannot be located after three attempts at contact Fails to comply with cancer treatment recommendation

Becomes eligible for SSI

√ NOTIFY Michele Barton via telephone or fax using the “BCCCNP Client Status” form (Appendix G) the dateBCCCNP MTA coverage will end and the reason for termination.

ALL breast and invasive cervical cancer clients are notified via letter from Michele Barton when the end dateis determined.

Clients with CIN 2 or 3 are notified of both start and end dates for Medicaid when enrollment into theprogram is confirmed.

√ CONTACT the client to inform her:

Reason BCCCNP MTA is terminated

Date MTA coverage will end Additional resources that may assist her for other health related problems, enrollment in marketplace

insurance, applying for Healthy Michigan Plan, etc.

VII. YEARLY REDETERMINATION OF BCCCNP MTA ELIGIBILITY

Clients enrolled in BCCCNP MTA are re‐evaluated yearly to determine continued eligbility for the program.

Prior to the anniversary date (one year from the client’s enrollment date into the BCCCNP MTA) Michele Barton will send a “REDETERMINATION REPORT” listing MTA client names and the due date for re‐determination.

√ REVIEW the “Redetermination report” to identify MTA client names and renewal due date.

√ CONTACT

Client to determine if she continues to meet the BCCCNP eligibility criteria and is still activelyreceiving cancer treatment.

o NOTE: Three (3) tries to contact client should be attempted. If client unable to becontacted, notify Michele Barton to terminate client’s MTA coverage.

Client’s treatment provider to determine if client is receiving treatment or care for a side‐effect posttreatment.

√ OBTAIN

Client’s signature on the BCCCNP MTA application (DCH 1088).o The same application is used for New and Renewing clients.

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o Citizenship and identify information ARE NOT required for renewing clients (unless a changein name or address has occurred during the past year).

o Application can be mailed to the client if client unable to present in person to sign renewalapplication.

Documentation* from the client’s cancer treatment provider stating that the client is stillundergoing breast or cervical cancer treatment (NOT surveillance monitoring).

o *Any of the following is acceptable documentation: driver’s license, passport, voter’sregistration, VISA, enhanced driver’s licnese, birth certificate.

Completion of the “Client Redetermination of Continued Breast or Cervical Cancer Treatment” form(Appendix G) by the provider OR Written note from provider stating that the client still requires breast or cervical cancer treatment OR Documentation of a verbal conversation in the client’s medical record between the BCCCNP Coordinator/Case Manager and the client’s health care provider that breast or cervical cancer treatment is still required.

√ DOCUMENT RENEWAL on top of MTA application form AND √ DOCUMENT Client’s status (renew ordiscontinue*) next to client’s name on REDETERMINATION REPORT

(NOTE: *If client MTA cliet is to be terminated, notify Michel Barton via phone or complete Client Status Update memo (Appendix H) stating the reason MTA should be terminated)

√ FAX COMPLETED REDETERMINATION report AND All signed MTA Renewal forms to Michele Barton at leastONE week prior to the date listed on the report.

√ COMPLETE all required information on MTA Navigation form and fax to MDHHS for data entry.

VIII. BCCCNP MTA HEARING/APPEAL RIGHTS

If a client disagrees with or is dissatisfied with BCCCNP MTA program decision(s) regarding termination of Medicaid coverage, she has the right to request an administrative hearing before the MAHS Department of Licensing and Regulatory Affairs.

The client needs to submit a written request for the hearing to the State Office of Administrative Hearings and Rules. The client may select, at her discretion, legal counsel to represent her during the administrative appeal.

The MAHS Department of Licensing and Regulatory Affairs will review the request and contact the client regarding the date and time of her hearing by the Administrative Law judge.

E.J. Siegl, MDHHS Program Director, will be notified of the date and time of the client’s hearing. E.J. will notify the BCCCNP Coordinator and request cancer treatment information on the client that determined her ineligibility for continued coverage through the BCCCNP MTA.

A written summary of the reason(s) the BCCCNP MTA coverage was discontinued for the client will be submitted to the Administrative Tribunal, the client requesting the hearing, and the BCCCNP Coordinator.

E.J. Siegl will present the case for termination of client’s BCCCNP MTA benefits before the judge and the client in a telephone hearing on the assigned date.

Final determination of the client’s request for reinstatement of BCCCNP MTA will be determined by the Administrative Tribunal judge.

