Transcript BMS Fall 2016

Fall Provider Workshops
2016
Tanya Cyrus, RN, MHA, CMCN
Director, Medicaid Management Information Systems
Sarah Young, Acting Deputy Commissioner
BMS Policy Coordination
October 11 - Charleston, WV
October 12 - Huntington, WV
October 14 - Beckley, WV
October 17 - Martinsburg, WV
October 18 - Wheeling, WV
October 19 - Morgantown, WV
October 20 - Parkersburg, WV
October 28 - Flatwoods, WV
WV Medicaid Enrollment Update
As of October 1, 2016, West Virginia Medicaid covers 524,301
individuals - approximately 29% of West Virginia’s population:
 There are 134,754 members who are currently enrolled in fee for service
(FFS), i.e., traditional/regular Medicaid.
 FFS includes foster care children, waiver recipients and elderly/disabled
categories.
 Approximately 389,537 members are receiving services through Mountain
Health Trust (MHT), the State’s Medicaid Managed Care Program.

MHT includes most children, pregnant women, adult expansion, parents
and caretaker relatives.
1
Managed Care Update
Effective January 1, 2017, West Virginia Medicaid is expanding its
Mountain Health Trust (MHT) Managed Care Program:
 Supplemental Security Income (SSI) population will be transitioned to
a Managed Care Organization (MCO).
 Does not include those who also receive Medicare, Medicaid
Waiver services, reside in a nursing facility or is a foster care child.
 MCO enrollment packets to be released in the fall of 2016.
This expansion will provide beneficiaries with:
 More assistance in coordinating their health care.
 MCO staff can help them access and obtain needed care.
 Increased access to medical professionals who provide care to
individuals with disabilities and complex medical conditions.
 Increased satisfaction with their care and overall improved health
status.
2
Managed Care Update (Cont.)
Continuity of Care:
 SSI members who are receiving services at the time of MCO enrollment will
be allowed 90 days to complete a current ongoing course of treatment with
a non-network provider.
 This will allow additional time for the provider to contract with the
member’s MCO.
 If provider does not wish to contract with the member’s MCO, the MCO
will work with the member and current non-network provider to identify
a new provider and ensure that an appropriate transition plan is
developed, including the exchange of patient records.
 MCOs will educate current providers on the upcoming changes.
 MCO enrollment broker, Maximus, will perform site visits to Medicaid
providers.
 Bureau for Medical Services (BMS) has already begun engaging provider
associations to perform outreach and educate providers.
3
Managed Care Update (Cont.)
What benefits are NOT included in the Managed Care Plans?
 Transplants
 Nursing Facility Services
 Medicaid Waiver Services
 Aged and Disabled (ADW)
 Intellectual and Developmental Disabilities (IDDW)
 Traumatic Brain Injury (TBIW)
 Non-Emergency Medical Transportation (NEMT)
 Hepatitis C medications
 Personal Care Services
 After meeting with providers, BMS decided not to transition the
personal care benefit to the MCOs, but will develop a process to
better manage the program.
 Personal Care Services providers will continue to send claims to
Molina for all members (FFS and MCO).
4
Managed Care Update (Cont.)
MCO Contact Information:
 Aetna Better Health of West Virginia (formerly CoventryCares)
Michelle Coon, Director of Operations/Site Manager, phone: 304-348-2017, email: [email protected]
 The Health Plan
Christy Donohue, Director, Medicaid, phone: 304-720-4923, email: [email protected]
 UniCare Health Plan of WV
Tadd Haynes, Chief Operating Officer, email: [email protected]
Anthony Duncan, Director, Network Relations, phone: 304-347-2481, email: [email protected]
Terri Roush, Manager, Network Relations, email: [email protected]
Carrie Blankenship, Network Education Representative, phone: 304-533-4086, email: [email protected]
 West Virginia Family Health
Donna Sands, Director of Operations/Controller, phone: 304-424-7661, email: [email protected]
5
Assuring Access to Care
November 2, 2015 – Centers for Medicare and Medicaid Services (CMS)
released 42 CFR Part 447 Medicaid Program; Methods for Assuring Access to
Covered Medicaid Services:
 Requires states to develop a Medicaid-specific access monitoring review
plan. The plan must, at a minimum, allow for monitoring of the following
services every three years:
 Primary care services
 Behavioral health services
 Physician specialist services
 Home Health services
 Pre- and post-natal obstetric services, including labor and delivery
 Must choose measures, data sources, baselines and thresholds to take into
account state-specific access to care delivery systems, beneficiary
characteristics and geography.
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Assuring Access to Care (Cont.)
 Must include a clear, data-driven approach that identifies the monitoring
methodology, data sources, assumptions, baselines and thresholds used to
monitor access to care and successfully capture:
 Extent to which beneficiary needs are met; availability of care and
providers; changes in beneficiary service utilization; and comparisons
