Fall Provider Workshops 2017

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1 Fall Provider Workshops 2017 West Virginia Department of Health and Human Resources Bureau for Medical Services (BMS) Sarah Young, Deputy Commissioner Joy Dalton, Director of Provider Services Dee Ann Price, Quality Unit Director September 18-Flatwoods, WV September 19-Charleston, WV September 20-Huntington, WV September 21-Beckley, WV September 25-Martinsburg, WV September 26-Morgantown, WV September 27-Wheeling, WV September 28-Vienna, WV

2 West Virginia Medicaid Enrollment Update As of August 20, 2017, West Virginia Medicaid covered 555,402 individuals - approximately 30% of West Virginia s population: Fee-for-service (FFS), i.e., traditional/regular Medicaid: 133,135 members are currently enrolled Includes foster care children, Medicaid Waiver recipients, nursing facility residents, elderly/disabled, and those who receive Medicare Mountain Health Trust (MHT), the State s Medicaid Managed Care Program: 422,267 members are currently enrolled Includes most children, pregnant women, adult expansion, parents and caretaker relatives 1

3 Managed Care Update: Carved Out Services What benefits are NOT included in the Managed Care Plans? Transplants Nursing Facility Services Medicaid Waiver Services Aged and Disabled Waiver (ADW) Intellectual and Developmental Disabilities Waiver (IDDW) Traumatic Brain Injury Waiver (TBIW) Non-Emergency Medical Transportation (NEMT)* Personal Care Services Pharmacy For these services, providers will continue to send claims to Molina for all members (FFS and MCO). *NEMT services are provided and paid for by Medical Transportation Management (MTM). 2

4 Managed Care Update: Contacts MCO Contact Information: Aetna Better Health of West Virginia (formerly CoventryCares) Michelle Coon, Chief Operations Officer, phone: , The Health Plan Christy Donohue, Director, Medicaid, phone: , UniCare Health Plan of West Virginia Terri Roush, Manager, Network Relations, phone: , West Virginia Family Health Jason Landers, President, phone: , 3

5 Medicaid 1115 Waiver Proposal SUD Services West Virginia Medicaid is in the final approval stages of the section 1115 waiver application submitted to the Centers for Medicare and Medicaid Services (CMS) that describes an approach to addressing the Substance Use Disorder (SUD) epidemic. Implementation is tentatively scheduled to begin January 1, Medicaid benefit expansions under the waiver include: Statewide adoption of the screening, brief intervention, and referral to treatment (SBIRT) method to ensure a consistent and effective diagnosis and enrollment process. Expanded coverage of withdrawal management in regionally identified settings. Coverage of a set of clinical and peer recovery support services and recovery housing supports designed to promote and sustain long-term recovery. Short term, residential substance abuse treatment for MCO members. Enhanced access to outpatient treatment, as appropriate, when residential treatment is not required. Coverage of methadone and methadone administration as part of the state s opioid treatment program. A comprehensive initiative for distributing naloxone and cross-training staff on administration of naloxone as part of the effort to reduce overdose deaths. 4

6 BMS Program Updates Take Me Home, West Virginia: Supports eligible Medicaid members to transition from facility-based, long-term services and supports to their own homes and apartments in the community. Has two transition navigator partner agencies: Metro Area Agency on Aging (AAA) Coordinating Council for Independent Living (CCIL) Has approximately 11 full-time equivalent (FTE) transition navigators across West Virginia. For more information about Take Me Home, West Virginia: Website: Phone:

7 BMS Program Updates (Cont.) BMS Quality Unit: CMS Adult Quality Measures (AQM) Grant extended to December Reporting to CMS Quality Core Measures. Quality Improvement Projects (QIPs): Prenatal behavioral health risk assessment and postpartum care visit. Implemented in the MCOs January Increasing follow-up rate after hospitalization for mental illness. Implemented in pilot hospital June 2016 November Rate of members keeping follow-up appointment after discharge from the pilot hospital increased by 23.46%. Look for the Quality Corner in Medicaid Provider Newsletter updates. 6