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IX. MDHHS BCCCNP MTA CONTACT STAFF

Michele Barton Quality Assurance Analyst Phone: 517‐241‐8164, Fax: 517‐373‐9305

E.J. Siegl, [email protected] BCCCNP Director/Nurse Consultant Phone: 517‐335‐8814, Fax: 517‐335‐8752

Tory Doney, [email protected] BCCCNP Lay Navigator Phone: 517‐335‐8854, Fax: 517‐335‐8752

X. REFERENCES

1. Michigan Breast and Cervical Cancer Control Navigation Program Eligibility Criteria.

2. Public Law 106‐354, Breast and Cervical Cancer Mortality Prevention Act of 1990 Amendment to PublicLaw 106‐354, Breast and Cervical Cancer Prevention and Teatment Act of 2000.

3. Health Care Financing Administration. Breast and Cervical Prevention and Treatment Act of 2000 –Frequently Asked Questions, page 5, question 14.

4. Centers for Medicare and Medicaid Services. Breast and Cervical Prevention and Treatment Act of 2000.Questions 10, 17, 18.

5. National Cancer Institute ‐ Breast Cancer Treatment ‐ Health Professional Version Updated February 2,2016. http://www.cancer.gov/types/breast/hp

6. National Comprehensive Cancer Network Clinical Practice Guidelines for Breast Cancer, Version 2, 2016.https://www.nccn.org/professionals/physician_gls/PDF/breast.pdf

7. National Cancer Institute ‐ Cervical Cancer Treatment – Health Professional Version Updated February4, 2016. http://www.cancer.gov/types/cervical/hp

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mailto:[email protected]

mailto:[email protected]

http://www.cancer.gov/types/breast/hp

https://www.nccn.org/professionals/physician_gls/PDF/breast.pdf

http://www.cancer.gov/types/cervical/hp

APPENDIX A

MTA PATIENT NAVIGATION FORM

The following information MUST be completed on the MTA Patient Navigation Form PRIOR to sending to MDHHS. COMPLETED FORMS should be faxed to Tory Doney or Sam Burke at 517-335-8752.

CHECK REQUIRED INFORMATION

Client Contact Information

Client Contact Information (Must be complete with client last name, first name, date of birth, state, zip code, and county – address, phone & email are optional.

HOUSEHOLD MEMBERS and INCOME

Race and Ethnicity

First Encounter: Type of Encounter

First Encounter: Check appropriate box for Enrollment or Re-Enrollment

For NEW Enrollments: check cancer diagnosis and record contact date and treatment start date

For –Re-enrollments record contact date

First Encounter Comments – record information pertaining to client treatment, resources needed, referrals initiated, etc.

Second Encounter: Type of Encounter

Record date of second contact for both new enrollments and re-enrollments.

Record MTA discontinue (D/C) date if MTA is discontinued.

Navigator signature

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May 2017

LCA: _________________

MBCIS # ______________

* Last Name * First Name M.I.

* Birth Date Street Address

Apt # City PO Box

* State * Zip Code * CountyPhone Number

( ) Home Work Cell Email Address

* Household Yearly Income: $_______________* Number of people in household: #___________

* Race and EthnicityHispanic or Latino? Yes No Unknown Refused

Race: Unknown Refused White Black Asian American Indian/Alaskan Native Hawaiian/Other Pacific

* Ethnicity – mark all that apply: Unknown Refused European Middle Eastern, North African, Arab African, Caribbean Islander Canadian /Latin American Indian Spaniard, Mexican, Central, South, or Latin American Puerto Rican, Cuban

ENROLLMENT INFORMATION 1st Encounter/Contact: Face-to-Face Telephone Mail Email Voicemail Text Message Encounter/Contact Date: ____ / ____ / ______ Other: _________________ Re-Enrollment Client eligible to renew MTA? YES NO – Reason MTA to be discontinued:

MTA End Date: ______ / ______ / ______ Treatment Ended - No longer eligible for program Obtained Insurance Other___________________________________

Additional Comments:

Non-Caseload Enrollment

MTA Begin Date: ______ / ______ / ______

Invasive Breast Cancer DCIS LCIS Invasive Cervical CIN 3/CIS CIN 2

Diagnosis Date: ______ / ______ / ______

Treatment Start Date: ______ / ______ / ______

2nd Encounter/Contact: Face-to-Face Telephone Mail Email Voicemail Text Message Encounter/Contact Date: ____ / ____ / ______ Other: _________________

Re-Enrollment (Complete all * items)