between Medicaid rates and rates paid by other public and private
payers.
 Findings identified as a result of the access monitoring plan’s procedures
will be used to develop corrective action plans to address overall access
deficiencies.
 BMS plan was posted for public comment July 13, 2016 through August 17,
2016.
 The finalized plan was submitted to CMS on September 22, 2016, and is
available on the BMS website at
http://www.dhhr.wv.gov/bms/CMS/Pages/West-Virginia-Medicaid-ProgramAccess-to-Covered-Medicaid-Services-Monitoring-Plan.aspx.
7
Adoption of CDC Opioid Guidelines
West Virginia Medicaid is incorporating the Centers for Disease Control and
Prevention (CDC) Opioid Prescribing Guidelines for the management of
chronic pain by:
 Reviewing coverage of non-pharmacological therapies.
 Implementing a program that calculates and tracks morphine-equivalent
dose.
 Improving access to behavioral health services.
 Placing a “hard stop” on the concurrent coverage of opiates and
benzodiazepines.
 Working to improve access to substance use disorders (SUD) screening and
treatment services.
 Developing uniform prior authorization form for opioids.
 Constructing template for treatment plan based on guidance.
 Implementation goal of January 1, 2017.
 Include Medicaid FFS and MCO members.
 CDC’s Opioid Prescribing Guidelines are available at
http://www.cdc.gov/drugoverdose/prescribing/providers.html
8
Medicaid 1115 Waiver Proposal
The federal government is encouraging states to use their Medicaid programs
to promote access to substance use disorder (SUD) treatment and prevention
services:
 Medicaid Section 115 waivers allow states to make system-wide changes to
their programs that are not normally permitted.
 The West Virginia Department of Health and Human Resources has
prepared a draft section 1115 waiver application that describes an approach
to addressing the SUD epidemic for Medicaid enrollees in West Virginia.
 The goal is to build a comprehensive continuum of care across the state to
more effectively prevent and treat substance use disorders in West Virginia
by:
 Providing additional Medicaid services to promote SUD treatment;
 Further integrating efforts currently underway through the Bureau for Behavioral Health
and Health Facilities;
 Looking across all state agencies to ensure resources are being leveraged wisely and
efficiently; and
 Accessing additional federal Medicaid funding to supplement existing state funding.
9
Medicaid 1115 Waiver Target Populations
 MCO members will be eligible for an enhanced set of SUD treatment
services under the waiver.
 Medicaid FFS members will access SUD services through traditional FFS
benefits.
 Waiver will include strategies focused on SUD prevention and treatment
among adolescents.
 At-risk families will be eligible for SUD treatment services to allow for
community-based treatment and supports to prevent the child being
placed out of home.
 Foster care youth will be able to receive SUD treatment services
through the Early and Periodic Screening, Diagnosis and Treatment
(EPSDT) benefit.
 Medicaid will build on existing efforts to raise awareness and address the
prevalence of babies born with exposure to substance use (31 out of
every 1,000 births in West Virginia).
10
Medicaid 1115 Proposal – SUD Services
Medicaid benefit expansions under the waiver:
 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.
 Short term, residential substance abuse treatment for Medicaid
managed care enrollees.
 Enhanced access to outpatient SUD 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.
 Coverage of a set of clinical and peer recovery support services and
recovery housing supports designed to promote and sustain long-term
recovery.
11
BMS Policy and Program Updates
Missed Appointment/Cancellation:


Effective April 1, 2016, two current dental terminology (CDT) codes were opened in
the Management Information Services (MMIS) for tracking purposes only:
 D9986 - Missed appointment;
 D9987 - Cancelled appointment;
 Fee for both codes set at zero dollars; and
 Medicaid members cannot be billed for these codes.
Medicaid is evaluating similar tracking to be used by medical providers.
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) and Coordinating Council for Independent
Living (CCIL).
 Has approximately 11 full-time equivalent (FTE) transition navigators across West
Virginia.
 For more information about the Take Me Home, go to the website at
www.dhhr.wv.gov/bms/Programs/Takemehome or call 304-356-4926.
12
BMS Policy and Program Updates (Cont.)
Drug Screening:
 BMS will continue to follow the CMS coding guidelines for
reporting drug testing procedures:
 Current requirement is to submit drug testing services to
BMS using CMS codes G0477-G0483.
 BMS will continue to require a prior authorization for drug
screenings performed over the service limit:
 Current service limit of 30 per calendar year.
 New service limit proposed is two per calendar month, for
dates of service on and after January 2017.
 The HF modifier must be included on all claims for drug
screening codes when related to substance abuse treatment
(e.g., Suboxone).
13
BMS Policy and Program Updates (Cont.)
BMS Quality Unit:



