MississippiCAN Program

Transcription

1 Office of the Governor Mississippi Division of Medicaid Mississippi Division of Medicaid MississippiCAN Program MPHCA Conference

2 Goals of MississippiCAN Program Mississippi Coordinated Access Network (MississippiCAN) implemented on January 1, 2011 is a statewide care coordination program designed to: Improve beneficiary access to needed medical services; Improve the quality of care; and Improve program efficiencies as well as cost effectiveness. OFFICE OF THE GOVERNOR MISSISSIPPI DIVISION OF MEDICAID 2

3 Evolution of the MississippiCAN Program Mississippi House Bill Second Extraordinary Session Mississippi House Bill Regular Session Mississippi House Bill Regular Session The MississippiCAN program has evolved from January 2011 to present. Increased limit to 45% of total enrollment of Medicaid beneficiaries, plus the categories of beneficiaries composed primarily of persons younger than nineteen(19) years of age Inclusion of services, except Inpatient Hospital Services (NET now included) OFFICE OF THE GOVERNOR MISSISSIPPI DIVISION OF MEDICAID 3

4 DOM Bureau of Coordinated Care The DOM Bureau of Coordinated Care manages two statewide programs designed to improve beneficiary access to needed medical services, and to improve the quality of care. Mississippi Coordinated Access Network (MississippiCAN) Children s Health Insurance Program (CHIP). There are two coordinated care organizations (CCOs) which provide services to these beneficiaries: Magnolia Health Plan and UnitedHealthcare. For questions regarding MississippiCAN, call or MississippiCAN.Plan@medicaid.ms.gov ms or view the website at OFFICE OF THE GOVERNOR MISSISSIPPI DIVISION OF MEDICAID 4

5 MississippiCAN Enrollment Beneficiaries can enroll at any time. Every member will have a 90 day window to make changes after his/her initial enrollment. During the 90 day window, mandatory members may only switch between the plans one time. During gthe 90 day window, optional o members may dis enroll or switch between the plans one time. DOM will have an open enrollment period each year (October December) to allow members to make changes. Enrollment is always effective at the beginning of the month and disenrollment, for those in the optional population, is effective the last day of the month. Newborns born to a Medicaid mom who is currently enrolled in MississippiCAN will automatically be placed in the same plan as the mother. OFFICE OF THE GOVERNOR MISSISSIPPI DIVISION OF MEDICAID 5

6 MississippiCAN Mandatory Populations Category of Eligibility Age 001 SSI Working Disabled Breast and Cervical Cancer Parents and Care Takers Pregnant Women Newborns Children (Beginning SFY 2015) 1 19** *088 formerly Pregnant Women and Infants (Infants/Newborns moved to 071) *085 formerly TANF (Parents moved to 075, and Children moved to new categories) *087 and 091 formerly Children (Moved to new categories 071, 072, 073, 074) OFFICE OF THE GOVERNOR MISSISSIPPI DIVISION OF MEDICAID 6

7 Category of eligibility MississippiCAN Optional Populations Age 001 SSI Disabled Child Living at Home DHS Foster Care Children DHS Foster Care Children 0 19 (Adoption Assistance) Note: Always check eligibility for the Date of Service to ensure submission to correct payer by methods below: Telephone Envision Web Portal at new address medicaid.com OFFICE OF THE GOVERNOR MISSISSIPPI DIVISION OF MEDICAID 7

8 Beneficiaries Who Are Not Eligible for MississippiCAN Beneficiaries enrolled in any waiver program. (ex. HCBS, TBI, IDDD, IL, MYPAC, etc.) Beneficiaries i i who are dually eligible. ibl (Medicare/Medicaid) Beneficiaries who at the time of application are institutionalized. (ex. Nursing Facility, ICF MR, Correctional Facilities, etc.) OFFICE OF THE GOVERNOR MISSISSIPPI DIVISION OF MEDICAID 8

9 New Medicaid and CHIP Eligibility Income Calculation Effective January 1, 2014, a new methodology based on Modified Adjusted Gross Income (MAGI) will be used for determining CHIP eligibility. As a result of a conversion to MAGI, children in households with income limits up to 133 percent of the federal poverty level will be transitioning from CHIP to traditional Medicaid. Federal authority for the change in the Medicaid limit that affects CHIP is Section 2001 (a)(5)(b) of the Affordable Care Act implemented through federal regulations for the Medicaid program at 42 CFR OFFICE OF THE GOVERNOR MISSISSIPPI DIVISION OF MEDICAID 9

