Prior to submitting claims for reimbursement, providers must ensure that the individual is eligible for and enrolled in one of Vaya Health’s benefit plans. To be eligible for the 1915(b) Medicaid plan, members must have a qualifying Medicaid category of aid from a county within the Vaya catchment area. To be eligible for the 1915(c) Innovations Waiver, the individual must be enrolled in the Waiver. Eligibility for non-Medicaid services is based on income and other requirements described below. Mobile Crisis Services are available to anyone within our catchment area regardless of eligibility for Medicaid or Non-Medicaid services.
Eligibility for Medicaid-funded services
The county Department of Social Services where the individual resides determines Medicaid eligibility. Vaya receives a Global Eligibility File (GEF) that contains information on the eligibility status of Medicaid beneficiaries who qualify for a category of aid covered by the Medicaid Waiver. The GEF is generated by NCTracks, updated daily and downloaded into AlphaMCS, which providers may access.
Our Eligibility and Enrollment Team can assist you with the enrollment process. As a provider delivering services to our members, you are required to submit requests and updates on member eligibility and enrollment. If an individual presents for services who is not eligible for Medicaid, and you reasonably believe the individual meets financial eligibility requirements, you must offer to assist the member in applying for Medicaid.
Eligibility for non-Medicaid-funded services
Additional eligibility guidelines are:
- Financial Eligibility: Household income for the individual must be 300 percent or less of the most recent federal poverty guidelines, based on family size.
- Other third-party coverage: Must be exhausted or not covered by the plan and provide proof of denial from insurer. Non-Medicaid funds may not be used to pay for deductibles or co-payments.
- Citizenship: The individual must be a U.S. citizen or legal resident. Only exception is for emergency services as defined in 42 CFR § 438.114 .
At times, an intellectual and/or developmental disability (IDD), including functional impairment, is established in adulthood but is not clearly established to have been present before adulthood. In these instances, Vaya will consider all information available (including school records, treatment records, reports from family and relatives, etc.) to make a determination whether it is probable that the IDD existed prior to age 22.
Our Eligibility and Enrollment Team can assist you by answering questions about topics including:
- Member lookup in AlphaMCS
- How to enroll a member into the non-Medicaid benefit plan and questions about enrollment
- How to update member information and questions about Client Update Requests
- Medicaid categories of eligibility
- How to obtain a Common Name Data Service (CNDS) number for a member
- Questions about a member’s Medicaid eligibility
- Questions about a member’s non-Medicaid funded benefits or target population
- Member demographic and eligibility information in NCTracks verses AlphaMCS
- Third-party insurance and dual eligibility
The team also:
- Processes discharges for non-Medicaid benefit plan members
- Verifies Medicaid, non-Medicaid and coordination of benefits (COB) coverage for providers and other Vaya departments
Vaya is responsible for the administration of the Medicaid 1915(b)/(c) Waiver in our catchment area. However, we do not serve all Medicaid categories of aid. Vaya serves the following categories:
- Aid to Families with Dependent Children (AFDC), ages 3 and older
- Foster children, age 3 and older
- Aged, age 65 and older
- Blind and disabled, age 3 to 20
- Blind and disabled, age 21 and older
- Innovations, all ages
The following Medicaid populations remain “fee-for-service” and are not covered by Vaya:
- Infants under age 3, unless eligible for Innovations
- Qualified Medicare beneficiaries
- Specified low-income beneficiaries
- Children enrolled in NC Health Choice
- Legal and Illegal aliens
- Individuals eligible for the Program of All-Inclusive Care for the Elderly
AAFCN, AAFCY, MAFCN, MAFMN, MAFNN, MAFWN, MICNN, MIC1N, MPWNN
Foster children (age 3 and older)
HSFCY, HSFMN, HSFNN, MFCNN, IASCN, IASCY
Aged (age 65 and older)
MAABN, MAACY, MAAMN, MAANN, MAAQN, MAAQY, SAABN, SAACN, SAACY, SAAQN, SAAQY
Blind and disabled (age 3 to 20; age 21 and older)
MABBN, MABCY, MABMN, MABNN, MABQN, MABQY, MADBN, MADCY, MADMN, MADNN, MADQN, MADQY, SADBN, SADCN, SADCY, SADQN, SADQY
Innovations (all ages)
1915(c) Waiver beneficiaries as identified by an Innovations waiver code (IN) in the state’s eligibility file