West Virginia Children s Health Insurance Program (WVCHIP) Crystal Fox, Benefit and Eligibility Specialist Fall 2017 Provider Workshop

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1 West Virginia Children s Health Insurance Program (WVCHIP) Crystal Fox, Benefit and Eligibility Specialist Fall 2017 Provider Workshop

2 Annual Income Guidelines for WVCHIP Family Size Medicaid Max WVCHIP Gold WVCHIP Blue WVCHIP Premium 2 $21,599 $24,360 $34,267 $48,720 3 $27,158 $30,630 $43,087 $61,260 4 $32,717 $36,900 $51,906 $73,800 5 $38,277 $43,170 $60,726 $86,340 6 $43,836 $49,440 $69,546 $98,800 1

3 Coverage Medical Services and WVCHIP Gold WVCHIP Blue WVCHIP PREMIUM Prescription Benefits Generic Prescriptions No Copay No Copay No Copay Listed Brand Prescriptions $5 $10 $15 Non-listed Brand Prescriptions Full Retail Cost Full Retail Cost Full Retail Cost Multisource Prescriptions 2 No Copay $10 $15 Medical Home Physician No Copay No Copay No Copay Visit Physician Visit (non-medical home) $5 $15 $20 Preventive Services No Copay No Copay No Copay Immunizations No Copay No Copay No Copay Inpatient Hospital No Copay $25 $25 Admissions Outpatient Surgical Services No Copay $25 $25 Emergency Department (is waived if admitted) No Copay $35 $35 Vision Services No Copay No Copay No Copay Dental Benefit No Copay No Copay $25 Copay for some non-preventive services

4 PERM Audit Payment Error Rate Measurement (PERM) measures improper payments in Medicaid and CHIP and produces error rates for each program. The current PERM cycle is reviewing Medicaid and CHIP Fee For Service (FFS) payments made by states October 1, 2015 September 30, Cycle 2, which includes West Virginia, closed August 15, 2017, and we will receive the results in November Our next cycle will run October 1, 2018 through September 30,

5 Medical Home Eligible Medical Home provider types are General Practice, Family Practice, Internal Medicine, and Pediatricians. Any Physician Assistant (PA) or Nurse Practitioners (NPs) practicing under these specialties is considered a back-up Medical Home provider and will not be assessed a copay when the supervising physician is the named Medical Home provider. Please note: the physician group/facility must also select to be a Medical Home provider along with the rendering provider. To become a Medical Home provider, please contact Molina Provider Enrollment at Encourage your patients to enroll in the Medical Home program, WVCHIP will waive the copay for sick visits and increase your reimbursement by the copay amount. WVCHIP should not be confused with Public Employees Insurance Agency (PEIA) who increased their Medical Home copays effective July 1,

6 Provider Enrollment The Affordable Care Act requires all providers to enroll or revalidate their enrollment information under new enrollment screening criteria. Enrollment and revalidation is mandatory for both Medicaid and WVCHIP providers. Enrollment in Medicaid does not fully enroll the provider in WVCHIP. Provisional enrollment will end September 30, Any provider not fully enrolled in the WVCHIP Plan will be terminated effective September 30, 2017 and claims will no longer be paid. To enroll in WVCHIP, contact Molina at , or , or online at 5

7 Out-of-State Providers WVCHIP will waive the out-of-state prior authorization requirement if the provider agrees to accept WVCHIP in-state fees as payment in full with no balance billing to the member. This agreement can be made during provider enrollment or any time thereafter by calling the provider enrollment department at Molina. WVCHIP uses the PEIA fee schedules. Go to to see PEIA fees. Dental fees can be found at: 6

8 Orthodontic Treatment Comprehensive orthodontic treatment is payable once per lifetime. Coverage is not automatic and must be prior authorized to be covered. Information should be mailed to: WVCHIP Orthodontic PA Request 350 Capitol Street, Room 251 Charleston, WV Information required for review: Panoramic film Cephalometric x-ray A standard series of 5 Intra and 3 Extra Oral photographs that meet the American Board of Orthodontic standards Treatment plan including findings, prognosis, length of treatment, and phases of treatment 7

9 Procedures Requiring Prior Authorization Abortion Nonemergency ambulance transport and hospital-to-hospital transport All inpatient admissions to hospitals/facilities (in-state and out-of-state) All admissions to rehabilitation or skilled nursing facilities Any potentially experimental/investigational procedure, medical device, or treatment Applied Behavioral Analysis treatment Chelation therapy Chiropractic services for children under age 16 Continuous glucose monitors Cosmetic/reconstructive surgery as a result of accident or birth defects CT scan of sinuses or brain - outpatient CTA (CT angiography) - outpatient Dental ridge reconstruction DEXA scans (dual energy x-ray absorptiometry) Dialysis services - outpatient 8

10 Procedures Requiring Prior Authorization (cont.) Durable medical equipment purchases of $1,000 or more, or rental more than 3 months Endoscopic treatment of Gastro-esophageal Reflux Disease (GERD) Hearing aids Heart Perfusion Imaging Home health care: exceeding 12 skilled nursing visits Hospice care IMRT (intensity modulated radiation therapy) - outpatient Hyperbaric Oxygen Therapy (HBOT) I.V. therapy in the home MRI scan of the breast, knee or spine (cervical, thoracic, and lumbar) Orthotics/prosthetics over $1000 Oral surgeries including orthognathic surgery Outpatient therapy services including occupation, physical, speech, and vision therapy beyond 20 visits PET Scans Sleep apnea services and equipment 9

11 Procedures Requiring Prior Authorization (cont.) SPECT (single photon emission computed tomography) of brain and lung Stereotactic Radiation Surgery and Stereotactic Radiation Therapy All inpatient surgical procedures Outpatient surgeries as listed below: cataract cochlear implants colonoscopy hysterectomy implantable devices including, but not limited to: implantable pumps, spinal cord stimulators, neuromuscular stimulators, and bone growth stimulators knee arthroscopy septoplasty or submucous resection spinal surgery including artificial disc, laminectomy, and/or fusion uvulopalatopharyngoplasty 10

12 Procedures Requiring Prior Authorization (cont.) Transplants and transplant evaluations (including, but not limited to: kidney, liver, heart, lung and pancreas, small bowel, and bone marrow replacement or stem cell transfer after high dose chemotherapy) (TTE) Transthoracic Echocardiogram Submit Prior Authorization Requests to: HealthSmart PO Box 2451 Charleston, WV

13 Resources Eligibility, application status, renewals and general information: WVCHIP HelpLine at Claims, benefits, and eligibility: Molina at Prior-authorizations: HealthSmart at Prescription drug benefits: CVS at Provider enrollment: Molina at

14 Contact Crystal Fox Benefits & Eligibility Specialist WVCHIP West Virginia Department of Health and Human Resources 350 Capitol Street, Room 251 Charleston, WV Phone: Fax: Follow DHHR on Facebook and Twitter for WVCHIP related announcements and information. 13