10 MississippiCAN 2014 Contract Changes The renewed MississippiCAN contract will be effective July 1, 2014, which may be viewed at ms under request for bids/proposals. Below are some changes in new contract: PCP assignment The member has thirty t (30) calendar days to select a Primary Care Provider (PCP). The Contractor must inform PCPs of Member assignments via web portal unless the PCP requests an alternate format (e.g., surface mail, secure fax) when completing the provider contract. If the Contractor elects to notify PCPs via web portal, the Contractor must confirm that the PCP received and has acknowledged receipt of the Member listing and acknowledges receipt of list of Members assigned to them. Pharmacy The Contractor must use the most current version of the Medicaid Program Preferred Drug List (PDL), which is subject to periodic changes. The Contractor must use the Medicaid PDL developed by the Division or its Agent and may not develop and use its own PDL. OFFICE OF THE GOVERNOR MISSISSIPPI DIVISION OF MEDICAID 10

11 MississippiCAN 2014 Contract Changes Non Emergency Transportation The Contractor shall provide Non Emergency Transportation for its Members to access Medically Necessary Services, in compliance with minimum Federal requirements for the provision of transportation services and according to DOM policies, which are outlined in Mississippi Administrative Code, Title 23, Part 201. Non Emergency Transportation shall be provided to Members who require transportation to and from Medicaid covered non emergency services Prior Authorization The Contractor shall have the capability and established procedures to receive Prior Authorization requests via secure web based submissions and facsimile from providers. The Contractor must make standard authorization decisions and provide notice within three (3) calendar days or two (02) business days following receipt of the request for services. OFFICE OF THE GOVERNOR MISSISSIPPI DIVISION OF MEDICAID 11

12 MississippiCAN 2014 Contract Changes Provider Network Requirements PCP providers Urban two within fifteen (15 ) minutes or thirty (30) miles Rural one within thirty (30) minutes or thirty (30) miles Credentialing The Contractor shall credential all completed application i packets within ninety (90) calendar days of receipt. In cases of network inadequacy, the Contractor shall credential all completed application packets within forty five (45) calendar days of receipt Claims: The Contractor shall encourage providers to submit claims as soon as possible after the dates of service. Providers shall be provided a minimum of ninety (90) calendar days and a maximum of six (6) months to submit claims from the date of service. Claims filed within the appropriate timeframe but denied may be resubmitted to the Contractor within ninety (90) calendar days from the date of denial. OFFICE OF THE GOVERNOR MISSISSIPPI DIVISION OF MEDICAID 12

13 MississippiCAN Contact Information Payer Card Color Type Service Telephone DOM Mississippi Medicaid Blue (new cards) Green (old cards) Multiple Medicare Red/White/Blue MississippiCAN (*) Magnolia Health Plan Purple Medical Cenpatico (same card) Behav Hlth Univita (same card) DME US Script (same card) Pharmacy MississippiCAN (*) UnitedHealthcare White Medical UBH OptumHealth (same card) Behav Hlth OptumRx (same card) Pharmacy CHIP UnitedHealthcare White Multiple OFFICE OF THE GOVERNOR MISSISSIPPI DIVISION OF MEDICAID 13

14 Contact Information for the MississippiCAN program Mississippi Division of Medicaid Phone: Toll free: Magnolia Health Plan ams/mississippican/ / Inquiry/Complaint Form available g Toll free: United Healthcare Toll free: OFFICE OF THE GOVERNOR MISSISSIPPI DIVISION OF MEDICAID 14

15 FQHC Encounter Rate Rule 1.3: Covered Services A. Medicaid defines an encounter as services provided by physicians, physician assistants, nurse practitioners, clinical psychologists, dentists, optometrists, ophthalmologists and clinical social workers. A clinic s encounter rate covers the beneficiary s i visit i to the clinic, i including all services and supplies, such as drugs and biologicals that are not usually self administered by the patient, furnished as an incident to a professional service. When services, supplies, drugs or biologicals are included in the clinic s encounter rates, the clinic cannot send the beneficiary to another provider that will bill Medicaid for the covered service, supply, drug or biological. content/uploads/2014/01/admin Code Part 211.pdf OFFICE OF THE GOVERNOR MISSISSIPPI DIVISION OF MEDICAID 15

