WV Bureau for Medical Services

& Molina Medicaid Solutions

On January 1, 2014, Medicaid eligibility was

expanded to qualified individuals ages 19 to 64

making 138% of the Federal Poverty Level.

112,464 members (as of April 12, 2014) have

been enrolled in the Alternative Benefit Plan

(ABP).

The ABP population will request prior

authorization (PA) from APS Healthcare, Inc.

(the UMC) when PA is required

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Chiropractic

• Limit of 24 treatments/year. Additional 6 treatments per calendar year can be

prior authorized if OT and PT services have not been utilized in combination

with chiropractic services.

Physical Therapy

• 30 visits per year for Habilitative and Rehabilitative services

(combined PT and OT)

Occupation Therapy

• 30 visits per year for Habilitative and Rehabilitative services

(combined PT and OT)

Speech Therapy

• Habilitative and Rehabilitative services

Home Health

• 100 visits per year

ABP does not offer long term care, such as personal care services, nursing home

services, etc.

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Background: • As of January 1, 2014, the Affordable Care Act

(ACA) requires states to provide Medically Frail members the option to choose between the Traditional Medicaid Plan or the ABP.

Definition (42CFR §440.315): • Individual having a chronic substance use

disorder, serious and complex medical condition, or a physical, behavioral, intellectual, or developmental disorder that requires additional care.

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Self Identification • Full Medicaid Application "Does this person (or you, depending on the person

completing the form) have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home?" If yes, member will receive a Medical Frailty Notice information them

of their choice.

• Every member will receive Rights and Responsibilities (R&R) including information about medical frailty and how to get more information regarding their coverage options. A copy of their R&R is provided to every member at the time

of their redetermination or in the event they have an eligibility category change.

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A member can self-identify at any time

during their eligibility period.

Additional Information • County Office

• Providers

• BMS website

• “Your Guide to Medicaid”

• Molina Member Services

• Molina website

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On January 1, 2014, some services were assigned cost sharing

(copay) amounts for Medicaid members which will effect the

following provider types:

• Practitioner

• Hospital

• Pharmacy

• Rural Health Clinic

• Federally Qualified Health Clinic

• Ambulatory Surgical Center

Cost Sharing applies to current and newly eligible individuals.

Services cannot be refused for populations with income at or

below 100% FPL if the member is unable to pay the copay amount.

Maximum Out of Pocket (OOP) cannot exceed 5% of the Members’

quarterly household income.

Tiered Cost Sharing Structure

• Tier 1 (Up to 50.00% FPL)

• Tier 2 (51.00 – 100.00% FPL)

• Tier 3 (101.00% FPL and above)

Service TIER 1 TIER 2 TIER 3

Inpatient Hospital (Acute Care 11x) $0 $35 $75

Office Visit (Physicians and Nurse Practitioners)

(99201-99205, 99212-99215 only for office visits for new and

established patients based on level of care)

$0 $2 $4

Non-Emergency use of Emergency Department - Hospital only

(Lowest level (99281) of Emergency Room visits in

hospitals. The definition of this visit is an emergency

department visit for the evaluation and management of a

patient, which requires these 3 key components: A problem

focused history; A problem focused examination; and

straightforward medical decision making.)

$8 $8 $8

Any outpatient surgical services rendered in a physician’s

office, ASC or Outpatient Hospital excluding emergency

rooms.

$0 $2 $4

Effective May 1, 2014, co-payments will be assessed on the total allowed charge for the prescription, regardless of preferred or non-preferred status.

The table below displays the new co-payment structure. All member categories previously excluded from co-pays will continue to be excluded.

Total Allowed Charge Co-payment

$0.00-$5.00 $0.00

$5.01-$10.00 $0.50

$10.01-$25.00 $1.00

$25.01-$50.00 $2.00

$50.01 and above $3.00

The OOP is the most the Member will ever be required to pay in any given quarter regardless of the number of healthcare services received.

Cost sharing cannot exceed 5% of the Medicaid members’ quarterly household income.

Each calendar year quarter, Members will have a maximum out of pocket (OOP) payment respective to their tier level.

After July 1, 2014, members’ quarterly OOP maximum costs will be based on pharmacy, medical and dental co-payments combined.