8 BMS Program Updates (Cont.) West Virginia Health Homes: The first Health Homes Program, launched July 1, 2014, for Medicaid members with bipolar disease who have or are at risk of having Hepatitis B or C, was expanded statewide in April Second Health Homes Program launched April 1, 2017 in 14 counties to address the co-occurring conditions of diabetes, pre-diabetes, obesity and have or are at risk of anxiety/depression. To participate in either of these Health Homes Programs, please list your contact information on the workshop evaluation. Additional Health Homes Program information is available on the BMS website: and the KEPRO website: Questions/concerns - contact KEPRO at or

9 BMS Program Updates (Cont.) Medicaid NEMT Broker is MTM (Medical Transportation Management): Recent NEMT statistics: Trips scheduled: July 2017 = 112,537 Calendar Year 2017 to date = 867,789 BMS is currently in the process of reprocuring a vendor to provide NEMT Broker services and hopes to have the new contract awarded by early

10 July 13, 2017: BMS Policy Update Final rule 42 CFR 484 for Home Health in effect, to be implemented by January August 29, 2017: Chapter 527 Managed Care Program was posted for Public Comment. Comments will be processed and posted with final policy update. Upcoming Changes to Provider Enrollment: Direct Care Workers 9

11 June 1, 2017: Provider Enrollment Update West Virginia Medicaid must be in compliance with the Fingerprint Based Criminal Background Check (FCBC) requirement of the February 2, 2011, federal regulations on provider enrollment and screening. FCBC requirement applies to certain provider types enrolled on and after August 1, 2015, including, but not limited to: Home Health Durable medical equipment, prosthetics, orthotics and supply providers (DMEPOS) Providers who have been excluded in the past 10 years Any other providers designated as high risk by BMS or CMS Providers enrolled in Medicare or another state s Medicaid or Children s Health Insurance Program (CHIP) and who have already had a FCBC do not have to undergo another check. 10

12 Provider Enrollment Update (Cont.) West Virginia Medicaid working with West Virginia Clearance for Access, Registry and Employment Screening (WV CARES) Program to implement FCBC process. Providers are responsible for FCBC-related fees. Check must be mailed to Molina prior to fingerprinting. Providers will have 30 days from date of notice to complete FCBC. August 1, 2017: New EFT forms are available on the State Auditor s Website ( to be completed with new enrollment and maintenance. December 31, 2017: All current MCO providers must be enrolled with West Virginia Medicaid or the MCO will terminate the provider contract. 11

13 Provider Enrollment Update (Cont.) January 1, 2018: Molina will begin screening new MCO network providers who must have a participation agreement in effect with the State Medicaid agency, even if they do not plan to participate in the Medicaid FFS program. Managed Care Federal Rule (March 2016) stated Medicaid has ultimate responsibility for screening, enrolling, and periodically revalidating all Medicaid MCO network providers. MCO network providers will also be subject to revalidation. June 1, 2018: Cycle 2 Provider Revalidation will begin for West Virginia Medicaid providers which will include MCO providers, as applicable. Provider Revalidation is required at least every five years for Medicaid providers under 2011 Federal regulations for Provider Screening and Enrollment. Revalidation date is based on most recent effective date. 12

14 Provider Enrollment Update (Cont.) Since August 2015, specific West Virginia Medicaid enrolled providers have the opportunity to determine presumptive eligibility: Hospitals Federally qualified health centers Rural health clinics Comprehensive community behavioral health centers Free clinics Entities interested in becoming an approved presumptive eligibility provider must: Be a Medicaid enrolled provider, Submit a presumptive eligibility enrollment package to BMS, and Complete an online training course. Medicaid Presumptive Eligibility Program information: 13