16 340B Drug Pricing Background: The 340B Drug Pricing Program resulted from enactment of the Veterans Health Care Act of 1992, which is Section 340B of the Public Health Service Act. Section 340B of the Public Health Service Act limits the cost of covered outpatient drugs to certain federal grantees, federally qualified health center look alikes, and qualified hospitals. These providers purchase, dispense and/or administer pharmaceuticals at significantly discounted prices. The significant discount applied to the cost of these drugs make them ineligible for the Medicaid drug rebate. State Medicaid programs are mandated to ensure that rebates are not claimed on these drugs. Providers who are enrolled as 340B providers with the U.S. Department of Health and Human Services (DHHS), Health Resources and Services Administration (HRSA) are referred to as 340B providers. 340B providers appear on the Office of Pharmacy Affairs Database, Reason for change: In an Office of the Inspector General (OIG) June 2011published report, the OIG recommended that CMS direct states to create written 340B policies regarding reimbursement of 340b drugs in Medicaid. As a follow up to the OIG s recommendations, CMS directed that states clarify reimbursement policies for 340B entities in the approved state plan. DOM has submitted a state plan amendment consistent with the regulations, including those found at 42 CFR and , to detail how these covered entities are reimbursed. This state plan amendment will enable MS to be in compliance with CMS regulations and clarify billing /reimbursement for 340B entities. OFFICE OF THE GOVERNOR MISSISSIPPI DIVISION OF MEDICAID 16

17 Program changes, effective July 1, 2014 DOM will allow providers to opt in or opt out. The Division of Medicaid defines opt in as the election by a covered entity to purchase and dispense/administer covered 340B drugs to Medicaid beneficiaries. The DOM defines opt out t as the election by a covered entity not to purchase and dispense/administer covered 340B drugs to Medicaid beneficiaries. Covered entities may change their opt in or opt out election by completing, signing and submitting the Medicaid 340B Covered Entity Attestation and Election Form to the Division of Medicaid. The change is effective thirty (30) days following the Division of Medicaid s receipt of the form. Covered entities changing their enrollment status must meet the requirements in Administrative Code, Part 200, Chapter 4, Rule 4.10.E.1) or 4.10.E.2). A contract pharmacy, defined by the Division of Medicaid as an agent of a 340B covered entity and ineligible to be a freestanding 340B covered entity, cannot dispense and bill the Division of Medicaid for 340B outpatient drugs for Medicaid beneficiaries. Billing (please see next page for detail pharmacy billing instructions) OFFICE OF THE GOVERNOR MISSISSIPPI DIVISION OF MEDICAID 17

18 Pharmacy Billing Instructions Pharmacy Billing instructions: These billing directions only address billing of 340B drugs. The non 340B drugs should continue to be billed using the Usual and Customary charge. The following section addresses only pharmacy providers who are 340B Covered Entities who have elected to opt in, that is dispense ALL of their 340B drugs to Medicaid beneficiaries i i at their 340B actual acquisition iti cost (340B AAC). It is understood d that t some 340B Covered Entities purchase both 340B drugs and non 340B drugs for their patients who are ineligible to receive 340B drugs. 340B providers who are enrolled with the department as a provider type other than pharmacy shall charge DOM no more than their actual acquisition cost for the drug product. NCPDP directions for POS billing of 340B drugs: In field 420 DK (Submission i Clarification i Code) enter a value of 20 (Description i 34ØB Indicates that, prior to providing service, the pharmacy has determined the product being billed is purchased pursuant to rights available under Section 34ØB of the Public Health Act of 1992 including sub ceiling purchases authorized by Section 34ØB (a)(1ø) and those made through the Prime Vendor Program (Section 34ØB(a)(8)). In field 423 DN (Basis Of Cost Determination) enter a value of 08 (34ØB /Disproportionate Share Pricing/Public Health Service Price available under Section 34ØB of the Public Health Service Act of 1992 including sub ceiling purchases authorized by Section 34ØB (a)(1ø) and those made through the Prime Vendor Program (Section 34ØB(a)(8)). Applicable only to submissions to fee for service Medicaid programs when required by law or regulation. ) In field 409 D9 (Ingredient Cost Submitted) the 340B actual acquisition cost must be entered. In field 426 DQ (Usual and Customary Charge or Total Charge) the lowest net charge that a non Medicaid, 340B eligible patient would pay for the same prescription must be entered. Example The total charge to a non Medicaid 340B eligible patient for a 30 day supply of Lisinopril 20 mg purchased under the 340Bprogram is $4.00. The same prescription p for a Medicaid beneficiary must be billed with an entry of $4.00 in the Usual and Customary Charge field. OFFICE OF THE GOVERNOR MISSISSIPPI DIVISION OF MEDICAID 18

