WV Bureau for Medical Services & Molina Medicaid Solutions

Transcription

1 WV Bureau for Medical Services & Molina Medicaid Solutions

2 On January 1, 2014, Medicaid eligibility was expanded to qualified individuals ages 19 to 64 making 138% of the Federal Poverty Level. 112,464 members (as of April 12, 2014) have been enrolled in the Alternative Benefit Plan (ABP). The ABP population will request prior authorization (PA) from APS Healthcare, Inc. (the UMC) when PA is required 2

3 Chiropractic Limit of 24 treatments/year. Additional 6 treatments per calendar year can be prior authorized if OT and PT services have not been utilized in combination with chiropractic services. Physical Therapy 30 visits per year for Habilitative and Rehabilitative services (combined PT and OT) Occupation Therapy 30 visits per year for Habilitative and Rehabilitative services (combined PT and OT) Speech Therapy Habilitative and Rehabilitative services Home Health 100 visits per year ABP does not offer long term care, such as personal care services, nursing home services, etc. 3

4 Background: As of January 1, 2014, the Affordable Care Act (ACA) requires states to provide Medically Frail members the option to choose between the Traditional Medicaid Plan or the ABP. Definition (42CFR ): Individual having a chronic substance use disorder, serious and complex medical condition, or a physical, behavioral, intellectual, or developmental disorder that requires additional care. 4

5 Self Identification Full Medicaid Application "Does this person (or you, depending on the person completing the form) have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home?" If yes, member will receive a Medical Frailty Notice information them of their choice. Every member will receive Rights and Responsibilities (R&R) including information about medical frailty and how to get more information regarding their coverage options. A copy of their R&R is provided to every member at the time of their redetermination or in the event they have an eligibility category change. 5

6 A member can self-identify at any time during their eligibility period. Additional Information County Office Providers BMS website Your Guide to Medicaid Molina Member Services Molina website 6

7 On January 1, 2014, some services were assigned cost sharing (copay) amounts for Medicaid members which will effect the following provider types: Practitioner Hospital Pharmacy Rural Health Clinic Federally Qualified Health Clinic Ambulatory Surgical Center Cost Sharing applies to current and newly eligible individuals. Services cannot be refused for populations with income at or below 100% FPL if the member is unable to pay the copay amount. Maximum Out of Pocket (OOP) cannot exceed 5% of the Members quarterly household income.

8 Tiered Cost Sharing Structure Tier 1 (Up to 50.00% FPL) Tier 2 ( % FPL) Tier 3 (101.00% FPL and above) Service TIER 1 TIER 2 TIER 3 Inpatient Hospital (Acute Care 11x) $0 $35 $75 Office Visit (Physicians and Nurse Practitioners) ( , only for office visits for new and $0 $2 $4 established patients based on level of care) Non-Emergency use of Emergency Department - Hospital only (Lowest level (99281) of Emergency Room visits in hospitals. The definition of this visit is an emergency department visit for the evaluation and management of a $8 $8 $8 patient, which requires these 3 key components: A problem focused history; A problem focused examination; and straightforward medical decision making.) Any outpatient surgical services rendered in a physician s office, ASC or Outpatient Hospital excluding emergency rooms. $0 $2 $4

9 Effective May 1, 2014, co-payments will be assessed on the total allowed charge for the prescription, regardless of preferred or nonpreferred status. The table below displays the new co-payment structure. All member categories previously excluded from co-pays will continue to be excluded. Total Allowed Charge $0.00-$5.00 $0.00 $5.01-$10.00 $0.50 $10.01-$25.00 $1.00 $25.01-$50.00 $2.00 $50.01 and above $3.00 Co-payment

10 The OOP is the most the Member will ever be required to pay in any given quarter regardless of the number of healthcare services received. Cost sharing cannot exceed 5% of the Medicaid members quarterly household income. Each calendar year quarter, Members will have a maximum out of pocket (OOP) payment respective to their tier level. Tier Level Out of Pocket Maximum 1 $8 2 $71 3 $143 After July 1, 2014, members quarterly OOP maximum costs will be based on pharmacy, medical and dental co-payments combined.