Tier Level Out of Pocket Maximum

1 $8

2 $71

3 $143

The following populations and services are exempt from copays:

• Pregnant Women including pregnancy-related services up to 60 days post-partum;

• Children under age 21;

• Native American and Alaska natives;

• Intermediate Care Facility or MR services;

• Preventive services;

• Individuals in Nursing Homes,

• Receiving Hospice services,

• Medicaid Waiver services,

• Breast and Cervical Cancer Treatment Program;

• Family Planning services; and

• Emergency services. Additional exemptions for Pharmacy include diabetic testing supplies

syringes and needles, BMS approved Home Infusion supplies and 3-day emergency supplies.

Cost sharing information is listed on the following: • AVRS

• 271 transaction

• Molina Web Portal

Molina will return a copay amount for the start date of service if the provider inquires on a date range.

No copays will be listed for members on the exemption list.

Remittance advices will be modified to include the copay amount that was deducted.

Starting January 10, 2014, approved

hospitals could start making Medicaid

presumptive eligibility determinations.

Only hospitals which were Medicaid

providers were allowed to apply for

HBPE.

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HBPE should be offered to individuals who are not already enrolled

in Medicaid, may be eligible for Medicaid, and are West Virginia

Residents, AND are a member of one or more of the following

groups:

• Children under Age 19

• Pregnant Women

• Adults between ages 19 and 64

• Former West Virginia Foster Care Children under age 26

• Certain Individuals Needing Treatment for Breast or Cervical

Cancer

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Individual or a person with reasonable knowledge must attest to

the information provided on the HBPE questionnaire.

HBPE begins either on the date the determination is made or in

certain cases 24 hours prior to the determination.

End date of HBPE period is the earlier of:

• The date the eligibility determination for regular Medicaid is

made or

• The last day of the month following the month in which the

determination of presumptive eligibility is made if no

application for Medicaid is filed by that date.

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BMS will be tracking each hospital’s performance

as dictated by the following measurements:

1. 75% of patients who have been approved for HBPE have

followed up and filled out the full Medicaid application

prior to their designated case expiration date.

2. 50% of patients found eligible for HBPE and who have

completed the full Medicaid application were found

eligible for full Medicaid benefits.

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Background • State Medicaid programs can cover hospital

costs for incarcerated individuals that qualify for

Medicaid and leave their correctional facility to

be hospitalized for at least 24 hours.

Maximizing HBPE Functionality

Multi-Agency Initiative

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Medicaid Management Information

System (MMIS) Implementation

Data Warehouse/Decision Support

System Implementation

Annual ID Card

T-MSIS

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Take Me Home, West Virginia • Detailed information packet & Technical Assistance available

for providers selected as service agency

Traumatic Brain Injury (TBI) Waiver Program • Applicants may be inpatient, at home or in community setting

• BMS TBI Program Manager: Teresa McDonough

• TBI Program Contact Information

Phone: 866-385-8920

Email: wvtbiwaiver@apshealthcare.com

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Telehealth Section added to both Behavioral

Health Clinic (Chapter 502) and Behavioral

Health Rehabilitation (Chapter 503)

Foster Children must be given priority for all

Assessment and Evaluation Services

Assertive Community Treatment (ACT) will be

reviewed based on fidelity factors

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Changes to ADW eligibility timelines to expedite enrollment process once a slot becomes available.

Policy change will require applicant be enrolled in the program within 60 days of receiving the slot.

Certified Letters being sent now when slot becomes available.

• Policy change to set timeline of 15 days to respond to letter.

• If letter is not picked up within 15 days, BMS will attempt contact by phone.

• If no contact can be made, the slot will be reassigned. Important: Members on the Managed Enrollment List must

keep BMS apprised of any change in their address and/or phone numbers.

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Hospice - Chapter 509 • Revised version effective May 1, 2014

• Face to Face encounter requirement – 42CFR §418.22

• Concurrent Care for Children – ACA, Section 2302

Hospice services may be provided to children under age 21 concurrently with curative treatment.