* Rec’d Signed Application – Date: ____/____/____* Rec’d Verification Tx from Prov – Date: ____/____/____* Treatment/therapy client currently receiving: Drug therapy Surgery Radiation Breast Reconstruction Supportive Therapy Post Treatment due to Side Effects Other______________________

*Side Effects/Problems from Treatment/Therapy? No Yes (describe below)

Non-Caseload Enrollment (Complete all * items)

* Rec’d Signed Application – Date: ____/____/____

* Rec’d Verification Tx from Prov – Date: ____/____/____* Type of treatment (check all that apply) Drug therapy Surgery Radiation Other ___________________________

* Referral to ACS: Date _____/_____/_____

* Does client use Tobacco Products? Yes No If Yes - Referred to QuitLine or other tobacco cessation resource? Yes No N/A Referrals made: ACS WISEWOMAN Other________________

* Education provided on annual Cancer Screening Yes NoNavigator Name: Date Faxed to MDHHS: / /

NAVIGATION MTA CLIENT ENCOUNTER FORM

APPENDIX B

MTA ELIGIBILITY APPLICATION CHECKLIST

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Michigan Breast and Cervical Cancer Control Navigation Program (BCCCNP)

MTA Eligibility / Application Checklist STEPS NEEDED √

Citizenship documents for enrollment

Fax application and documents to Michele Barton (FAX: 517-373-9305)

Refer to American Cancer Society’s Patient Navigation Program

African-American women, ≤ age 50, with invasive breast cancer, need to be

referred for genetic counseling and indicated testing

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APPENDIX C

MTA CITIZENSHIP / IDENTITY DOCUMENTATION

REQUIREMENTS

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Citizenship / Identity Documentation Requirements

Eligibility requirements for BCCCNP MTA include verification of the client’s citizenship and identify by producing any of the following documents:

Citizenship Documentation • U.S. Passport• Certificate of Naturalization• Certificate of U.S. citizenship• Birth certificate• Report or certification of birth abroad of a US citizen• U.S. Citizen ID card• Adoption papers• Military record if it shows state born• Voter ID Card• Enhanced Michigan Driver’s License

Identity Documentation - (Photo ID) • Driver’s License/Photo ID Card• U.S. Passport (can be also used for citizenship documentation)• School Photo ID• Federal, state, or local government ID• U.S. military ID card

NOTE: If the client cannot obtain the required citizenship / identity documentation: • Inform the client that she has 15 calendar days to produce the missing citizenship or

identity documentation. • Inform Michele Barton that documentation verifying client citizenship and/or identity

will be forthcoming; client unable to obtain it at the time the application was signed. • If unable to obtain documentation during that time period or if the client requires

assistance in obtaining supporting documents (e.g. a copy of her birth certificate), notify E.J. Siegl.

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APPENDIX D

BREAST & CERVICAL CANCER TREATMENT PROGRAM

MEDICAID APPLICATION

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MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES

BREAST AND CERVICAL CANCER PREVENTION AND TREATMENT PROGRAM APPLICATION FOR MEDICAID

Last Name First Name Middle Initial

Address Apt. or Lot Number

City State MI

Zip Code County Birthdate (MM/DD/YYYY)

Social Security Number Phone Number (Area Code, Number)

( ) Treatment

Begin Date End DateDo you intend to stay in Michigan?

YES NO

Are you a United States citizen? (If NO, attach a copy of USCIS status.)

YES NO

Racial /Ethnic Heritage: (optional codes noted in bold)

A-Asian or Pacific Islander; B-Black or African American (Non-Hispanic); E-Other Race or Ethnicity; H-Hispanic; I-Native American / American Indian / Alaskan Native J-Native Hawaiian; O-Caucasian/White (Non-Hispanic); Z-Mutually Defined or Multiracial

Do you have health insurance? YES NO

If YES, name of insurance company Policy Number

ACKNOWLEDGEMENTS

This is your copy of your rights and responsibilities as an applicant for or beneficiary of Medicaid benefits. By signing the application you acknowledge that you understand your rights and responsibilities and that you are applying only for Medicaid through the Breast and Cervical Cancer Prevention and Treatment Program (BCCPTP).

