Q1: What is changing and why?

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Brittany Wilkinson
6 years ago
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1 Q1: What is changing and why? A1: Over the past few years, the Centers for Medicare & Medicaid (CMS) and the State of Tennessee (State) have increased efforts to coordinate the care of people that are enrolled in both Medicare and Medicaid (dual eligible enrollees). Effective January 1, 2014, in an effort to help improve the coordination of care for these enrollees, Volunteer State Health Plan (VSHP) is offering a new Dual Special Needs Plan (D-SNP). This plan is a Medicare Advantage HMO managed by VSHP that will only enroll dual eligible members. In this endeavor, CMS developed the Medicare-Medicaid Coordination Office to align incentives between Medicare and Medicaid through financial models in support of the State s efforts for improved care integration for Medicare-Medicaid enrollees (Financial Alignment Demonstration Initiative). The goal of this Initiative is to increase access to seamless, quality programs integrating primary, acute, behavioral, prescription drugs and long-term care services. Additionally, the Bureau of TennCare submitted a proposal to CMS to implement the Financial Alignment Demonstration Initiative. VSHP formally expressed its support for these efforts by CMS and the Bureau of TennCare; however, the D-SNP being offered to our Health Care Professionals as described above and in the attached Amendment, is not part of that Initiative. In addition to improved coordination efforts by CMS, the Bureau of TennCare developed requirements for D-SNPs to improve the coordination of care and benefits for dual eligible enrollees. These requirements are located in an agreement that all D-SNPs in Tennessee must execute with the Bureau of TennCare called Medicare Improvement for Patients and Providers Act of 2008 (MIPPA) agreement. The MIPPA agreement requires D-SNPs and TennCare MCOs exchange information related to dual eligible members. It also requires D-SNPs send all processed claims to the Bureau of TennCare for payment of dual eligible enrollees cost sharing by TennCare. Q2: What is the timeline on this amendment and when can I expect to receive referrals for this D-SNP network? What do I need to do if I choose not to participate? A2: The Amendment will become effective thirty (30) days after the date of delivery of this notice. No action is required to accept this Amendment. Rejections must be received in writing within thirty (30) days after the date of delivery of this notice, otherwise the Amendment will be deemed accepted. Assuming the application for this plan is approved, members will be enrolled in the Fall of 2013, with coverage beginning for dates of service on and after January 1, 2014.

2 Q3: When I read this amendment, it appears that it will be over a year before I will see members who are in this network. Is this a typo? Is it really supposed to be January 1 st, 2013 instead of January 1 st, 2014? A3: No, this is not a typographical error. VSHP is currently developing requirements and other pertinent elements needed to implement its D-SNP. We are developing our D-SNP network at this time due to the D-SNP application process required by CMS. VSHP will file its application with CMS to become a D-SNP around February A requirement of the application is the filing of a provider network that meets CMS guidelines for network adequacy. Q4: VO has attached a fee schedule including CPT codes that are no longer in existence on January 1, 2013 and the effective date of the attached fee schedule is January 1, Please advise. A4: Due to the timelines mentioned above, the amendment that was distributed for the D-SNP network still includes the codes that will be deleted per the AMA next year. Though we were aware of this impending change, specifics were not released by the AMA until September of this year. We are in process of mapping existing codes to the new codes for behavioral health but, given the approval timelines associated with the D-SNP documents and revised fee schedules for all networks, it was necessary to keep the two projects separate. An updated D-SNP fee schedule will be developed well in advance of the January 1 st, 2014 implementation of the D- SNP network. Q5: I share an office with three other providers. I got this amendment yesterday, and so did two others in my office. One provider did not receive the amendment. Was this in error? He participates in BlueCare and TennCare Select just like the rest of us. A5: This could be an error, but it could also be due to the provider s licensure and discipline. Because this is a network in which all members will have Medicare and TennCare, it must meet Medicare s network requirements. Currently, Medicare only recognizes physicians, psychologists, clinical social workers and advanced practice nurses licensed and/or certified at the highest level for their respective disciplines. If the provider you referenced falls into one of these categories, please have him/her contact your regional network manager for assistance.

3 Q6: Are there any unique authorization requirements associated with this network? A6: We are still evaluating some of the policies and requirements that will be in place when this network is implemented, but we anticipate authorization requirements will very closely align with those in place currently for Medicare and TennCare members enrolled in BlueCare and TennCare Select. Q7: Where will I submit my claims? A7: Claims will be submitted to Volunteer State Health Plan/BlueCross BlueShield of TN, much like you file them currently for BlueCare and TennCare Select members. Q8: Does this amendment automatically make me a Medicare provider? A8: No. If you are not currently enrolled in Medicare, you will need to enroll prior to January 2014 to remain in the D-SNP network. The second page of the amendment packet you received includes additional information regarding enrollment in Medicare, as well as a link to the CMS Medicare enrollment web page. Q9: Where can I find additional information about this new D-SNP network? A9: We will continue to update this FAQ as questions are submitted. These updates will be posted at Your regional network manager is also available to assist you. Included in this FAQ is a contact list by region. Q10: Although there is a footnote in the rate schedule that indicates that APN's who are licensed and authorized to prescribe psychotropic medication and credentialed and contracted by VO will be reimbursed for the respective CPT codes, there is no rate established for their services other than the in the contract amendment. Our APN's are credentialed with VO and have their own Medicare numbers. A10: This appears to be an oversight in the development of the fee schedule. Our intent is to reimburse medication management services delivered by APNs who are enrolled in Medicare and are practicing within their scope and under the supervision of a physician. Updated fee schedules will be distributed once 2013 AMA coding changes have been finalized and will include a provision for reimbursement of APNs. Q11: Will the services of a Physician Assistant who is credentialed with VO be reimbursed for the CPT codes involving psychotropic medication prescription and monitoring?

