Healthy Connections Medicaid Update. Dr. Tan Platt, Medical Director South Carolina Department of Health and Human Services August 13, 2017

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1 Healthy Connections Medicaid Update Dr. Tan Platt, Medical Director South Carolina Department of Health and Human Services August 13, 2017

2 Medicaid Overview 2

3 Healthy Connections Medicaid Healthy Connections Medicaid is the name of South Carolina s Medicaid program Managed by the South Carolina Department of Health and Human Services (SCDHHS) Individuals who meet certain categorical, financial and non-financial requirements may qualify for benefits Eligibility is determined through an application process 3

4 Medicaid Explained Jointly funded by state and federal governments NOT the same thing as Medicare The federal government requires certain mandatory coverage groups and benefits The federal government gives states the right to provide for optional coverage groups and benefits so eligibility can vary from state to state 4

5 Who is Eligible for Healthy Connections Medicaid? Children under age 19 Individuals receiving cash assistance such as Supplemental Security Income (SSI) Individuals age 65 or older, blind or disabled Pregnant women Families with dependent child(ren) Individuals diagnosed and found to need treatment for either breast or cervical cancer, or pre-cancerous lesions Individuals qualifying for family planning, a limited benefit package that is not the same as full Medicaid 5

6 Medicaid Mandatory Services/Providers Physicians, mid-wives, certified nurse practitioners Hospital inpatient and outpatient services Laboratory and x-ray services Family planning services and supplies Rural health clinics and federally qualified health centers Home health care for adults Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services 6

7 Medicaid Optional Services Prescription drugs Dental care Vision services Hearing aids Personal care services for the frail, elderly and disabled 7

8 Millions Changes in Fund Balances $600 $500 $400 $300 $200 $100 $- FY FY FY FY FY FY (Estimated) Funds Available 3% Reserve Target FY (Budget) The year-end projections for FY and assume: Proposed changes in dental rates occur, even without a funded decision package. Either the DSH cuts do not occur, or if they do, then the excess matching funds are used to raise hospital rates. 8

9 South Carolina Medicaid Enrollment Full Medicaid Members: 1.05 million* Limited Medicaid Members: 207k* 64% of Medicaid members are age 0 to 18 Roughly 60% of all children in SC are on Medicaid *as of July 2017, to account for six-month look back 9

10 Full-Benefit Members and Expenditures % of Enrollment % of Expenditures Children Disabled Adults Other Adults Elderly Children Disabled Adults Other Adults Elderly Children represent almost 64% of enrollment, but only 33% of projected expenditures Disabled adults make up approximately 13% of enrollment, but account for over 34% of projected expenditures 10

11 South Carolina Healthy Connections Medicaid Initiatives 11

12 South Carolina Reporting and Identification Prescription Tracking System (SCRIPTS) 12

13 Opioids 13

14 Governor s Task Force In response to OIG report highlighting SC s lack of a plan to address the growing epidemic of opioid abuse and overdose State Plan to Prevent and Treat Prescription Drug Abuse; released on December 1, 2014 Mandatory use of the PDMP was one of the strongest recommendations 14

15 Licensing Boards November 2014: Joint Revised Pain Management Guidelines Approved by the SC Boards of Medical Examiners, Dentistry, and Nursing It will be considered the standard of care to assess and evaluate the current status of pain treatment prior to initiating new treatment or adjusting current treatment. The registration and utilization of SC PMP is considered mandatory for prescribers to provide safe, adequate pain treatment. 15

16 SCDHHS Policy Beginning April 1, 2016, Medicaid required that providers must assess a patient s controlled substance prescription activity through SCRIPTS before issuing a prescription for any controlled substance Schedules II, III, IV Provider must maintain documentation that the SCRIPTS database was evaluated prior to the issuance of the prescription Failure to perform an evaluation of the SCRIPTS data will result in recoupment of Medicaid funds for the office visit during which the prescription was issued 16

