Presentation Overview Overview of Medicaid Coverage Policies for Perinatal Care Rachel Currans-Henry, MPP Director, Bureau of Benefits Management Division of Medicaid Services April 23, 2018 1. Importance of perinatal coverage policies to Medicaid 2. Who is eligible 3. What benefits are available 4. Additional HMO responsibilities and programs 5. Resources Division of Medicaid Services 2 Medicaid Births Year Wisconsin Medicaid Percent 2012 66,493 32,837 49.4 2013 66,595 33,588 50.4 2014 67,119 32,315 48.1 2015 67,004 31,505 47.0 2016 66,593 30,750 46.2 Medicaid Births In calendar year 2016, Wisconsin Medicaid covered 30,750 (46.2%) state births. The majority of these births were to women enrolled in a managed care organization (MCO). o MCO births: 19,837 (64.5%) o Fee-for-service (FFS) births: 10,913 (35.5%) Division of Medicaid Services 3 Division of Medicaid Services 4 Medicaid Births 2016 Wisconsin Medicaid Non-Medicaid Number of Births 66,593 30,750 (46.2%) 35,843 (53.8%) Adequate Prenatal Care 47,634 (71.5%) 18,882 (61.4%) 28,752 (80.2%) Premature ( 36 weeks) 6,373 (9.6%) 3,561 (11.6%) 2,812 (7.8%) Low Birth Weight (< 5.5.lbs) 4,938 (7.4%) 3,051 (9.9%) 1,887 (5.3%) Eligibility Pregnant Women Wisconsin Medicaid covers pregnant women with incomes up to 300 % of the federal poverty level (FPL). Per federal law, there is no asset test for pregnant women. Medicaid eligibility can be backdated to the first of the month up to three months prior to the month of application. Division of Medicaid Services 5 Division of Medicaid Services 6 1
Pregnant women are eligible for coverage through the end of the month in which the 60 th post-partum day occurs. Other health insurance coverage does not preclude Medicaid coverage, as Medicaid pays last. Pregnant women are generally eligible for the duration of the pregnancy. Division of Medicaid Services 7 After the 60-day postpartum period ends, the eligibility system determines if her eligibility can continue under another health care category, for example: parents or caretakers. Division of Medicaid Services 8 Women are not automatically evaluated for Family Planning Only Services (FPOS) eligibility, but can submit an application. FPOS income limit is at 300% FPL. Household size is always one (the applicant). Individuals may apply: Online at access.wisconsin.gov. By phone. In person at their local income maintenance agency. By completing a paper application and mailing it to the local agency. Division of Medicaid Services 9 Division of Medicaid Services 10 Pregnant women are allowed immediate access to health care coverage through presumptive eligibility (PE). Coverage determined by health care providers Income limit same as for continuous coverage Women covered for ambulatory services only (no inpatient care) The PE period begins on the day eligibility is determined and continues through the end of the following month. One PE period per pregnancy Services delivered FFS during the PE period Division of Medicaid Services 11 Division of Medicaid Services 12 2
Eligibility Newborn Mothers must report the newborn within 10 days of the birth, and Medicaid will add coverage for the infant as soon as we are notified. In many cases the hospital or HMO reports the birth. Physicians and other obstetric care providers report if the baby is born outside of hospital setting. Eligibility Newborn, continued Babies born to Medicaid mothers: Are Medicaid-eligible for the first 12 months with no limit on income. Are referred to as continuously eligible newborns (CENs). Division of Medicaid Services 13 Division of Medicaid Services 14 Eligibility Newborn, continued Babies born to non-medicaid mothers do not meet the criteria for CENs but the mother may apply for Medicaid coverage for the newborn. The hospital (or other health care provider) can make a PE determination for the baby. PE cannot be backdated; it begins on the eligibility determination date. Division of Medicaid Services 15 Eligibility Newborn, continued When applying for ongoing coverage, the mother can request retroactive coverage for the baby to include the date of birth, if necessary. Division of Medicaid Services 16 Eligibility Newborn, continued Babies are assigned their own Medicaid ID and are issued a ForwardHealth card. If mother is in an HMO, the baby is enrolled in the same HMO. The HMO provides outreach and care coordination for the mother and baby. The HMO assists with identifying a primary care provider for the newborn, if necessary. BadgerCare Plus Prenatal Program Covers pregnant women who meet BadgerCare Plus eligibility criteria but who do not qualify because of their immigration or citizenship status or who are in prison or jail. PE not an option for these women. All Medicaid-covered services are allowed, including prenatal care, prenatal vitamins and other prescription drugs, and hospital stay. Division of Medicaid Services 17 Division of Medicaid Services 18 3