11 The following populations and services are exempt from copays: Pregnant Women including pregnancy-related services up to 60 days post-partum; Children under age 21; Native American and Alaska natives; Intermediate Care Facility or MR services; Preventive services; Individuals in Nursing Homes, Receiving Hospice services, Medicaid Waiver services, Breast and Cervical Cancer Treatment Program; Family Planning services; and Emergency services. Additional exemptions for Pharmacy include diabetic testing supplies syringes and needles, BMS approved Home Infusion supplies and 3-day emergency supplies.

12 Cost sharing information is listed on the following: AVRS 271 transaction Molina Web Portal Molina will return a copay amount for the start date of service if the provider inquires on a date range. No copays will be listed for members on the exemption list. Remittance advices will be modified to include the copay amount that was deducted.

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16 Starting January 10, 2014, approved hospitals could start making Medicaid presumptive eligibility determinations. Only hospitals which were Medicaid providers were allowed to apply for HBPE. 16

17 HBPE should be offered to individuals who are not already enrolled in Medicaid, may be eligible for Medicaid, and are West Virginia Residents, AND are a member of one or more of the following groups: Children under Age 19 Pregnant Women Adults between ages 19 and 64 Former West Virginia Foster Care Children under age 26 Certain Individuals Needing Treatment for Breast or Cervical Cancer 17

18 Individual or a person with reasonable knowledge must attest to the information provided on the HBPE questionnaire. HBPE begins either on the date the determination is made or in certain cases 24 hours prior to the determination. End date of HBPE period is the earlier of: The date the eligibility determination for regular Medicaid is made or The last day of the month following the month in which the determination of presumptive eligibility is made if no application for Medicaid is filed by that date. 18

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20 BMS will be tracking each hospital s performance as dictated by the following measurements: 1. 75% of patients who have been approved for HBPE have followed up and filled out the full Medicaid application prior to their designated case expiration date % of patients found eligible for HBPE and who have completed the full Medicaid application were found eligible for full Medicaid benefits. 20

21 Background State Medicaid programs can cover hospital costs for incarcerated individuals that qualify for Medicaid and leave their correctional facility to be hospitalized for at least 24 hours. Maximizing HBPE Functionality Multi-Agency Initiative 21

22 Medicaid Management Information System (MMIS) Implementation Data Warehouse/Decision Support System Implementation Annual ID Card T-MSIS 22

23 Take Me Home, West Virginia Detailed information packet & Technical Assistance available for providers selected as service agency Traumatic Brain Injury (TBI) Waiver Program Applicants may be inpatient, at home or in community setting BMS TBI Program Manager: Teresa McDonough TBI Program Contact Information Phone:

24 Telehealth Section added to both Behavioral Health Clinic (Chapter 502) and Behavioral Health Rehabilitation (Chapter 503) Foster Children must be given priority for all Assessment and Evaluation Services Assertive Community Treatment (ACT) will be reviewed based on fidelity factors 24

25 Changes to ADW eligibility timelines to expedite enrollment process once a slot becomes available. Policy change will require applicant be enrolled in the program within 60 days of receiving the slot. Certified Letters being sent now when slot becomes available. Policy change to set timeline of 15 days to respond to letter. If letter is not picked up within 15 days, BMS will attempt contact by phone. If no contact can be made, the slot will be reassigned. Important: Members on the Managed Enrollment List must keep BMS apprised of any change in their address and/or phone numbers. 25