I agree to the release of information and supporting proof in order to evaluate and verify eligibility. I agree that the Department of Community Health (DCH) or Local Public Health agency may use necessary medical information about me, including any information about HIV or AIDS, to determine eligibility for a specific program or for other administrative purposes. I understand that these agencies will maintain confidentiality according to federal requirements at 42 CFR 431.300-431.307 and any other applicable federal and state laws and regulations. I understand that when the DCH pays the cost of medical services, any right to recover costs from a third person or public or private contractor, except Medicare, is transferred to the Department. Payment of any recovery under such right is to be made directly to the State of Michigan, DCH, or its agent. I understand that this application is only for Medicaid coverage under the BCCPTP. I understand that if found not eligible for health benefits under the BCCPTP, I may be eligible for Medicaid benefits on some other basis. I understand I have the right to complete the DHS-1171 to apply for cash benefits, food assistance, day care assistance or other services at the local Department of Human Services (DHS) office. I understand that if I get more benefits than I am entitled to through my fault, I may have to repay any extra benefits received. I understand that I must report changes, such as name, address, Medicaid program participation, or health insurance coverage, within 10 days of the change. I understand that computer cross-checking may be used to verify information I have provided on this application.

If you would like help with the pursuit of financial or medical support, contact your local DHS office. If you need help with reading or writing to complete this application, under the Americans with Disabilities Act you are invited to make your needs known to your local treatment program case manager.

You have the right to appeal a decision by the Department of Community Health. You will be notified of your rights if your application is denied for any reason.

SIGN YOUR APPLICATION I certify under penalty of perjury that the information on the application is true, complete, and accurate to the best of my knowledge. I understand that any misrepresentation of the facts means that benefits may be taken away. I authorize the state to verify the information on this application.

Applicant's Signature Date

I certify that this applicant meets all eligibility criteria for the BCCPT program.

Case Manager/Breast and Cervical Cancer Control Program (BCCCP) Coordinator Signature Date

Printed Case Manager/BCCCP Coordinator Name Telephone Number

Citizenship documentation attached? YES NO Identity documentation attached? YES NOFAX APPLICATION AND DOCUMENTATION TO: (517) 373-9305

Authority: Social Security Act XIX, Public Law 106-354. The Michigan Department of Community Health is an equal opportunity Completion: Is Voluntary, but is required if Medical Assistance Program Payment is desired. employer, services and programs provider.

DCH-1088 (08/08) Previous editions are obsolete.

APPENDIX E

MTA RELEASE OF INFORMATION (ROI)

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MEDICAID TREATMENT ACT (MTA) RELEASE OF INFORMATION (ROI)

I UNDERSTAND THAT:

• Any personal information obtained about me will be kept confidential• This information will not be given to anyone outside of this program without my written

permission• Only information about me that does not identify me will be used in grouped reports

or for other scientific purposes concerned with controlling breast and cervical cancer.• I may be asked sometime in the next several years to answer questions about my breast

or cervical health, or my experiences with this screening program. I understand I amnot required to answer such questions. If I do, I do not have to identify myself.

• AIDS-related information about me will not be released unless I provide written consenton a separate document.

I GIVE PERMISSION AND AGREE TO:

• Provide the BCCCNP Agency with information about me, including my health historyand reports of screening and diagnostic tests and procedures relating to breast orcervical cancer.

• Allow the BCCCNP Agency to give information regarding my case to:o My physiciano Any consulting physiciano Any clinic or hospital to which I may be referredo My health insurance companyo Any other individual designated by meo The Michigan Department of Health and Human Services, which is running this

program for the State of Michigan.

I have been able to ask questions about this program and this form, and have been given answers to my questions. Based on my understanding of this screening and follow-up program, I wish to enroll. BCCCNP Agency Phone number is (________/________-_________).

Signature of client Date

Signature of person obtaining informed consent Date

THIS FORM IS IN EFFECT FOR ONE YEAR FROM THE DATE OF SIGNATURE

Reviewed: 12/2017 17

APPENDIX F

MTA BREAST & CERVICAL TREATMENT START/END

DATES

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MEDICAID TREATMENT ACT (MTA)

Guidelines for Determining / Documenting Breast and Cervical Cancer

Treatment Start / End Dates

A. Documenting Cancer Treatment Start Date in the Michigan Breast and Cervical Information System (MBCIS)

1. ALL BCCCNP CASELOAD or NAVIGATION-ONLY clients diagnosed with breast orcervical cancer must have a final diagnosis, diagnosis date, and treatment start date documented in MBCIS.

2. The Cancer Treatment Start Date is defined as the actual date the client FIRSTreceives a cancer treatment (E.g. chemotherapy, radiation therapy, surgery, targeted therapy) based on the type of cancer diagnosed.