Emergency Medicaid Non-qualifying aliens who do not apply for the BadgerCarePlus Prenatal Program are covered for labor and delivery only. The mother s prenatal and post-partum care are not covered. Newborns born to these mothers are eligible for continuous eligibility coverage. Division of Medicaid Services 19 Medicaid and BadgerCare Plus Benefits Wisconsin Medicaid covers all services allowed under Federal Medicaid laws. Federal law mandates coverage of certain services, while making others optional. For example, coverage of hospital services is mandatory, but coverage of prescription drugs is optional. Comprehensive preventive and pregnancy-related services are covered with no copays. Division of Medicaid Services 20 Preventive and Pregnancy -Related Services Prenatal Vitamins Prenatal vitamins o Covered for females of childbearing age o Prior to May 2015, covered only for pregnant and lactating women Iron (ferrous gluconate/ferrous sulfate) o Covered for adults and children o No diagnosis or age restrictions Preventive and Pregnancy -Related Services Prenatal Vitamins, continued Folic acid for women of childbearing age with no prior authorization or diagnosis restriction Makena and 17-P (compound) injections o Providers must attest that the member meets the clinical criteria for administration of the injection. o Medical professional must administer these as pharmacies are not reimbursed. o Medicaid covers both on a FFS basis. Division of Medicaid Services 21 Division of Medicaid Services 22 Drug Utilization ForwardHealth prospective drug utilization review system: Alerts pharmacists if a drug is contraindicated for pregnant women. Allows pharmacists to make a professional judgement on whether to proceed with dispensing the drug. Division of Medicaid Services 23 Tobacco Tobacco cessation drugs and counseling Tobacco cessation drugs, over-the-counter (OTC) and prescription o Includes nicotine gum, patches, or lozenges o All products, including OTC require a written prescription Diagnosis restriction applies Medication therapy management covered o Pharmacist can talk about available options Division of Medicaid Services 24 4
Opioids Wisconsin Medicaid covers all FDA-approved medications for the treatment of opioid use disorders Buprenorphine tablets o Covered for pregnant women ages 16 and older o Prior authorization required Counseling Wisconsin covers substance abuse counseling. The reimbursement rate increased on January 1, 2018. Division of Medicaid Services 25 Division of Medicaid Services 26 Weight Management Services Covered as an evaluation and management visit Five visits per calendar year, then prior authorization Prescription drugs, with prior authorization Screenings Screening services, including depression screening, pap tests, mammograms, and other medically necessary screenings identified by the health care provider. Division of Medicaid Services 27 Division of Medicaid Services 28 Obstetric Care Services Full coverage of obstetric care services, including prenatal care, labor and delivery, ultra-sound, and labs Elective cesarean sections reimbursement same as vaginal delivery Contraceptives and Supplies Immediate postpartum long-acting reversible contraceptives (LARCs) o LARC methods include intrauterine devices or systems and contraceptive implants o Additional payment to hospitals Breastfeeding supplies, including breast pumps Division of Medicaid Services 29 Division of Medicaid Services 30 5
Obstetric Care Services Covered In addition to physicians, obstetric care services covered when provided by: Nurse practitioners. Nurse midwives. Licensed midwives (since January 1, 2017) with reimbursement limited to office, home or birthing center (no facility fee). Obstetric Care Services Covered, continued Many obstetric care procedure codes are eligible for an enhanced fee if provided in a Health Professional Shortage Area (HPSA): Newborn care Preventive medicine codes Office visits (new and established patients) Emergency department visits Division of Medicaid Services 31 Division of Medicaid Services 32 Care Coordination or Case Management Prenatal care coordination (PNCC) services Statewide benefit targeted to pregnant women at risk of having a poor birth outcome Include outreach, care coordination, health education, and nutritional counseling Providers required to administer an