19 340B FAQs Are MSCAN (aka coordinated/managed care) claims included? Yes What will happen if a 340B entity does not complete and return the attestation form to Medicaid? The new policy, including attestation form, is in alignment with CMS and OIG recommendation for Medicaid agencies. It is Medicaid s intent that all 340B providers will complete the form and submit to Medicaid. If a 340B provider does not submit said attestation form, then this provider will be considered a non 340B entity. That fact may trigger audits from 340b regulatory bodies and drug manufacturers. I am a prescriber and I don t know why I received the 340B letter/attestation. What am I to do with this? OFFICE OF THE GOVERNOR MISSISSIPPI DIVISION OF MEDICAID 19

20 Preferred Drug List (PDL) What is a PDL? A medication list of preferred drugs selected as best of the best clinically, safety wise and monetarily. Does Medicaid still cover non preferred drugs? Yes, but prior authorization is needed d Why should we use the PDL? Every time a non preferred drug is used for a Medicaid beneficiary, MS Medicaid and the State of Mississippi lose money. Is every drug on the PDL? No. A drug class is not included if there are limited cost savings for that class of drugs, if there is little use of the drug, or if the class is mostly generic. This is monitored closed and DOM may decide to add or delete a class from the PDL as needed. How many classes on the PDL? Over drug classes are on DOM s PDL. Where can we find the PDL? On Medicaid swebpageat at drug list/ OFFICE OF THE GOVERNOR MISSISSIPPI DIVISION OF MEDICAID 20

21 Advantages of PDL Goal of the PDL is to have as many cost effective drugs available as possible. Preferred drugs do not need a prior authorization Adult beneficiaries (< 21) can get more than two branded drugs if the branded drugs are on the PDL. Save Medicaid and the MS taxpayers money OFFICE OF THE GOVERNOR MISSISSIPPI DIVISION OF MEDICAID 21

22 What is the Uniform PDL? Medicaid and MSCAN are working together to have a uniform or the same Preferred Drug List (PDL) for Medicaid, UHC, and Magnolia. Start Date Will help providers and beneficiaries OFFICE OF THE GOVERNOR MISSISSIPPI DIVISION OF MEDICAID 22

23 Helpful Tips Bookmark the Pharmacy Services webpage for your easy reference Here are some examples of what can be found on this page: PDL updated Billing Tips (other insurance, hospice) Medicaid Cough and Cold quick List 90 Day Maintenance List 72 Hour Emergency Prescription Prior Authorization Forms Latest Pharmacy News ICD9 codes at Point Of Sale Over The Counter (OTC) Formulary OFFICE OF THE GOVERNOR MISSISSIPPI DIVISION OF MEDICAID 23

24 MSCAN Pharmacy Information Magnolia Return POS Message : BILL MSCAN PLAN: Magnolia ; BIN# This is their PBM or US Script s Pharmacy Helpdesk number If you need to contact the Plan, call UHC or UnitedHealthcare Return POS Message: BILL MSCAN PLAN: UHC ; BIN# GROUP: ACUMS This is their PBM or RX Solutions Pharmacy Helpdesk number If you need to contact the Plan, call OFFICE OF THE GOVERNOR MISSISSIPPI DIVISION OF MEDICAID 24

25 Why does Medicaid do that? Fd Federal Regulations and Drug Coverage Medicaid covers most drugs and drug classes, but not all. Why is that? From the inception of Medicaid (early 1970 s) to the early 90s, every state had its own Medicaid state specific pharmacy formulary. States had the authority and ability to control and monitor pharmacy costs. 1990, OBRA 90 abolished state specific Medicaid drug formularies which caused Pharmacy budgets to skyrocket. Every prescription drug had to be covered (other than federal specified exclusions see below) if manufacturer participates p in rebate program. That means, that Medicaid does not cover the drugs listed below or we only cover some of the drugs listed below. Federal Exemptions: commonly know as 1927s are found in Section drugs used dfor cosmetic purposes; drugs for weight gain or weight loss; drugs for fertility; drugs to treat cough and colds; Over The Counter (OTC) drugs; DESI (less than effective drugs as determined by the FDA) drugs; and RX vitamins. OFFICE OF THE GOVERNOR MISSISSIPPI DIVISION OF MEDICAID 25

26 Occasionally the overall cost for a Brand may be less than for the Generic Federal rebate Medicaid payment to pharmacies is higher for brand Supplemental rebates l Overall cost Medicaid overall cost after rebates is lower for brand Brand Generic