Indian Health Services (IHS)/Memorandum of Agreement (MOA) New Managed Care Payment Arrangement 4/17/2018 1
IHS/MOA Presentation Overview Background on Policy Change Overview of New Payment Arrangement IHS Reimbursement Process Overview 2
Background on Policy Change AB 1467 (Chapter 23, Statutes of 2012) expanded Medi-Cal managed care statewide, beginning in 2013. Previously, managed care was only in 30 counties (primarily urban areas) The transition to a managed care delivery system created a new way for tribal health clinics to bill for Medi-Cal services which required: 1) billing the Managed Care Plan for a contracted amount and then, 2) billing the DHCS for the estimated balance of the federal OMB rate fore each visit Additionally, the clinics are required to submit reconciliations after each fiscal year to receive the full amount of the federal OMB rate. If the estimated amount was too much, this process resulted in clinics owing the DHCS. Clinics reported to DHCS that this process was too cumbersome and lengthy. In May 2017, Mari Cantwell (Medicaid Director) shared DHCS plan for implementing the new Managed Care payment arrangement 3
Background on Policy Change Expansion of Managed Care Since 2010, the Medi-Cal program has 4
Background on Policy Change Prior to January 1, 2018 As result, IHS/MOA providers continue to serve a higher proportion of Medi-Cal managed care plan (MCP) beneficiaries Prior to January 1, 2018, DHCS policy required the reimbursement of IHS/MOA providers through a 3-step process for MCP beneficiaries: 1) IHS/MOA provider receives partial reimbursement from MCP, 2) DHCS then issues a Managed Care differential payment (Former code 18), 3) DHCS completes payment to OMB rate via annual reconciliations. 5
New Managed Care Payment Arrangements for IHS/MOA Services Post January 1, 2018 IHS/MOA clinics: MCPs are required to pay IHS/MOAs for covered services at the full applicable OMB rate (for services rendered on or after January 1, 2018) MCP s are required to pay the most current OMB encounter rate during the calendar year for which it applies and as an interim rate in a subsequent calendar year if an updated OMB rate has not been published. MCP s shall ensure interim payments are reconciled to the updated applicable OMB rate in accordance with contractual prompt payment requirements. DHCS eliminated the option of Managed Care Differential Payments (Former code 18) to IHS/MOA clinics (Prov. Type 075) for services rendered on or after 1/1/2018. Code 18 interim rate has been set to pay at $0.00, effective January 1, 2018 (DOS) 6
New Managed Care Payment Arrangements for IHS/MOA Services Post January 1, 2018 MCPs: DHCS released an All Plan Letter (APL# 17-020) outlining the MCP s requirements and submitted contract amendments to CMS (pending approval) For services rendered on or after January 1, 2018, MCPs are now required to pay eligible IHS/MOAs for covered services at the full applicable OMB rate. DHCS has carved-out all IHS/MOA utilization from the MCP s monthly risk-based capitation. MCPs are required to submit separate monthly payment files to DHCS to receive a payment for each encounter equal to the applicable OMB rate. This contract arrangement between DHCS and MCPs is non-risk based. 7
New Managed Care Payment Arrangements for IHS/MOA Services IHS/MOA s are still required to continue to submit complete and accurate encounters/claims to MCPs for covered services Effective January 1, 2018, MCPs are required to reimburse IHS/MOA for eligible services at the applicable OMB encounter rate: $287.72 Dual Rate CY 2018 (Medi-Cal beneficiaries with full Medicare coverage or Medicare Part B only) $427.00 Non-Dual Rate CY 2018 (Medi-Cal beneficiaries that do not have Medicare Coverage or has Medicare Part A only) Rates are defined in Attachment #2 of APL 17-020 and will be updated annually No changes to the annual reconciliation requirement for IHS/MOA Providers 8
Overview of IHS/MOA Reimbursement Process IHS/MOA can be reimbursed for up to 3 encounters per patient, per day One face-to-face Medical service encounter One face-to-face Mental Health service encounter One face-to-face Ambulatory service encounter MCPs will continue to require IHS/MOA clinics to submit complete encounters The definition for the encounter types referenced above can be found in the DHCS Medi-Cal provider manual http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/indhealth_o01o03.doc 9
IHS/MOA Reimbursable Categories of Service and Providers Category of Service Service Provider Service Medical Mental Health Doctor of Medicine or Osteopathy Physician Assistant Nurse Practitioner Nurse Midwife Registered professional nurse or licensed practical nurse Licensed Clinical Psychologist* Doctor of Psychiatry Licensed Clinical Social Worker* Marriage and Family Therapist* Physician services Physician assistant services Nurse practitioner services Nurse midwife services Visiting nurse if services are provided in the Tribal facilities Clinical psychologist services Psychiatry Services Clinical social worker services Marriage and Family Therapist Services Ambulatory Licensed Acupuncturist Acupuncture Services Doctor of Optometry Optometry services Physical Therapist Physical therapy services Occupational Therapist Occupational therapy services Speech Pathologist Speech Pathology Services** Audiologist Audiology Services ** Doctor of Podiatry Podiatry Services ** Chiropractor Chiropractic Services** * Interns must be under the supervision of a licensed mental health professional, in accordance with the requirements of applicable state laws. **Subject to Optional Benefits Exclusions ***Subject to Medi-Cal participation requirements. 10
Billing for Non-Managed Care Beneficiaries and Services Non-Managed Care Beneficiaries This new payment arrangement does not impact the billing for Medi-Cal beneficiaries that are not enrolled with a MCP IHS/MOA clinics should continue to bill fee-for-service (FFS) HIPAA compliant codes for non-mcp beneficiaries Non-Managed Care Services Dental services are excluded from this payment arrangement and continue to use Code 03. FFS carve-out services, which are not billed to MCP s, providers should continue to bill FFS HIPAA compliant codes To the extent that a service is contracted with a MCP but is not considered a billable service for the OMB rate (pharmacy, non-emergency medical transportation) the IHS/MOA clinic should continue to bill the MCP at their negotiated rate (non-omb) 11
Annual Reconciliations IHS/MOA providers will continue to be required to submit annual reconciliation request to DHCS A&I for the following claims: Medi-Cal Managed Care claims Dual eligible Medi-Cal Managed Care claims Medicare Crossover claims Medicare Advantage Plan Crossover claims DHCS A&I will continue to review the filed reconciliation requests to ensure IHS-MOA s received the federal MOA per-visit reimbursement rate 12
Further Questions For Managed Care patient access or contract issues please contact: DHCS Managed Care Operations mmcd.tpgmc@dhcs.ca.gov For Annual Reconciliation questions please contact: DHCS Audits & Investigations clinics@dhcs.ca.gov For Indian Health Program related issues please contact: DHCS-Indian Health Program Andrea.Zubiate@dhcs.ca.gov 13