Healthy Connections Medicaid Update

Dr. Tan Platt, Medical Director

South Carolina Department of Health and Human Services

August 13, 2017

2

Medicaid Overview

• 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

Healthy Connections Medicaid

3

• 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

Medicaid Explained

4

• 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

Who is Eligible for Healthy Connections Medicaid?

5

• 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

Medicaid Mandatory Services/Providers

6

• Prescription drugs

• Dental care

• Vision services

• Hearing aids

• Personal care services for the frail, elderly and disabled

Medicaid Optional Services

7

$-

$100

$200

$300

$400

$500

$600

FY 2011-12 FY 2012-13 FY 2013-14 FY 2014-15 FY 2015-16 FY 2016-17(Estimated)

FY 2017-18(Budget)

Mill

ion

s

Funds Available 3% Reserve Target

8

Changes in Fund Balances

• The year-end projections for FY 2016-17 and 2017-18 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.

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

• 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

Full-Benefit Members and Expenditures

% of Enrollment

Children Disabled Adults Other Adults Elderly

% of Expenditures

Children Disabled Adults Other Adults Elderly

11

South Carolina Healthy Connections Medicaid Initiatives

12

South Carolina Reporting and Identification Prescription Tracking System (SCRIPTS)

13

Opioids

Governor’s Task Force

14

• 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

Licensing Boards

15

• 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.”

SCDHHS Policy

16

• 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

Exceptions to Mandatory PDMP Use

17

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 providerex. 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

• Hepatitis C medications

• Spinraza-Spinal Muscle Atrophy

• Emflaza-Muscular Dystrophy

• Acthar-Lupus nephritis and other indications

Other Drug Issues

18

19

Telemedicine

• 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 access-related 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

Overview

20

Covered Services:

• Office or other outpatient visits (99201 – 99215)

• Inpatient consultation (99251-99255)

• 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

• 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

SC Telehealth Alliance

22

• 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

• 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

SC Telehealth Alliance (cont.)

23

Telemedicine Utilization

24

5851370

5259

6785

4721

0

1000

2000

3000

4000

5000

6000

7000

8000

FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 (YTD)

Un

iqu

e C

laim

s

Axis Title

25

Healthy Outcomes Plans (HOP)

26

Proviso 33.21 Sec A, C, D – Medicaid Accountability and Quality Improvement Initiative

• 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

Overview

27

• 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:

• 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

Status/Statistics

28

• 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.

Successes/Preliminary Evaluation

29

30

Nutritional Counseling Initiative Update

• In April 2013, Obesity (BMI>30) was formally recognized as a disease

• Approximately 30% of Medicaid recipients are considered obese

Medicaid Coverage: Nutritional Counseling for Obesity Initiative

31

13th highest

31.7%(2015)

• 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!

Nutritional Counseling Policy

32

• 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

The Initiative

33

34

Billing Basics: Adult Interventions

Intervention Flow

35

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.

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)

Billing Healthcare Common Procedure Coding System (HCPCS) Service Codes - Physicians

HCPCS Codes Modifier Description Maximum Units per calendar

year

G0447 SC

Annual face to face obesity screening (15 min. session) Initial visit only (USPSTF

5As)

1

G0447 -

Face to face behavioral counseling

for obesity (15 min. session)

(USPSTF 5As)

Total of 5 subsequentfor either group or

individual behavioral counseling

G0447 HBGroup Face to face

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

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 27.0-27.9 Z6835 BMI 35.0-35.9 Z6844 BMI 60.0-69.9

Z6820 BMI 20.0-20.9 Z6828 BMI 28.0-28.9 Z6836 BMI 36.0-36.9 Z6845 BMI 70 or greater

Z6821 BMI 21.0-21.9 Z6829 BMI 29.0-29.9 Z6837 BMI 37.0-37.9 Z6854

BMI Pediatric, greater

than or equal to 95% for

age

Z6822 BMI 22.0-22.9 Z6830 BMI 30.0-30.9 Z6838 BMI 38.0-38.9

Z6823 BMI 23.0-23.9 Z6831 BMI 31.0-31.9 Z6839 BMI 39.0-39.9

Z6824 BMI 24.0-24.9 Z6832 BMI 32.0-32.9 Z6841 BMI 40.0-44.9

Z6825 BMI 25.0-25.9 Z6833 BMI 33.0-33.9 Z6842 BMI 45.0-45.9

Z6826 BMI 26.0-26.9 Z6834 BMI 34.0-34.9 Z6843 BMI 50.0-59.9

Billing Basics: Pediatrics

• 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

Guidelines for Pediatricians

40

• Document ICD-10 Diagnosis Codes:• Z68.54 Pediatric BMI greater than or equal to 95th percentile

for age

• Z71.3 Dietary surveillance and counseling

Billing Healthcare Common Procedure Coding System (HCPCS) Service Codes

41

• 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.

Billing HCPCS Service Codes forLicensed Dietitians and Pediatricians

42

• 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) – 2,620

• 358 of these were billed by RDs

Subsequent visit claims (97803) – 339

• 296 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

Utilization Statistics

43

• 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

Challenges

44

45

South Carolina Birth Outcomes Initiative (SCBOI)

• 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

SCBOI Programs

46

47

CDC Infant Mortality Report

• 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 1of only 3 (Connecticut and Colorado) to see a decline of more than 20%

48

Infant Mortality cont.

• 77% of all South Carolina birthing hospitals have achieved a 0% rate for non-medically necessary EEDs at 36-38 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 2015

Success of Non-Medically Necessary EEDs

49

• 96% 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%

Utilization through FY 2015

50

IPI LARC Percentage FY 2015

51

17% Inpatient

84% Outpatient

• 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)

Centering Cohort Study: Published

52

• 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

CenteringPregnancy

53

• 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%

Baby-Friendly Certification

54

• 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

Mother’s Milk Bank of South Carolina

55

• By the end of April 2016, 44 hospitals in SC received the first-year training.

• Year 2 curriculum started Aug. 2016• 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.

SimCOACH™ Training: By the Numbers

56

57

New Initiatives and Recent Changes

• 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)

Safe Sleep Initiative

58

• 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

PRTF

59

• 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: https://msp.scdhhs.gov/autism/

Autism

60

• 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

Elimination of Monthly Prescription Benefit

61

• 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

Tobacco Cessation Treatments

62

• 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)

Immunizations

63

64

Medicaid Dental Benefit

Covered Dental Procedures

65

Coverage

Procedure Categories Child

< 21

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

Dental Benefit: Children Under Age 21

66

• 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 13th birthday

Dental Benefit: Adults Ages 21+

67

• 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

68