15 Provider Enrollment Edits Unenrolled Prescriber Edit: West Virginia Medicaid has opted for a phased-in approach for remaining unenrolled prescribers to mirror Medicare s approach. Unenrolled Prescriber Edit means that prescriptions (new or refill) written by providers who are not enrolled with West Virginia Medicaid on January 1, 2019, will be denied. This edit applies to all providers who prescribe, including those newly eligible to enroll as part of revalidation (i.e., hospital residents, physician assistants). 14

16 Program Integrity Update Provider Screening of Employees and Contractors: West Virginia Medicaid is required by CMS to direct providers to: Screen employees and contractors for excluded persons to prevent Medicaid payments for items/services furnished or ordered by excluded individuals and entities. Search the Office of Inspector General s List of Excluded Individuals and Entities (LEIE) monthly to capture new exclusions or reinstatements that occurred since the last search. LEIE s online searchable database: 15

17 Goals and Objectives: Medicaid ID Cards Achieve administrative savings Maximize investment in eligibility verification technology MMIS web portal: Molina Automated Voice Response System (AVRS) ( ) Aligns with feedback from Spring 2017 Provider Workshops 99% report having access to the internet 89% indicate they already use portal and/or AVRS 75% indicate that less than 50% of members bring cards to appointments 16

18 BMS Resources West Virginia Department of Health and Human Resources, Bureau for Medical Services (West Virginia Medicaid) Mailing address: 350 Capitol Street, Room 251 Charleston, WV Telephone: Website: Medicaid Fee-for-Service (FFS) Molina Fiscal Agent: KEPRO (formerly APS Healthcare) UM Contractor: HMS TPL Contractor: Medicaid Managed Care (Mountain Health Trust) Maximus Enrollment Broker: MCOs Aetna Better Health of WV, The Health Plan, UniCare, & WV Family Health Scion Dental Benefits Manager: FFS & Managed Care MTM NEMT Broker: Phone: Fax:

19 Pharmacy Program Update West Virginia Department of Health and Human Resources Bureau for Medical Services (BMS) Vicki Cunningham, Director of Pharmacy Services Bill Hopkins, Pharmacy Operations Manager Brian Thompson, Drug Utilization Coordinator

20 Medicaid Pharmacy Services Benefit On July 1, 2017, Pharmacy Services were carved out of Managed Care Benefit. Prior Authorization Vendor - Rational Drug Therapy Program Phone: FAX: Provides prior authorization service for prescriptions written for self-administration or to be administered in the home setting (home infusion). Billed by the pharmacy with a National Drug Code (NDC). Cannot provide prior authorization services for drugs to be administered in an infusion center or a prescriber s office and billed with a J Code (known as Buy and Bill). BMS maintains that prescribers have the right to determine the most appropriate site of administration for their patients medications to assure safe and effective treatment. 19

21 Medicaid Pharmacy Service Benefit: Exceptions FFS Covers: Prescriptions dispensed by a pharmacy to be administered at home AND obtained by the member ONLY with a prescription Clotting Factor for Hemophilia Spinraza MCO Covers: Drugs administered in an office setting, facility, or infusion center, billed with J-Codes/HCPCS code. Administration of these drugs 20

22 Medicaid Pharmacy Service Benefit: Exceptions If a prescription is written for the following drugs, they will be covered by the FFS Pharmacy Program, but can be administered in the prescriber s office. If prescribers choose to buy and bill these products with a J Code, they should check with the MCO first to assure coverage. Depo-Testosterone Injectable Progestin Contraceptives Vaccines Synagis Remicade Lupron Depot IVIG Neulasta Neupogen Oncology Agents Makena NOTE: Drugs billed as medical claims with a J Code must be billed to the MCOs. Prescriptions written for a pharmacy to fill are billed to the FFS Pharmacy Program. 21

23 Medicaid Pharmacy Services Benefit: Contacts West Virginia Medicaid Pharmacy Services Office: Prior Authorization Vendor - Rational Drug Therapy Program: Phone: FAX: Molina Provider Services: Phone: Molina Pharmacy Help Desk: Phone:

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