initial, comprehensive assessment using a standardized tool Division of Medicaid Services 33 Postpartum Period At least one face-to-face PNCC visit during the postpartum period is required. Mothers are encouraged to choose a primary health care provider for their baby. Visit addresses the importance of immunizations and regular well-child checkups (i.e., HealthChecks) for the baby. Division of Medicaid Services 34 Memorandum of Agreement PNCC providers must sign a memorandum of agreement (MOU) with HMOs. The HMO and PNCC agency must designate at least one individual as the key point of contact. If requested by the HMO, PNCC providers are required to share a copy of the completed Pregnancy Questionnaire within two days. Division of Medicaid Services 35 PNCC providers are required to make written contacts with Medicaid-enrolled primary care providers, including obstetric and pediatric care providers. PNCC services are reimbursed on a FFS-basis for women enrolled in a Medicaid HMO. Division of Medicaid Services 36 6
Care Coordination Child care coordination in Milwaukee County and the city of Racine does not provide direct services, just care coordination activities. Targeted case management is primarily a countybased program that does not provide direct services, just care coordination activities. Family Planning Drugs and supplies, including coverage of contraceptive methods from condoms and LARCs to sterilization, per the member s choice Counseling and education Sexually transmitted disease testing and treatment Related lab and radiology Division of Medicaid Services 37 Division of Medicaid Services 38 Screening Mental health and substance abuse screening for pregnant women: Includes screening for substance use, depression, and trauma. Requires no particular screening tool but tool must be evidence-based (e.g., AUDIT or PHQ-9). One screening is allowed per pregnancy and is billed using the procedure code H0002 with modifier HE or HF. Brief, preventive mental health counseling and substance abuse intervention are limited to four hours per pregnancy and are billed with procedure code H0004 with modifier HE or HF. Division of Medicaid Services 39 Division of Medicaid Services 40 A wide range of providers are allowed for the screening and brief intervention. Physicians and physician assistants Nurse practitioners Nurse midwives (not mental counseling) PNCC providers (not mental health counseling) Medicaid covers screening, brief intervention, and referral to treatment (SBIRT) services for all full-benefit members Limited to one every 12 months Brief intervention limited to four hours every 12 months Providers required to complete DHS training Division of Medicaid Services 41 Division of Medicaid Services 42 7
Licensed professionals require four hours of training that may be conducted in-person or online. On a case-by-case basis, DHS may exempt individuals with expertise in the field of substance abuse screening and motivational interviewing from this training. Unlicensed individuals must: Complete at least 60 hours of training with at least 30 hours of training completed in-person. Provide services under the supervision of a licensed health care professional. Follow written or electronic protocols for evidencebased practice. Division of Medicaid Services 43 Division of Medicaid Services 44 Wisconsin Medicaid reimburses SBIRT under the following CPT codes: H0049 (Alcohol and/or drug screening) H0050 (Alcohol and/or drug service, brief intervention, per 15 minutes) Division of Medicaid Services 45 Transportation Medicaid generally covers transportation for a member going to and from a Medicaid-covered service. Women identified with a high-risk pregnancy are not required to ride a bus and will use a common carrier. Mothers may bring her infant to postpartum visits as an additional passenger. Division of Medicaid Services 46 HMO Contract Requirements To ensure network adequacy, HMOs must: Ensure the delivery network is sufficient to meet the requirements of the contract. Include an adequate number of obstetric care and other primary care providers. Include access to licensed midwives. Division of Medicaid Services 47 HMOs must meet distance requirements for primary care providers and non-specialized hospitals, including: Primary care providers within a 20-mile radius (10 miles if Milwaukee, Kenosha, Racine, or Madison) Hospital within a 20-mile distance in Brown, Dane, Kenosha, Milwaukee, Ozaukee, Racine, Washington, and Waukesha counties Hospital within 35-mile distance in all other counties Division of Medicaid Services 48 8
