Healthy Connections Medicaid Update

Dr. Tan Platt, Medical Director

South Carolina Department of Health and Human Services

July 31, 2016

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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

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• 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

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• 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?

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• 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

• EPSDT services

Medicaid Mandatory Services/Providers

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• Prescription drugs

• Dental care

• Vision services

• Hearing aids

• Personal care services for the frail, elderly and disabled

Medicaid Optional Services

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• A $475 billion program in 2013

• 71.2% of expenditures are for acute care services (hospitals, physicians, drugs, etc.)

• 24.9% pays for nursing homes and long term care services.

• Includes 65% of all nursing home residents and 43% of all the nation’s long term care costs (AARP)

• 3.8% to hospital disproportionate share hospital payments

National Medicaid Expenditures

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Source: Kaiser Family Foundation, FY2014

• Costs of Medicaid coverage is substantially less than private insurance to cover people of similar health status¹

• In the past decade, Medicaid cost per beneficiary grew much slower than patients with employer-sponsored insurance¹

• Medicaid costs per beneficiary are projected to rise no more rapidly than costs for privately insured patients

• Private health insurance spending grew 4.4% to $991 billion in 2014²

• Medicaid spending grew 11% to $495.8 billion in 2014, or 16% of total national health expenditure²

Efficiency and Effectiveness

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Sources: ¹ Edwin Park, Matt Broaddus, Jessica Schubel and Jesse Cross-Call Center, “Frequently Asked Questions About Medicaid,” Centers on Budget and Policy Priorities (CBPP), January 21, 2016, www.cbpp.org/sites/default/files/atoms/files/9-24-13health.pdf ² NHE Fact Sheet, Centers for Medicare and Medicaid Services (CMS), www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html

• For most of the 72.5 million Medicaid beneficiaries private insurance is not an option

• Expansion of eligibility for low income children in the 1980’s & 1990’s led to a 5.1% reduction in childhood deaths¹

• Expansion of eligibility for low income pregnant women in the 1980’s & 1990’s led to an 8.5% reduction in infant mortality and a 1.9% reduction in incidence of low birth weight¹

Efficiency and Effectiveness (cont.)

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Source: ¹ Janet Currie, Jonathan Gruber, “Saving Babies: The Efficacy and Cost of Recent Changes in the Medicaid Eligibility of Pregnant Women,” Journal of Political Economy, 1996, vol. 106, no. 6, http://www.princeton.edu/~jcurrie/publications/saving_babies.pdf

• Average enrollment is projected to increase at an average annual rate of 3% over 10 years reaching 78.8 million in 2023

• ACA newly eligible adult enrollment is projected to reach 12 million people by 2023

• Over the next 10 years, expenditures are projected to increase at an average annual rate of 6.2% and reach $835 billion by 2023

• ACA newly eligible expenditures are projected to be $457 billion from 2014-2023

Medicaid’s Future

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Source: “2014 Actuarial Report of the Financial Outlook of Medicaid,” Centers for Medicare and Medicaid Services, 2014, www.medicaid.gov/medicaid-chip-program-information/by-topics/financing-and-reimbursement/downloads/medicaid-actuarial-report-2014.pdf

• SCDHHS’ budget makes up 16 percent of the entire South Carolina state budget

• SCDHHS is appropriated more than $1.1 billion in general state funds by the General Assembly

• Total state budget is approximately $6.8 billion

• SCDHHS aims to maintain 3 percent in reserves

SCDHHS Budget Snapshot

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Background: Changes in Fund Balances

* FY 2016-17 assumes the agency’s request is approved as submitted.

$-

$100

$200

$300

$400

$500

$600

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

FY 2016-17(Budget)

Mill

ion

s

Funds Available 3% Reserve Target

• Full-benefit membership continues to hold around 1 million, even with required restart of annual reviews. Added an additional month of prior notice of reviews. Sharing better reports with managed care plans, earlier than in the past. Authorized plans to outreach to members to complete annual review

forms.