Centers for Medicare and Medicaid Services (CMS) Adult Quality Measures (AMQ)
Grant will conclude on December 21, 2016.
Reporting to CMS Adult and Child Quality Core Measures.
Collaborating with Medicaid MCOs and External Quality Review Organization (EQRO).
Adult Quality Measures Grant - Two Quality Improvement Projects (QIPs):

Prenatal behavioral health risk assessment and postpartum care visit:
 Working with current MCOs;
 Expanding statewide with the MCOs in 2016; and
 Multiyear QIP.

Increasing follow-up after hospitalization for mental illness:
 Pilot project conducted June 20, 2016 – November 30, 2016.
 BMS partnering with The Behavioral Health Pavilion of the Virginias, a service of Princeton
Community Hospital.
 The QIP:

Includes member communication regarding importance of follow-up appointment;

Provides information on transportation services; and

Identifies barriers for members to attend their follow-up appointment.
Look for the “Quality Corner” in each Medicaid Provider Newsletter for QIP updates.
14
BMS Health Homes Program Update
West Virginia Health Homes:
 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.
 Must be receiving services from a provider in Cabell, Kanawha, Mercer, Putnam,
Raleigh or Wayne counties.
 Currently 609 members enrolled.
 Six BMS-approved Health Homes Providers.
 West Virginia plans to expand this program statewide in 2017.
 Additional Health Homes Program information is available on the BMS website:
www.dhhr.wv.gov/bms/ or the KEPRO website: www.kepro.com.
 Questions/concerns - contact KEPRO at 304-343-9663 or 1-800-461-0655.
 Second Health Homes Program under development to address the co-occurring
conditions of diabetes and obesity.
15
Transportation Update
Medicaid Non-Emergency Medical Transportation (NEMT) Broker
is MTM (Medical Transportation Management):
Recent NEMT statistics:
 September 30, 2016
 Calls received - 57,733
 Trips scheduled - 36,265
 Trips denied - 2,143
 Year-to-Date 2016:
 Calls received - 541,742
 Trips scheduled - 477,538
 Trips denied - 19,190
16
ICD-10 Update
2017 ICD-10 Codes:
 Effective October 1, 2016.
 Apply to discharges and patient encounters occurring October 1,
2016 through September 30, 2017.
 Diagnosis codes (ICD-10-CM) include 1,974 additions, 311 deletions
and 425 revisions for new total of 71,486 codes.
 Many of the new are laterality codes.
 Procedure codes (ICD-10-PCS) include 3,827 additions, 12 deletions
and 491 revisions for new total of 75,789 codes.
 2017 ICD-10 Code Tables and General Equivalence Mappings (GEMs)
available on CMS website at:
https://www.cms.gov/Medicare/Coding/ICD10/2017-ICD-10-CM-and-GEMs.html.
 Direct ICD-10 claim inquiries to:
 Molina’s Provider Relations Unit at 1-888-483-0793.
17
Provider Revalidation Update
Provider Revalidation required every five years for Medicaid providers under
February 2, 2011, Federal regulations for Provider Screening and Enrollment:
 Effective September 25, 2016, Cycle 1 Provider Revalidation ended.
 October 1-31, 2016 - Provider Revalidation Cycle 1 wrap-up:
 Medicaid will be placing payholds and/or terminating provider
participation for providers who are not currently in communication with
and working with Molina to complete their revalidation.
 Once terminated, provider will not receive reimbursement for dates of
service between date of termination and re-enrollment.
 Excludes fingerprint-based criminal background check (FCBC)
requirement for which Medicaid must comply by June 1, 2017.
 November 2016 – West Virginia Medicaid will submit Molina’s provider
file to CMS for comparison of dually enrolled provider data.
 Cycle 2 Provider Revalidation will begin for WV Medicaid providers in June
2018.
 Revalidation date will be based on most recent effective date.
18
Provider Enrollment Update
January 1, 2017 - A provider’s effective date of enrollment will be based on the date Molina
receives a complete provider enrollment application.
 June 1, 2017 – West Virginia Medicaid must be in compliance with the FCBC requirement of
February 2, 2011 federal regulations on provider enrollment and screening:
 Applies to “high risk” providers enrolled on and after August 1, 2015:
 Currently applies to Home Health, durable medical equipment, prosthetics, orthotics and
supply providers, providers who have been excluded in the past 10 years and any others