17 Exceptions to Mandatory PDMP Use The following instances are exempt from this requirement: Issuance of less than a five-day supply of a controlled substance Issuance of a controlled substance prescription to a Medicaid member who is enrolled in hospice Instances where a controlled substance is administered by a licensed healthcare provider ex. nursing home, assisted living or ICF-MR Instances where the SCRIPTS system is unavailable Patients on chronic therapy should be assessed at initiation and at least every 90 days 17

18 Other Drug Issues Hepatitis C medications Spinraza-Spinal Muscle Atrophy Emflaza-Muscular Dystrophy Acthar-Lupus nephritis and other indications 18

19 Telemedicine 19

20 Overview Telemedicine is the delivery of medical care via secure, electronic communications from one site to another Telemedicine is a tool can help to minimize many accessrelated issues by introducing local services into communities where they were previously unavailable Coverage of telemedicine services began in 2011 SCDHHS monitors trends and regularly evaluates policy for any appropriate updates or additions Benefits: Increase access to care Address provider shortages Ease burden of travel/transportation 20

21 Covered Services: Office or other outpatient visits ( ) Inpatient consultation ( ) Psychotherapy (90832, 90834, 90837) Psychiatric diagnostic interview examination (90791, 90792) Neurobehavioral status examination (96116) Electrocardiogram interpretation and report only (93010) Echocardiography (93307, 93308, 93320, 93321, 93325) Referring Sites: The office of a physician or practitioner Hospital (Inpatient and Outpatient) Rural Health Clinics and Federally Qualified Health Centers Community Mental Health Centers Schools Approved Providers: Physicians Nurse Practitioners Physician Assistants Policy 21

22 SC Telehealth Alliance Increased involvement with telemedicine came through its inclusion in the budget proviso beginning in 2013, when SCDHHS was directed to allocate funds to MUSC Hospital Authority for the growth of telemedicine Since 2013, the budget proviso has called for the development of a statewide, open access telemedicine network, which came to be known as the South Carolina Telehealth Alliance (SCTA) The SCTA is a collaboration of health systems, hospitals, providers, payers and state agencies SCTA mission - to improve health in SC through telehealth Primary responsibility - operationalizing the strategic plans to develop and implement a telehealth network, and grow telehealth in South Carolina 22

23 The SCTA Advisory Council is a group of stakeholders responsible for generating the strategies and tactics included in the annual strategic plan SCTA Advisory Council Representation: Four Regional Hubs (PH-USC, MUSC, GHS, McLeod) Palmetto Care Connections Department of Mental Health Department of Health and Human Services SCETV SC Telehealth Alliance (cont.) Two rural providers Two members of the South Carolina legislature SCDHHS is represented on the SCTA Advisory Council as well as other SCTA subcommittees and workgroups 23

24 Unique Claims Telemedicine Utilization FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 (YTD) Axis Title 24

25 Healthy Outcomes Plans (HOP) 25

26 Proviso Sec A, C, D Medicaid Accountability and Quality Improvement Initiative 26

27 Overview Incentive program to participating communities (hospitals, primary care safety net providers and community organizations) designed to improve health outcomes and reduce system costs through better coordinated care of the uninsured, chronically ill, high-utilizers, or those who will become high-utilizers, of emergency departments and inpatient services 27

28 Participants (as of May 2017): FY17 enrollment target is 13,897 14,960 total enrolled HOP participants; 108% of enrollment goal 96% (14,303) participants under care plan management plans Providers: 100% participation from 56 SC Medicaid-designated hospitals leading 44 HOPs Partnerships: Status/Statistics Estimated 56 Hospitals and 76 Primary Care Safety Net Providers (FQHCs, RHCs, Free Clinics) partnered at 104 sites 30 participating behavioral health clinics (MH and DAODAS 28

29 Successes/Preliminary Evaluation Mean All Emergency Department Visits decreased from 3.14 visit per HOP participant to 2.78 visits Participants demonstrating High Need for behavioral intervention decreased from 66% to 61% Participants with a Level 4 (highest level of engagement according to the Patient Activation Measure) increased from 27.01% to 29.22% $24.8 million in avoided projected 4-yr payments (FFYs 15-18) *Note: These results are based on HOP participants under care plan management for at least six months. 29