26 Hospice - Chapter 509 Revised version effective May 1, 2014 Face to Face encounter requirement 42CFR Concurrent Care for Children ACA, Section 2302 Hospice services may be provided to children under age 21 concurrently with curative treatment. Prior Authorization (PA) for Hospice Services Requests with diagnosis of ONLY failure-to-thrive or dementia require documentation of additional qualifying diagnoses based on Federal and State regulations Revenue codes for Community Care & Inpatient Care require PA Hospice Care in Nursing Home (Revenue code 0658) requires PA for reimbursement APS Healthcare, Inc. to begin pricing hospice service as part of PA 26

27 Early Fall 2014, changes to coverage for Drug Screening, including but not limited to: Max of 24 drug screens per calendar year PA required for services over the limit Not covered: Specimen integrity testing, urine alcohol testing, & confirmatory testing, performed on the same day of service as a standard drug test Certain quantitative drug screens, when performed on the same day as a drug screen service Pre-Employment/employment, medicolegal, school-related or court ordered drug screenings 27

28 On 4/1/14, President Obama signed bill that included delay of ICD-10 until October 1, 2015 at earliest Molina and BMS are continuing ICD-10 preparations BMS ICD-10 BMS ICD-10 webpage ICD-10 Testing with Providers ICD-10 Readiness Survey Policy Remediation for ICD-10 New policy format recommended by CMS Current policy being revised and will be released in new format 28

29 NOTE: This is a sample of the new policy format that BMS will be using when existing policy is remediated for ICD-10. This is not an actual policy. 29

30 April 1, 2014 PTP edits related to immunization administration with E&M services If MUE is less than units billed, entire claim line denied Appeals for PTP and MUEs to Molina Reviewed by Certified Coder BMS Medical Director review, as appropriate 30

31 Ordering/Referring/Prescribing provider that does not bill WV Medicaid directly If ORP not enrolled in WV Medicaid, then servicing provider claim will not be paid Edits to be implemented later this year Initially edits will be implemented with warning message and claim will not deny After short period, edit will be set to deny claim Edit for required ORP info by summer Edit for enrollment status of ORP by end of

32 Beginning May 2014 Letter or to Providers from Phases 1 through 4 who have not completed revalidation If no response, then BMS will place provider names, NPI and address on website 2 weeks later Payhold After 120 days on payhold - Participation with WV Medicaid will be terminated Process will continue with all provider phases All providers must be revalidated by January 1,

33 CMS Adult Quality Measures, including but not limited to: Adult BMI Assessment Chlamydia, Breast & Cervical Cancer Screening Diabetes Care Hypertension Prenatal and Postpartum Care Post-hospitalization follow-up for Mental Illness June 2014, Medical Record Requests 33

34 Recovery Audit Contractor Reprocurement initiated Target date = end of summer 2014 PCP Enhanced Payment audits underway MIG audits Hospice reviewing records Labs identifying providers 34

35 DME BMS does not enroll Out-of-State DME providers unless supplier is sole source DME Suppliers cannot provide the diagnosis or clinical documentation on the Certificate of Medical Necessity form. The diagnosis and/or clinical documentation must be provided by the ordering practitioner. Transportation Claims Must include pickup and destination modifiers Self-Disclosure Follow instructions on website Impact of Failure to Disclose on Provider Enrollment 35

36 Pediatric Dental Services transitioned to Managed Care January 1, 2014 All WV Medicaid MCOs currently use Scion as Dental Benefit Manager Dental Billing Guide on BMS website Dental Prior Authorization (PA) Requests Medicaid members in MCO to Scion Foster children and Medicaid members not enrolled in MCO to APS Healthcare, Inc. 36

37 WV Bureau for Medical Services ( ) 350 Capitol Street, Room 251 Charleston, WV To send an to BMS, go to website below, complete text boxes, & submit Medicaid Member Services ( ; ) Medicaid Provider Services ( ; ) Medicaid Pharmacy Help Desk ( ) Rational Drug Prior Authorizations ( ) APS Healthcare Customer Service ( , ext. 6954) Clinical Support - WVMI: ( ) 37