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Full-Benefit Membership

1,044,250 1,034,705 1,040,654 997,945 1,021,019

-

200,000

400,000

600,000

800,000

1,000,000

1,200,000

FY 2014-15Forecast

FY 2014-15Actual

FY 2015-16Forecast

FY 2015-16Current

Projection

FY 2016-17Forecast

Elderly

Disabled Adults

Other Adults

Children

• Children represent over 63% of enrollment, but less than 30% of projected expenditures

• Disabled adults make up approximately 13% of enrollment, but account for over 38% of projected expenditures

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Full-Benefit Members and Expenditures

% of Expenditures % of Enrollment

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South Carolina Healthy Connections Medicaid Initiatives

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South Carolina Reporting and Identification Prescription Tracking System (SCRIPTS)

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Opioids

Governor’s Task Force

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• 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

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• 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

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• Beginning April 1, 2016, Medicaid 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

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The following instances are exempt from this requirement:

• Issuance of less than a five (5) 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 provider.

• Instances where the SCRIPTS system is unavailable.

• Patients on chronic therapy should be assessed at initiation and at least every 90 days.

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Nutritional Counseling Initiative

• SCDHHS strategy targets adults with BMI 30+ in Medicaid

• Excludes: • Beneficiaries authorized for bariatric surgery/gastric

banding

• Pregnant women

• Beneficiaries whose medication may cause weight gain. Example medications include:

• Atypical Antipsychotics • Long-Term use of oral corticosteroids • Certain Anticonvulsant Medications • Tricyclic Antidepressants

Target Population

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Intervention Flow

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Identification

• Initial visit with Physician, Physician’s Assistant, Nurse Practitioner. Adult Medicaid beneficiary with BMI 30+. Establishes exercises plan for 5 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

• LD 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 Physician

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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 subsequent for either group or

individual behavioral counseling

G0447 HB Group 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

Physician

Billing Healthcare Common Procedure Coding System (HCPCS) Service Codes

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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 International Classification of Diseases (ICD-10) Diagnosis Codes

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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

• Pediatricians/FPs may address obesity management after diagnosing during EPSDT visit.

• SCDHHS recommends the physician utilize the 5 A’s as recommended by the USPSTF.

• Ask, advise, access, assist and arrange

• Pediatricians can bring a child back for obesity related visits and utilize existing CPT and ICD-9 codes.

• Also, they may now refer patients to licensed dietitians for nutritional counseling.

• Dietitians will use the 97 code series for children.

Childhood Obesity

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Billing Healthcare Common Procedure Coding System (HCPCS) Service Codes Pediatricians

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HCPCS Code Description

99201-99215

Provider must bill the appropriate level of Evaluation and

Management Services.

Document ICD-9 Diagnosis Code: V65.3 Dietary surveillance and counseling

Pediatricians

• RHC may bill for individual and group nutritional counseling visits under this policy using the G and S code series.

• Rural Health Clinics must bill for Nutritional Counseling codes utilizing their GP legacy/NPI number and not their RHC legacy/NPI number

• All claims must include the appropriate Z-code for tracking of the patient’s BMI.

• All documentation standards listed in the policy apply.

Rural Health Clinic

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• FQHC reimbursed using the encounter code: T1015

• May bill for individual and group nutritional counseling visits.

• The encounter code includes both the provider and the dietitian visit within the one unit of a T1015.

• For tracking purposes, G codes and S codes must be reported, but will not be paid.

• All claims must include the appropriate Z-code for tracking of the patient’s BMI.

• All documentation standards listed in the policy apply.

FQHC

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Medically Complex Children’s (MCC) Waiver

• The Medicaid MCC waiver is a statewide program serving medically complex children from birth to age 18

• Services offered: • Care coordination • Respite care • Pediatric medical daycare • State plan services:

Incontinence supplies (diapers, wipes) Personal care (bathing, personal grooming, meal prep, etc.) Private duty nursing Transportation (for medical purposes only) Durable medical equipment (wheelchair, bed, etc.)

• The MCC waiver currently serves 795 children, and is administered and operated by SCDHHS

About the MCC waiver

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• Children must: • Be a resident of South Carolina and Medicaid eligible

• Meet institutional level of care

• Have both chronic physical and health conditions that are expected to last longer than 12 months

• Meet medical criteria which determines the child needs comprehensive medical, nursing, health supervision or intervention

Eligibility

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• Priority is given to children: • Being discharged from the hospital

• Requiring private duty nursing (PDN) services

• Served by the SC Department of Social Services (DSS) foster care program

• With an eligible family member of the Armed Services who maintains a South Carolina residence

Priority Categories

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• Monthly contact with a registered nurse (RN) care coordinator by phone or in-person

• Quarterly visits in the home with the child and primary caregiver present

Conditions of Participation

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Autism Spectrum Disorder (ASD) Services