30 Nutritional Counseling Initiative Update 30

31 Medicaid Coverage: Nutritional Counseling for Obesity Initiative In April 2013, Obesity (BMI>30) was formally recognized as a disease 13 th highest 31.7% (2015) Approximately 30% of Medicaid recipients are considered obese 31

32 Nutritional Counseling Policy August 1, 2015: SCDHHS launched a nutrition counseling initiative to help change behavior and establish better food choices in our diet by pairing patients with the nutrition experts registered/licensed dietitians! 32

33 The Initiative As part of SCaleDown, SC Obesity Action Plan Improve patient care by enhancing the health care system s ability to effectively diagnose, counsel and refer patients to needed obesity treatment, nutritional counseling and support services Population targets: Those insured under Medicaid Adults with a BMI 30 kg/m2 Children with a BMI 95th percentile Reimbursed services: Six visits with a Primary Care Provider Physician, physician assistant and/or nurse practitioner Six visits with a registered, licensed dietitian 33

34 Billing Basics: Adult Interventions 34

35 Intervention Flow Identification Initial visit with physician, physician s assistant, nurse practitioner. Adult Medicaid beneficiary with BMI 30+. Establishes exercises plan for five subsequent visits and refers to a licensed dietitian. Referral Referral to licensed dietitian for nutritional counseling. Sets appointment. Handles referral process and follow-up. Licensed Dietitian Licensed dietitian reviews physician plan with patient and establishes plan to include follow up during subsequent visits. Reporting Licensed dietitian reports back to referring physician within 48 hours. Shares healthy eating plan and patient compliance. 35

36 Billing Healthcare Common Procedure Coding System (HCPCS) Service Codes HCPCS Code Description Maximum Units S9470 Nutritional counseling, dietitian visit (Initial, individual visit) Limit 1 per year; $27.82 per 30 minute unit/session (Cannot bill more than once per patient per year) S9452 *HB modifier to be added when the visit takes place in a group setting* Nutrition classes, non-physician provider (Individual or group session; group sessions not to exceed 5 patients) Limit 5 per year; $27.82 per 30 minute unit/session (Cannot bill more than once per day per patient)

37 Billing Healthcare Common Procedure Coding System (HCPCS) Service Codes - Physicians HCPCS Codes Modifier Description Maximum Units per calendar year G0447 SC G G0447 HB Annual face to face obesity screening (15 min. session) Initial visit only (USPSTF 5As) Face to face behavioral counseling for obesity (15 min. session) (USPSTF 5As) Group Face to face behavioral counseling 1 Total of 5 subsequent for either group or individual behavioral counseling Total of 5 subsequent for either group or individual behavioral counseling Reimbursement amount is $20 G0447 can be billed in conjunction with an E&M code on initial visit by appending the NCCI 25 modifier to the E&M code

38 Billing International Classification of Diseases (ICD-10) Diagnosis Codes ICD-10 Description ICD-10 Description ICD-10 Description ICD-10 Description Z681 BMI less than 19 Z6827 BMI Z6835 BMI Z6844 BMI Z6820 BMI Z6828 BMI Z6836 BMI Z6845 BMI 70 or greater Z6821 BMI Z6829 BMI Z6837 BMI Z6854 BMI Pediatric, greater than or equal to 95% for age Z6822 BMI Z6830 BMI Z6838 BMI Z6823 BMI Z6831 BMI Z6839 BMI Z6824 BMI Z6832 BMI Z6841 BMI Z6825 BMI Z6833 BMI Z6842 BMI Z6826 BMI Z6834 BMI Z6843 BMI

39 Billing Basics: Pediatrics

40 Guidelines for Pediatricians Pediatricians may address obesity management after diagnosing during EPSDT visit SCDHHS recommends the physician utilize the 5 A s as recommended by the US Preventive Services Task Force Pediatricians can bring a child back for obesity-related visits and utilize existing CPT and ICD-10 codes Also, pediatricians may now refer patients to licensed dietitians for nutritional counseling. Dietitians will use the 97 code series for children 40

