alabama medicaid agency medicaid "rules"

Alabama Medicaid Agency

Medicaid “Rules”

• Medicaid was established in 1965 by federal law to provide medical assistance to low income and resource individuals.

• States may choose to have a Medicaid program, but must comply with all federal Medicaid requirements once a program has been implemented.

• Funded through a federal and state partnership (generally 70/30 in Alabama)

“Rules”

• Federal law sets minimum eligibility and benefit levels.

• With few exceptions, Alabama’s program is at the federal minimum level for eligibility.

• Alabama has one of the most conservative benefit packages in the country.

• Medicaid cannot make any more program cuts and still be in compliance with federal regulations.

Don’t be confused…

• Medicaid is a federal and state program and provides medical assistance to low income and resource individuals.

• Medicare is a federal program to provide medical insurance generally to individuals aged 65 and older.

Challenges

• The benefits available to children enrolled in the Medicaid program are more comprehensive than almost any available private insurance.

• Restrictive federal regulations and resource limitations present challenges to program management

• Provider participation• Scope of services for adults

Challenges

• Enrollment as Entitlement• Multiple standards

– Adult eligibility extremely limited which discourages family units to have effective medical care

• Trusts and annuities circumvent requirements

• Match Rate • State can receive no less than 50% federal

match• Poor states pay disproportionately

• Part D MMA

Challenges

• Patient Education• Changing addresses• Minimal motivation to change behavior to more

appropriate use– Cannot incent recipients based on behavior

• Medical Inflation• New technologies• Life style drugs• Pharmacy ingredient cost driven by manufacturer

Challenges

• Provider Participation• Reimbursement Rates• Access to care

• Unfunded Mandates• Premiums and co-pays for Medicare recipients• The State is the final payer behind the Federal

government for those eligible for Medicare• EPSDT• MMA

• Medicare Modernization Act, 2003

• Health Insurance Portability and Accountability Act(Currently implementing NPI)

• Pryor Amendment, 1990 (Mandated open drug formulary)

• OBRA 1989 (Mandated the EPSDT program)

• CCA 1988 (Mandated coverage of QMB)

History of Unfunded Mandates

The Face of Medicaid

DemographicsFY 2003

Medicaid covers:• 19.9% of Alabama’s total population

(includes all eligibility categories)• 46% of all deliveries in Alabama• 37.1% of Alabama’s children (under 19)• 21.2% of Alabama’s elderly (65 and above)• 74% of nursing home residents in facilities

with certified beds (65% of all beds in Alabama)

Eligibility For Medicaid

• SOBRA Children– Federal minimum

•133% Poverty through age 5•100% Poverty age 6 through age 18

• Medicaid for Low Income Families (MLIF)– Adult with child in the home

•Less than 15% Poverty •$194 per month income for family of

four– Covers 15% of poverty families

Eligibility For Medicaid

• SSI related– Income level determined annually by

federal government– Disabled, aged, blind determined by

federal agency•$564 per month income for individual,

$846 for couple in FY 2004• Nursing Facilities/ Institutionalized

– 300% SSI•$1692 income per month in FY 2004•All but $30 per month applied to

facility payment

State Children on Medicaidunder age 21

Other63%

Medicaid37%

Growth in Eligibles

• 5.69% increase from 2002 to 2003

• 7.54% increase from 2001 to 2002

• 5.79% increase from 2000 to 2001

• Prior to 2000, historical growth was between 2 and 4%

• Increase has been seen primarily in children and QMB

0-523%

6-2031%

21-6432%

65 & over14%

Medicaid Eligibility by Age

High Medicaid Counties

These 13 counties have the highest concentration

of Medicaid eligibles across the general population

(30% or greater).

Bullock 33% Lowndes 34%Butler 32% Macon 30%Conecuh 30% Marengo 30%Dallas 41% Perry 44%Greene 40% Pickens 30%Hale 33% Sumter 40%

Wilcox 48%

These 14 counties have the highest concentration

of Medicaid eligibles across the children’s population (50% or greater).