designated as “high risk” by BMS.
 Providers enrolled in Medicare or another state’s Medicaid or CHIP program and who have
already had a FCBC do not have to undergo another check.
 Research underway at West Virginia Medicaid to determine if currently enrolled “high risk”
providers have FCBC recorded in Medicare’s provider enrollment, chain and ownership system
(PECOS).
 West Virginia Medicaid working with West Virginia Clearance for Access, Registry and
Employment Screening (WV CARES) Program to implement FCBC process.
 Providers who must meet the FCBC requirement will receive notification from BMS
informing them of the procedures they must follow and three pre-selected MorphoTrust
locations for fingerprinting.
 Providers responsible for FCBC-related fees.
 Providers will have 30 days from date of notice to complete FCBC.
19
Provider Enrollment Update (Cont.)
March 2016 Federal Rule on Medicaid Managed Care included requirement
that any provider that is a member of an MCO network must independently
have a Medicaid provider participation agreement in effect with the state
agency:
 Federal Rule stated Medicaid has ultimate responsibility for screening,
enrolling, and periodically revalidating all Medicaid MCO network providers.
 State Medicaid agencies must be in compliance by July 1, 2018.
 Managed Care rule included two options for state Medicaid agencies to be
compliant with screening, enrollment and revalidation requirements:
 Each MCO can conduct federally required activities for its network
providers, or
 Medicaid can conduct federally required activities for FFS and Medicaid
MCO providers.
 West Virginia Medicaid chose unified approach.
 Planning meetings to begin within next month.
20
Claim Edits
BMS Edit Workgroup reviewing/updating MMIS edit-related configuration:
 Third Party Liability (TPL) edits;
 Medicare action codes, claim adjustment reason codes (CARCs) and
remittance advice remark codes (RARCs); and
 Custom, agency-created edits.
Provider enrollment edit:
Claim Edit Name and
Disposition
Unenrolled Prescriber - Deny
Edit Description
Change edit disposition to “Deny” when
prescriber is not enrolled
Date of
Edit Implementation
November 1, 2016
Important: Unenrolled Prescriber Edit means that prescriptions (new or refill)
written by providers who are not enrolled with West Virginia
Medicaid on November 1, 2016, will be denied. This edit applies to
all providers who prescribe, including newly eligible to enroll as
part of revalidation, (i.e., hospital residents, physician assistants).
21
BMS Program Integrity (PI) Update
Payment Error Rate Measurement (PERM) Record Requests:
 Provider education sessions to be scheduled and conducted by CMS PERM contractor.
 Upcoming PERM sample size tripled from prior audit which means more providers may be
required to submit medical records.
Electronic Health Record (EHR) Audits:
 Currently conducting EHR audits for Program Year 2014.
 Audits will continue through the end of Program Year 2021.
 Reminder: Provider documentation and system compliance must support information in
attestation.
Medicaid Integrity Contractor Audits (MIC):
 Some hospice audits for medical necessity completed.
 Additional round of hospice audits underway (providers have already been notified and
submitted documentation).
 Recoveries underway following audits of non-citizen services.
 Upcoming topics for audits:
 Lab services for providers who have labs within their offices, and
 Dental audits.
Home Health Reviews:
 Draft reports to be issued in next few weeks.
22
BMS Resources
West Virginia Bureau for Medical Services (West Virginia Medicaid)
Mailing address:
350 Capitol Street, Room 251
Charleston, WV 25301
Telephone: 304 558-1700
Website: http://www.dhhr.wv.gov/bms/
Medicaid Fee-for-Service (FFS)
Molina – Fiscal Agent https://www.wvmmis.com/default.aspx
KEPRO (formerly APS Healthcare) – Utilization Management Contractor http://wvaso.kepro.com
HMS – TPL Contractor
BerryDunn – Project Management Contractor
Medicaid Managed Care (Mountain Health Trust)
Aetna Better Health of WV, The Health Plan, UniCare and WV Family Health - MCOs
Scion - Dental Benefits Manager www.sciondental.com
Maximus – Enrollment Broker https://www.mountainhealthtrust.com/
FFS & Managed Care
MTM- Non-emergency Medical Transportation Broker https://www.mtm-inc.net/west-virginia/
23