41 Billing Healthcare Common Procedure Coding System (HCPCS) Service Codes Document ICD-10 Diagnosis Codes: Z68.54 Pediatric BMI greater than or equal to 95th percentile for age Z71.3 Dietary surveillance and counseling 41

42 Billing HCPCS Service Codes for Licensed Dietitians and Pediatricians RD reimbursement amount is $13.91 per 15 min. session ($27.82 daily max.) All groups are limited to five patients Nutritional counseling units billed are based on a 15-minute time unit session and are limited to two per day with a maximum of 12 in a year. 42

43 Utilization Statistics 105 RD/LDs enrolled as providers in Medicaid FY2017 (July 2016-January 2017) Utilization Report Adults Update Provider claims (G0447) 181 Dietician initial visit claims (S9470) 29 Dietician subsequent visit claims (S9452) 18 Pediatrics Update 12,682 E&M provider claims with obesity diagnosis Initial visit claims (97802) 2, of these were billed by RDs Subsequent visit claims (97803) of these were billed by RDs SCDHHS sent survey to RDs to build statewide map to help providers identify the practicing locations of Medicaid-enrolled RDs 43

44 Challenges Number of visits 12 per year Split 6 RD/6 MD Length of visits 30 min too short for initial Reimbursement Rate $27.82/30 min (RD) Cost-prohibitive for private practice Making the connection MDs may not know local RD RD they do know may not be enrolled in Medicaid Codes new/different 44

45 South Carolina Birth Outcomes Initiative (SCBOI) 45

46 SCBOI Programs Non-medically Necessary Early Elective Deliveries (EEDs) Screening, Brief Intervention and Referral to Treatment (SBIRT) Long-Acting Reversible Contraceptives (LARCs) Inpatient Insertions Baby-Friendly Designated Hospitals and Safe Sleep CenteringPregnancy Supporting Vaginal Births (SVB) Neonatal Abstinence Syndrome Mother s Milk Bank of South Carolina (MMBSC) Safe Sleep Initiative 46

47 CDC Infant Mortality Report 47

48 Infant Mortality cont. South Carolina is 1 of 11 states (and D.C.) that has seen a decline in infant mortality rates of at least 16% Out of the 11 states (and D.C.), South Carolina is 1 of only 3 (Connecticut and Colorado) to see a decline of more than 20% 48

49 Success of Non-Medically Necessary EEDs 77% of all South Carolina birthing hospitals have achieved a 0% rate for nonmedically necessary EEDs at weeks gestation Since launch of the program, the state has achieved a 73% reduction in EEDs overall SC birthing hospitals achieved an overall rate of less than 3% in the third quarter of

50 Utilization through FY % increase associated with inpatient insertion of LARCs for females below the age of 18 74% increase associated with inpatient insertion of LARCs for females above the age of 19 Overall, inpatient LARC insertions now comprise 17% of total LARC use LARC utilization for outpatient insertion increased 10% 50

51 IPI LARC Percentage FY % Inpatient 84% Outpatient 51

52 Centering Cohort Study: Published Featured in Maternal Child Health Journal in 2016 Group Prenatal Care Results in Medicaid Savings with Better Outcomes: A Propensity Score Analysis of CenteringPregnancy Participation in South Carolina. Gareau S, Lopez-Defede A, Loudermilk B, Cummings TH, Hardin JW, Picklesimer AH, Crouch E, Covington-Kolb S. (2016) 52

53 CenteringPregnancy Participants had: Increased breast feeding rates Lower premature birth rates Fewer low birth weight babies Lower gestational diabetes rates Fewer NICU admissions All statistically relevant 53

54 Baby-Friendly Certification Program started in 2013 Since launch, a total of 12 hospitals to date are now Baby-Friendly accounting for 41% of all births and 34% of Medicaid births in SC The national average is 22% 54

55 Mother s Milk Bank of South Carolina Through Dec. 2016, MMBSC has: Received over 100,000 ounces of human milk from 198 approved donor moms Distributed more than 64,144 ounces of pasteurized, donor human milk to SC hospitals for sick infants 55