4 A11: We are currently evaluating the possibility of extending the network to include Physician Assistants who are enrolled in Medicare, have appropriate and relevant experience, and are practicing within the scope of their licensure and supervision. Q12: There was no reimbursement for the M0064 code for any level of staff. Our current Medicare and Medicare Advantage Plan contracts do reimburse for M0064 for both physicians and nurse practitioners. Please verify that this is a non reimbursable code for this contract. A12: This was an oversight in the development of the fee schedule. We will include M0064 for physicians and APNs. Updated fee schedules will be distributed once 2013 AMA coding changes have been finalized. Q13: Our amendment included a rate for Crisis Stabilization Unit services, but we have a freestanding CSU that is not enrolled in Medicare because it is not in a hospital. Is CSU a reimbursable benefit under the D-SNP? A13: If a service is not a Medicare benefit but is a TennCare benefit, under the D-SNP you should follow TennCare MCC authorization and claims filing policies and procedures. Q14: We offer Residential Detoxification and Substance Abuse Residential Rehabilitation services that are not Medicare reimbursable because they are provided in a freestanding facility. However, they are rendered in Tenncare approved facilities. Will we therefore continue to be reimbursed according to our Tenncare contract? A14: If a service is not a Medicare benefit but is a TennCare benefit, under the D-SNP you should follow TennCare MCC authorization and claims filing policies and procedures. Q15: The majority of the CPT codes referenced in the amendment will be replaced in Jan Will we expect to receive a revised amendment with revised rates in 2013? A15: Yes please see additional detail in A4. Q16: There is a requirement in the amendment that Facility agrees to no less than annually, submit to VSHP, copies of its latest filed and latest approved (settled) Medicare cost reports. We do not file Medicare cost reports and would not be able to comply with this. There are other references to the Medicare cost reports as well. Please advise on this requirement. A16: This language is not applicable to providers who are not required by CMS to file Medicare cost reports.

5 Q17: Is this TennCare Plus? A17: This D-SNP is not part of the of the TennCare Plus program that the Bureau of TennCare has proposed to CMS under the Capitated Financial Alignment Demonstrations Initiative. VSHP has formally expressed its support of the TennCare Plus proposal. Q18: Is this a BlueAdvantage Health Plan? A18: Although VSHP will use some of the same staff as Blue Advantage to perform certain functions, the VSHP D-SNP is not Blue Advantage. The VSHP D-SNP will most likely be named BlueCare Plus. Q19: When will the D-SNP section of the VSHP Provider Administration Manual be available? A19: We should complete the D-SNP section of the VSHP PAM by July 1, Q20: How many of the duals are eligible for the D-SNP? A21: Almost all of the Duals are eligible for D-SNP. In Tennessee, there are approximately 135,000 dual members eligible for D-SNPs. Q22: There are 135,000 duals across the state and 40% are enrolled VSHP s TennCare plan. Is the Special Needs Program a sub-set of Duals? A22: SNP members are a sub-set of dual eligible members. However the 135,000 members are all eligible to be enrolled in a VSHP D-SNP. Q23: What will the member benefit package look like? A23: It will have a cost share that is similar to Original Medicare. However, the Bureau of TennCare is responsible for the payment of the cost sharing. Q24: What would the Member Cost Sharing consist of under this plan? Would these patients still have a Medicare deductible and copay? Or would the Cost Sharing be structured completely differently from current Medicare Cost Sharing amounts? A24: We are still evaluating the member s cost sharing. However, it will be similar to Medicare Fee- For-Service. The Bureau of TennCare will be responsible for reimbursing the hospital for any member cost sharing. Additionally, VSHP has entered into an agreement with TennCare to send them the Medicare D-SNP claims that we process and TennCare will process the cost sharing based on the information that we send them. Therefore, the provider will not be required to bill the Bureau of TennCare directly to receive any TennCare cost sharing reimbursement. This is similar to the process

6 that is used today for Fee-For-Service Medicare. However, our process with TennCare should work better because we have years of experience submitting claims data to the Bureau of TennCare and should have a very high pass rate. Q25: Is the provider required to send a claim to TennCare to receive a payment for the member s cost sharing? A25: VSHP has entered into an agreement with TennCare called the MIPPA that requires VSHP to coordinate the cost sharing payment with the Bureau of TennCare. Therefore, VSHP will send claims processed by our organization directly to the Bureau of TennCare via 837 format to be processed for cost sharing. Q26: How will the members know which card to give providers? A26: The provider will need a copy of both cards, but instead of using Medicare, they will have BlueCare Plus. Q27: Will there be education for the providers or members? A27: Yes, members may give the wrong card and providers will bill to the wrong place. Internally, if a member has BlueCare and a D-SNP, we should be able to coordinate and cross claims for them. If the member does not have VSHP s TennCare plan and does have the VSHP D-SNP, VSHP will coordinate with TennCare and the member s TennCare MCO to the extent allowed/required by the MIPPA agreement. Q28: What are the network requirements? A28: Requirements differ by county based on the CMS requirements. We may have to request exceptions for some specialties, the same as we do now for the TennCare plan.

Template Language for Memorandum of Understanding between Duals Demonstration Health Plans and County Behavioral Health Department(s)

Template Language for Memorandum of Understanding between Duals Demonstration Health Plans and County Behavioral Health Department(s) Updated Draft February 14, 2013 In the duals demonstration, participating