Barbour 50% Greene 64%

Bullock 66% Hale 52%Butler 56% Lowndes 56%Conecuh 57% Perry 68 %Crenshaw 51% Pike 52%Dallas 66% Sumter 65%Escambia 50% Wilcox 71%

High Medicaid Counties

• In FY 2005, Medicaid will pay approximately $3.9 billion to providers for various health care services rendered; $2.8 billion represents federal funds brought into the State.

• Medicaid expenditures supported more than 84,323 jobs in various industries within the state.

1Economic Impact of the Alabama Medicaid Agency on the Economy of the State of Alabama and its Counties, Amy K. Yarbrough, MSHA, MBA, Administrative Fellow, University of Alabama at Birmingham

Economic Impact

• 5 counties receive Medicaid payments in excess of $100 million.

Jefferson $474 million Mobile $275 million Tuscaloosa $137 million

Madison $118 millionMontgomery $302 million

• 9 counties receive Medicaid payments in excess of $60 million.

• 16 counties receive Medicaid payments in excess of $40 million.

• 31 counties receive Medicaid payments in excess of $20 million.

Financial Impact by County

• Without Medicaid revenue, critical components of Alabama’s healthcare infrastructure could not continue to exist.

• 52% of the patient days at Children’s Hospital are paid for by Medicaid

• 77% of the patient days at USA Children’s and Women’s Center are paid for by Medicaid

Source: Information obtained from Medicare Cost Reports as filed.

Financial Impact by Hospital

Program Funding

Federal Funds72.07%

Benefit Payments96.52%

Administrative Costs

3.48%

State Funds27.93 %

Where It Comes From, Where It Goes

Pharmacy Factor

• Despite Alabama having one of the lowest annual growth rates in the country, Medicaid’s Pharmacy Program is the fastest growing area.

• Without question, the driving force behind the unsustainable growth is the cost of medications.

• Medicaid faced a $60 million state,$220 million total fund shortfall in FY 2004.

• Medicaid faced a $182 million state, $623.9 million total fund shortfall in FY 2005.

• Through the strong support of Governor Riley and the Alabama Legislature, Medicaid has been made whole for FY 2004 and 2005.

Budget Outlook

What percent of General Funddoes Medicaid receive?

16.10% 16.07%

18.94%18.53%

20.25% 20.42%

19.35% 19.16%

17.92%18.28%

25.61%

20.06%

15%

17%

19%

21%

23%

25%

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Need additional $65 million State funds• Loss of IGT for UPL payments $24.4 million• Inflation $36.4 million• Change in FMAP (69.41% from 70.83%) $52.4 million• 53rd week provider payroll $9.3 million• Medicare premium increase $ 6.6 million

Total $129.1 million

Assumptions: 3% inflation for all programs except Nursing Homes at 4% and Pharmacy at 15%

$50 million generated from Intergovernmental Transfers, $15 million from savings in Pharmacy program

FY 2006

Medicaid is a business that:• Places almost $4 billion into Alabama’s economy

• Contributes $2.7 billion new federal dollars into Alabama; almost $9 billion after the rollover effect

• Supports over 84,000 jobs

• Provides the cornerstone of Alabama’s healthcare infrastructure

Medicaid: The Industry

Medicaid is a business that:

• Is efficient compared to private health coverage

• Between 2000-2003, Medicaid per capita growth in the cost of acute care was 6.9%.

• For employer-sponsored health insurance, the growth is 12.6% and for all private insurance coverage is 9%.

• Nationally, Medicaid administrative costs are in the range of 4 to 6% while commercial insurers administrative costs are often well above 10%.