• ASD Interim Services via Early, Periodic, Screening and Treatment (EPSDT)

• Complete applications can be sent to autism@scdhhs.gov and include the following documents:

• Healthy Connections Medicaid member identification (ID) number

• Indication of when PDD waiver services will expire (applicable only if member is currently receiving PDD waiver services)

• Results of an EPSDT visit that demonstrates the medical necessity for ASD services

• Attestation by a doctor, developmental pediatrician or current ASD services provider with treatment recommendations (e.g., specific problem behaviors to be addressed), including recommended hours

• Comprehensive assessment report that confirms the presence of ASD

• The report must include developmental history, a detailed description of observed behavior and results from standardized ASD diagnostic tools, as applicable. The diagnostic assessment must have been performed by a qualified examiner with training in the assessment of children and youth with ASD.

Autism Spectrum Disorder (ASD) Interim Services

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• List of necessary documents to go with application (cont.):

• Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) or (DSM-5)

diagnostic profile, to establish proof of met criteria

• Checklist for Autism in Toddlers (CHAT) or Modified-CHAT assessment form, if

applicable

• Medical profile (e.g., summary of last medical visit, description of medical complications, etc.)

• Speech and language therapy notes, if applicable (e.g., summary of last visit/progress review)

• Family history, including, but not limited to, family history of ASD (e.g., maternal and paternal history and maternal and paternal grandparent history)

• Past therapies profile sheet (e.g., therapy modalities, frequency, duration, outcome, etc.)

• Genetic testing, if applicable

• Prior Authorization or Denial Letter from member's primary insurance carrier

Necessary Documents (cont.)

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• Review time typically takes two weeks, provided the document set is complete

• Number of requests to date: 2023

• Number of authorizations: 771

• Total pending: 1,252 • Under review: 9

• Incomplete document set: 1,243

ASD Services Applications

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South Carolina Birth Outcomes Initiative (SCBOI)

1. Non-medically Necessary Early Elective Deliveries (EEDs)

2. Screening, Brief Intervention and Referral to Treatment (SBIRT)

3. Long-Acting Reversible Contraceptives (LARCs) Inpatient Insertions

4. Baby-Friendly USA

5. CenteringPregnancy

6. Supporting Vaginal Births (SVB)

7. Neonatal Abstinence Syndrome

8. Mother’s Milk Bank of South Carolina (MMBSC)

SCBOI Programs

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Percentage of Birthing Hospitals at 0% for Non-Medically Necessary EEDs

4th Quarter of 2014

• All payers 56% of all SC birthing

hospitals attained a 0% EED rate

• SC Medicaid 64% of all SC birthing

hospitals attained a 0% EED rate

3rd Quarter of 2015

• All payers 64% of all SC birthing

hospitals attained a 0% EED rate

• SC Medicaid 76% of all SC birthing

hospitals attained a 0% EED rate

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76% of all South Carolina birthing hospitals have achieved a 0% rate for non-medically necessary EEDs- 36-39 weeks

• Since launch of the program, the state has achieved a 70% 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

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FY2013-FY2015 LARC Data Results

• LARC inpatient insertions increased 110%

• LARC utilization for outpatient insertion increased 10%

• Overall, inpatient LARC insertions now make up 17% of total LARC use

• In Nov. 2015, released the SC Postpartum Toolkit on Choose Well website

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• 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

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• 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

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• Program started in 2013

• Since launch, a total of 11 hospitals to date are now Baby-Friendly accounting for 36% of all births and 34% of Medicaid births in SC

• The national average is 17%

Baby-Friendly Certification

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• Through Dec. 2015, MMBSC has: • Received almost 42,000 ounces of human milk from 97

approved donor moms

• Created almost 6,000 bottles of pasteurized, donor

human milk

Mother’s Milk Bank of South Carolina

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• By the end of April 2016, 44 hospitals have received training.

• 1,065 healthcare professionals trained to date (including pilot program)

• 152 physicians

• 791 nurses

• 122 others – respiratory therapists, nurse midwives, nursing/medical students, etc.

• Year 2 Curriculum • Hemorrhage; pre-eclampsia; breech

SimCOACH™ Training: By the Numbers

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Adult Dental Benefit

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$750 per year-preventive services

Less than 10% of eligible beneficiaries have used the

full benefit

Consider recommending to high risk patients

ex.-diabetes with poor control, heart disease

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Dr. Marion Burton

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