HMOs must provide: Women with direct access to a women s health specialist for routine and preventive health care services. Prenatal care within two weeks of an appointment request, or three weeks if the request is for a specific HMO provider who is accepting new patients. Division of Medicaid Services 49 With the importance of interconceptioncare and early intervention for high-risk pregnancies, DHS shares data with HMOs about enrolled women at risk of a poor outcome. Some HMOs offer incentives to providers to notify the HMO of the confirmed pregnancy. Division of Medicaid Services 50 The Obstetric Medical Home initiative is a patient-centered model to provide enhanced care coordination. The goal is to improve birth outcomes and reduce birth disparities for high-risk pregnant women. The approach to care is comprehensive and teamoriented. Obstetric medical homes are available in Dane, Kenosha, Milwaukee, Ozaukee, Racine, Rock, Washington, and Waukesha counties. Obstetric medial homes identify not only the medical care needs, but social factors that could have a negative impact on the pregnancy outcome or newborn s health. Care coordinators track and follow-up on test results and referrals. The medical home actively supports and promotes patient self-care and adherence to treatment recommendations. Division of Medicaid Services 51 Division of Medicaid Services 52 Transition plan requirements, regardless of birth outcome, include: Collaboration with the HMO to ensure continuity of care for the mother and newborn. A primary care provider for both mother and newborn. An initial appointment for the newborn. If the birth outcome was poor, the HMO must: Ensure appropriate follow-up and ongoing contact with the mother. Provide interconception education and care specific to the mother s needs. Ensure preventive medicine visits for mother and baby. Assist with referral and follow-up on appointments. Division of Medicaid Services 53 Division of Medicaid Services 54 9
Participating providers receive $1,000 for each eligible woman that meets all criteria, and $2,000 if the woman had a good birth outcome. Since 2011, DHS has paid over $3 million in Obstetric Medical Home initiative payments, with the majority of women having good birth outcomes. The key to the Obstetric Medical Home initiative is enhanced care coordination of both medical and psychosocial needs. All BadgerCare Plus HMOs are required to meet quality benchmarks, and a portion of their capitation payment is at risk for financial incentive. Division of Medicaid Services 55 Division of Medicaid Services 56 Wisconsin Medicaid tracks the following quality measures related to pregnancy, birth, and the first year after birth. Prenatal and postpartum care (PPC) Healthcare Effectiveness Data and Information Set (HEDIS) o Timeliness of prenatal care (PPC-PC) o Post-partum (PPC-PP) visit within 21-56 days of delivery W15 (HEDIS) o Collected beginning in 2016 o Well-child visits in the first 15 months of life Division of Medicaid Services 57 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 2016 Wisconsin Medicaid HMO Data BadgerCare Plus and Wisconsin Medicaid Average 2016 PPC-PN and PPC-PP National 50 th 81.80% Percentile = 82.3% National 75 th PPC-PN Percentile = 67.5% 66.70% PPC-PP Wisconsin: Near 50 th percentile for PPC-PN; Near 75 th percentile for PPC-PP Division of Medicaid Services 58 70.00% 60.00% 50.00% 2016 Wisconsin Medicaid HMO Data BadgerCare Plus and Wisconsin Medicaid Average 2016 W15 (Well-Child Visits in First 15 Months of Life) -Six Visits or More National 50 th Percentile = 62% 60.9% Resources Wisconsin Medicaid and BadgerCarePlus: www.dhs.wisconsin.gov 40.00% 30.00% 20.00% 10.00% ForwardHealthPortal: www.forwardhealth.wi.gov/wiportal 0.00% 6 Visits or more Wisconsin: Just below national 50 th percentile 59 Division of Medicaid Services 60 10
Resources ForwardHealth Portal includes: HMO contract Obstetric medical home guide and annual reports Provider handbooks and training information Member resources, including helpful fact sheets Enrollment data Fee schedules Resources Federal Medicaid and Children s Health Insurance Program: www.medicaid.gov Division of Medicaid Services 61 Division of Medicaid Services 62 Legal Framework State Medicaid Law and Regulations Law o Wis. Stat. ch.49 Regulations o Wis. Admin. Code chs. DHS 101 to 109 Wis. Admin. Code ch. DHS 103 is Eligibility Wis. Admin. Code ch. DHS 107 is Covered Services Legal Framework Federal Law and Regulations: Law: o Social Security Act: Titles 19 (Medicaid) and 21 (CHIP) Regulations: 42 C.F.R Chapter IV Division of Medicaid Services 63 Division of Medicaid Services 64 Questions? Division of Medicaid Services 65 11