Prior Authorization (PA) for Hospice Services

• Requests with diagnosis of ONLY failure-to-thrive or dementia require documentation of additional qualifying diagnoses based on Federal and State regulations http://www.gpo.gov/fdsys/pkg/FR-2013-08-07/pdf/2013-18838.pdf

• Revenue codes for Community Care & Inpatient Care require PA

Hospice Care in Nursing Home (Revenue code 0658) requires PA for reimbursement

APS Healthcare, Inc. to begin pricing hospice service as part of PA

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Early Fall 2014, changes to coverage for

Drug Screening, including but not limited to:

• Max of 24 drug screens per calendar year

PA required for services over the limit

• Not covered:

Specimen integrity testing, urine alcohol testing, & confirmatory

testing, performed on the same day of service as a standard drug

test

Certain quantitative drug screens, when performed on the same day

as a drug screen service

Pre-Employment/employment, medicolegal, school-related or court

ordered drug screenings

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On 4/1/14, President Obama signed bill that included

delay of ICD-10 until October 1, 2015 at earliest

Molina and BMS are continuing ICD-10 preparations

BMS ICD-10 email ICD10@wv.gov

BMS ICD-10 webpage https://www.wvmmis.com/SitePages/ICD-10%20Transition.aspx

ICD-10 Testing with Providers

ICD-10 Readiness Survey

Policy Remediation for ICD-10 • New policy format recommended by CMS

• Current policy being revised and will be released in new format

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NOTE: This is a sample of the new policy format that BMS will be using when existing

policy is remediated for ICD-10 . This is not an actual policy.

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April 1, 2014 PTP edits related to

immunization administration with E&M

services

If MUE is less than units billed, entire

claim line denied

Appeals for PTP and MUEs to Molina • Reviewed by Certified Coder

• BMS Medical Director review, as appropriate

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Ordering/Referring/Prescribing provider that does not

bill WV Medicaid directly

If ORP not enrolled in WV Medicaid, then servicing

provider claim will not be paid

Edits to be implemented later this year

• Initially edits will be implemented with warning

message and claim will not deny

• After short period, edit will be set to deny claim

Edit for required ORP info by summer

Edit for enrollment status of ORP by end of 2014

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Beginning May 2014 • Letter or email to Providers from Phases 1 through 4

who have not completed revalidation • If no response, then BMS will place provider names,

NPI and address on website • 2 weeks later – Payhold • After 120 days on payhold - Participation with WV

Medicaid will be terminated • Process will continue with all provider phases

All providers must be revalidated by January 1, 2015

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CMS Adult Quality Measures, including

but not limited to: • Adult BMI Assessment

• Chlamydia, Breast & Cervical Cancer Screening

• Diabetes Care

• Hypertension

• Prenatal and Postpartum Care

• Post-hospitalization follow-up for Mental Illness

June 2014, Medical Record Requests

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Recovery Audit Contractor • Reprocurement initiated

• Target date = end of summer 2014

PCP Enhanced Payment audits underway

MIG audits • Hospice – reviewing records

• Labs – identifying providers

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DME

• BMS does not enroll Out-of-State DME providers unless

supplier is sole source

• DME Suppliers cannot provide the diagnosis or clinical

documentation on the Certificate of Medical Necessity form.

• The diagnosis and/or clinical documentation must be provided

by the ordering practitioner.

Transportation Claims

• Must include pickup and destination modifiers

Self-Disclosure

• Follow instructions on website

Impact of Failure to Disclose on Provider Enrollment

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Pediatric Dental Services transitioned to

Managed Care January 1, 2014

All WV Medicaid MCOs currently use Scion as

Dental Benefit Manager

Dental Billing Guide on BMS website

Dental Prior Authorization (PA) Requests

• Medicaid members in MCO – to Scion

• Foster children and Medicaid members not

enrolled in MCO – to APS Healthcare, Inc.

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WV Bureau for Medical Services (304 558-1700)

350 Capitol Street, Room 251

Charleston, WV 25301-3710

www.dhhr.wv.gov/bms

To send an email to BMS, go to website below, complete text boxes, & submit

• http://www.dhhr.wv.gov/bms/pages/contact.aspx

Medicaid Member Services (888-483-0797; 304-348-3365)

Medicaid Provider Services (888-483-0793; 304-348-3360)

Medicaid Pharmacy Help Desk (888-483-0801)

Rational Drug Prior Authorizations (800 847-3859)

APS Healthcare

• Customer Service (1-800-346-8272, ext. 6954)

• Clinical Support - WVMI: (1.800.642.8686)

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