3. The BCCCNP Patient Navigator is responsible for:a. Determining the treatment start date after verifying with the

client/client’s provider the type of treatment and date treatmentreceived.

b. Evaluating the MTA client’s status within 2-3 months post initiation oftherapy and at annual re-determination date to verify continued receiptof treatment and continued program eligibility.

c. Adjusting MTA start and end dates based on date of client’s diagnosis andreceipt of treatment.

B. Guidelines for Determining Breast Cancer Treatment Start Date 1. Breast cancer treatment is determined based on:

a. Histologic type of breast cancer (E.g. mucinous, medullary, tubular, etc.)b. Stage of breast cancer

• Describes the severity of the cancer based on the size and/orextent (reach) of the original (primary) tumor, involvement oflymph nodes, and if the cancer has metastasized to otherparts of the body.

• Classified by stages from Stage 0 (in-situ cancer) to Stage 4(metastatic cancer).

c. Grade of the primary tumor• Describes how serious and aggressive the cancer cells are• Classified as Grade 1 (low grade) to Grade 3 (high grade)

d. Menopausal status of the client (pre-post menopause)e. Estrogen receptor (ER) and progesterone receptor (PR) status of the tumorf. Human epidermal growth factor type 2 receptor (HER2/neu) overexpression

and/or amplification

• Breast cancer is commonly treated by various combinations ofone or more of the following modalities:

• Breast Surgery (E.g. Mastectomy, Breast conserving19

surgery/lumpectomy with/without axillary node dissection or sentinel node biopsy)

• Pre-operative or post-operative chemotherapy• Radiation therapy• Targeted Therapy (E.g. Endocrine/Hormonal, HER2 Therapy)

2. Guidelines for determining breast cancer treatment start/end dates based ondiagnosis and treatment options are listed in Table 1.

C. Guidelines for Determining Cervical Cancer Treatment Start Date 1. Cervical cancer/pre-cancer treatment is determined based on:

a. Type of cancer: pre-cancer (CIN 2, CIN 3) or invasive cancer (squamous cell oradenocarcinoma)

b. Location of cancer within cervixc. Age of clientd. Decision to have children

2. Treatment of pre-cervical cancer lesions (CIN 2, CIN 3): any of the following:a. Conizationb. Loop electrosurgical excision procedure (LEEP)c. Laser surgery

3. Treatment of invasive cervical cancer: One or more of the following options:a. Hysterectomyb. Radiation Therapyc. Chemotherapyd. Targeted Therapy (Avastin)

4. Guidelines for determining cervical cancer/pre-cancer treatment start/end datesbased on diagnosis and treatment options listed in Table 2.

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Table 1 Breast Cancer Treatment Start Dates Breast

Cancer Diagnosis

Treatment Options MBCIS Treatment Start Date

MTA Application Start Date

MTA Application End Date

1. LCIS 1. Observation ONLY afterBiopsy confirming diagnosis.

No further surgery scheduled AND client NOT ELIGIBLE for Targeted Therapy

Date of BIOPSY confirming cancer diagnosis

1st of month cancerdiagnosed from BIOPSY

END date is 2 months (60 days) from MTA start date.

2. Targeted Therapyto decrease the incidence of subsequent breast cancers (Requires Oncology Consult visit)

Date of Oncology Consult visit AND verification client has the prescribed targeted therapy medication for treatment.


No END date.

MTA continues until Targeted Therapy is completed.

3. Bilateral prophylactic totalmastectomy, without axillary node dissection.

Date of BIOPSY confirming cancer diagnosis

1st of month cancer diagnosed from BIOPSY

If client opts for breast reconstruction, MTA continues until breast reconstruction completed.

If no reconstruction, MTA END date is 2 months (60 days) post mastectomy date.

2. DCIS 1. Breast-conserving surgery(lumpectomy) without lymph node surgery and radiation therapy with or without Targeted Therapy

Date of Oncology Consult visit. Need verification client has the prescribed targeted therapy medication for treatment if consult occurs PRIOR to surgery.


No END date.

MTA continues until Targeted Therapy is completed OR resolution of side effects (if any) from radiation or targeted therapy.

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Breast Cancer Diagnosis




If no targeted therapy, treatment start date is date of lumpectomy.

2. Total Mastectomy withOr without sentinel node biopsy +/- reconstruction and Targeted Therapy

Date of Oncology Consult. Need verification client has the prescribed medication for targeted therapy treatment if consult occurs PRIOR to surgery.

If no targeted therapy, treatment start date is date of mastectomy.