56 SimCOACH Training: By the Numbers By the end of April 2016, 44 hospitals in SC received the first-year training. Year 2 curriculum started Aug Hemorrhage; pre-eclampsia; breech 628 healthcare professionals from 24 hospitals trained in year 2 curriculum to date 67 physicians 511 nurses 50 other healthcare workers respiratory therapists, nurse midwives, nursing/medical students, etc. 56

57 New Initiatives and Recent Changes 57

58 Safe Sleep Initiative Mission: To eliminate sleep-related infant deaths by providing prevention education and consistent messaging and support to healthcare providers, parents, caregivers and the community Monthly meetings held at 9:30 a.m. at the South Carolina Hospital Association (SCHA), before BOI meetings First meeting was April 12, 2017 Obtaining signed pledge of support from CEOs of all 44 SC birthing hospitals Developing comprehensive toolkit of resources based on the 2016 Safe Sleep Recommendations from the American Academy of Pediatrics (AAP) 58

59 PRTF Effective July 1, 2017, Psychiatric Residential Treatment Facility (PRTF) services are part of the Medicaid managed care benefit Continuation of the transfer of the global behavioral health benefit to the MCOs Allows for better care coordination 59

60 Autism Effective July 1, 2017, autism spectrum disorder (ASD) services are part of the SC State Medicaid Plan Medically necessary services will now be available until the beneficiary turns 21 ASD will be covered by both fee-for-service (FFS) Medicaid and managed care The Pervasive Development Disorder (PDD) waiver will continue through Dec. 31, 2017 PDD waiver participants will transition to the state plan between July 1, 2017-Dec. 31, 2017 More information: 60

61 Elimination of Monthly Prescription Benefit Starting July 1, 2017, there is no longer a prescription limit for adult Medicaid beneficiaries Allows patients with chronic diseases to get all the medications they need to manage their health 61

62 Tobacco Cessation Treatments Effective July 1, all seven FDA approved medications are available for Medicaid beneficiaries without copays or prior authorization required Bupropion for tobacco abuse Varenicline Nicotine gum Nicotine lozenge Nicotine nasal spray Nicotine inhaler Nicotine patch Same for FFS and managed care members SC Tobacco Quitline and web-based counseling available at no charge 62

63 Immunizations As of July 1, 2017, SCDHHS will cover these immunizations for beneficiaries 19 years of age or older: Serogroup B Meningococcal (MenB) Measles, Mumps, and Rubella (MMR) Varicella (VAR) Measles, Mumps, Rubella and Varicella (MMRV) 63

64 Medicaid Dental Benefit 64

65 Covered Dental Procedures Procedure Categories Child < 21 Coverage Adult 21+ Examinations Radiographs Prophylaxis Fluoride Application Dental Sealants Amalgam Restorations Composite Restorations Pre-Fabricated Crowns Build Up/ Post and Core Endodontic Treatment Dentures Periodontal Treatment Orthodontics Extractions Anesthesia/ Sedation 65

66 Dental Benefit: Children Under Age 21 Access 99.4% visited the physician for any reason (includes pediatricians, family physicians, FQHCs and RHCs 53.6% visited the dentist for any reason Utilization 1.8% of children ages 0 to 11 received oral health services (fluoride varnish by a physician)* 4.8% of children ages 0 to 5 received oral health services (fluoride varnish by a physician)* Among those that received fluoride varnish by a physician, only 1 in 6 children received more than one application Key Points Use the medical home to provide oral health services for children Increase utilization of oral health services (fluoride varnish application) *SCDHHS policy allows fluoride varnish up to the 13 th birthday 66

67 Dental Benefit: Adults Ages 21+ Access 100,676 adult patients visited the dentist for any reason Utilization $750 Annual Cap 2,640 adult patients exhausted the benefit (0.5% of those who sought dental services) Oral surgery is #1 service category utilized by adult population along with related sedation services (sedation services, if medically necessary, do not count towards the $750 limit) Key Points Increase awareness among health professionals for referring patients to the dentist Educate patients about the importance of oral health in overall health and managing chronic diseases 67

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