If no reconstruction, and no Targeted Therapy MTA END date is 2 months (60 days) post mastectomy date

If client opts for breast reconstruction, MTA continues until breast reconstruction and Targeted Therapy completed.

3. InvasiveBreast Cancer

Breast –conserving surgery with axillary node staging and radiation therapy with/without chemotherapy and/or targeted therapy.

Date of breast –conserving therapy (lumpectomy)


No END Date.

MTA continues until chemotherapy and/or targeted therapy is completed.

2. Mastectomy (FIRST) with axillarynode staging +/- reconstruction followed by radiation, chemotherapy, and/or targeted therapy.

Date of Mastectomy 1st of month cancerdiagnosed from BIOPSY

No END Date

MTA continues until radiation, chemotherapy and/or targeted therapy completed OR breast reconstruction completed

Neoadjuvant therapy (Targeted therapy or Chemotherapy PRIOR to surgery to shrink tumors)

Date of Oncology Consult visit. Need verification client has the prescribed targeted therapy


No END date.

MTA continues until targeted therapy and/or chemotherapy completed.

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Breast Cancer Diagnosis




(Requires Oncology Consult visit) medication for treatment if consult occurs PRIOR to surgery

Table 2 Cervical Cancer/Pre-cancer Treatment Start Dates Cervical Cancer

Diagnosis Treatment Options MBCIS Treatment Start Date MTA Start Date MTA End Date

1. CIN 2(pre-cervical cancer)

1. Surgical procedure (LEEP,Conization)

Date of Surgical Procedure (LEEP, Cone) POST Biopsy

1st of monthtreatment is scheduled

END date is 2 months (60 days) POST procedure. This includes month of LEEP/Cone and one month post. Can be extended if dysplasia identified on LEEP/Cone.

2. CIN 3/CIS 1. Surgical procedure (LEEP,Conization).

Date of Surgical Procedure POST Biopsy

1st of monthtreatment is schd

Last day of month 6 months post treatment

2. Hysterectomy for CIN 3/CIS ifdysplasia involves margins.

Date of Surgical Procedure POST Biopsy


Last day of month 6 months post treatment

3. Adenocarcinoma

1. Hysterectomy Date of Surgical Procedure POST Biopsy


No END date. MTA continues until treatment completed per

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or Squamous Cell Carcinoma

2. Gynecology Oncology Consult forpossible chemotherapy (depending on extent of disease invading surround tissues)

Date of Surgical Procedure POST biopsy (if no surgery performed then date of Gyn Onc Consult


No END date. MTA continues until treatment completed per Gyn/Onc

3. Radiation Oncology Consult Date of Surgical Procedure POST biopsy (if no surgery performed then date of Radiation/Oncology Consult


No END date. MTA continue until treatment completed per Rad/Onc

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APPENDIX G

MTA CLEINT REDETERMINATION FOR

CANCER TREATMENT

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MEDICAID TREATMENT ACT CLIENT REDETERMINATION FOR CONTINUED BREAST OR CERVICAL CANCER TREATMENT

Agency Name: ____________________________________________ Date sent to Provider: ___________________

BCCCNP Client Name: Date of Birth: _________________

In order to determine continued eligibility for Medicaid services, please indicate below the status of the above named BCCCNP client.

The client is still receiving treatment for (check one): Breast cancer Cervical cancer CIN II CIN III/CIS

FOR CERVICAL CANCER TREATMENT:The client has completed cancer treatment. She received

(procedure) on (date). *

* She can return to Family Planning or BCCCNP for follow-up Pap tests post treatment.

FOR BREAST CANCER TREATMENT:The client has completed cancer treatment and can return to routine or surveillance screening.

Signature Date

Additional Information:

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APPENDIX H

MTA CLIENT STATUS MEMO TO MICHELE BARTON, MTA

QUALITY ANALYST

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MEDICAID TREATMENT ACT M E M O R A N D U M

DATE:

TO: Michele Barton, Quality Assurance Analyst FAX: 517-373-9305

FROM:

RE: BCCCNP MTA Client Status Update

The following BCCCNP client:

Name: _______________________________ DOB: _____________________

Beneficiary ID Number: __________________________________

Has / is:

Completed cancer treatment

Failed to renew yearly application

Non-compliant with treatment

Other: ____________________

Her Medicaid end date is: _________________________

Please verify that you have received this fax and call if you have any questions.

Thank you.

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medicaid treatment act (mta) client eligibility ... · mta application and copies of appropriate...

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