Medicaid: The Industry

Medicaid is a business that:

• Administers the second largest insurance program in Alabama

• Operates with one of the lowest administrative rates of any organization in the country at 2.6%. Over 97% of Medicaid’s total budget is spent on health care benefits and services for recipients

Medicaid: The Industry

Patient 1st

• Medical Home for eligible patients

• Constant source of primary care– Less reliance on Emergency Room care

• Coordination of referrals• Case management by physician• Specialized case management available when

needed

• Program accountability

• Historically 1,500 PMPs and 425,000 enrollees

Program Enhancements

Disease Intervention• Telemetry concept – in-home monitors communicate

with centralized database.

• Database alerts appropriate staff when intervention needed

• Partnership with USA Hospital and the Alabama Dept. of Public Health

• Target chronic diseases – initially Diabetes Mellitus– Monitor high risk patients for primary disease and

co-morbidities and care is directed by primary physician

• InfoSolutions• PDA tool for physicians• Download patient prescription

information each morning• Patient specific Preferred

Drug information • Alternative treatment options

• ePocrates

Program Enhancements

from

Blue Cross and Blue Shield of Alabama

A Medical Information NetworkA Medical Information Network

InfoSolutionsInfoSolutions

e-Prescribinge-Prescribing

Preferred Drug Program

• Preferred Drug Lists (PDL) offer an effective way to provide safe and effective therapy options in a cost efficient manner. 27 state Medicaid programs use a PDL and more are adding this component.

• Most employment-related insurance today use a preferred drug list.

• The new Medicare drug benefit is predicated on a system of formularies and preferred drug lists.

• Medicaid uses a Pharmacy and Therapeutics (P&T) Committee to conduct in-depth clinical reviews to insure safe and effective drugs are placed on the PDL.

• The PDL has been designed to foster safe and cost-effective drug therapy.

• Medicaid monitors the impact of the PDL and prior authorization.

• Based on Medicaid studies there has been no increase in other Medicaid costs as a result of pharmacy initiatives.

• Studies will continue to insure program costs in other areas are not adversely affected (ER, Hospital, Physicians).

Impact on Other Programs

Premise

Good oral health prevents pain, suffering,

missed days of school or work and unnecessary costs due to dental

treatment.

Why Is Good Oral Health Important?

• Dental related illness causes poor children to “miss” 12 times more school days than children from higher income families

• Poor oral health has been associated with other medical problems including heart disease and premature births

Is There An Oral Health Problem In Alabama?

• Two out of five Alabama schoolchildren are estimated to have untreated tooth decay

• Almost 70% of low-income children in Alabama did not visit a dentist last year

Is There An Oral Health Problem In Alabama?

• Alabama has 30% fewer dentists per capita than the nation and our dentists are not distributed evenly (38 dentists in Alabama versus 54 per 100,000 population nationally)

• One-third of all Alabamians over age 65 have no teeth, the 9th highest percentage in the country

Dental ProgramVision Statement

To ensure every child in Alabama enjoys optimal health by providing equal and timely access to quality, comprehensive oral health care, where prevention is emphasized promoting the total well-being of the child.

Alabama Medicaid Dental Program

• Approximately 450,000 Medicaid eligible children with limited access to dental services

• 8 counties with no Medicaid dentists or one Medicaid dentist

• Limited participation in other counties with most not accepting new Medicaid patients

Currently…..

• Increased dental rates to100% of BCBS 2001 rates

• More procedure codes covered

• Increased provider assistance

• Made case management services available

• Increased enrolled dentists to 700

Where to begin?

• Where do I find ______?

Alabama Medicaid Provider Manual

• Updates Quarterly

• Provides All Information on Policy and Billing

• Now Available on CD Rom

Chapters you need….

Chapter 1 Introduction

Chapter 2 Enrollment

Chapter 3 Eligibility

Chapter 4 Prior Authorization

Chapter 5 Filing Claims

Chapter 6 Receiving Reimbursement

Chapter 7 Rights and Responsibilities

Chapter 13 Dental

Appendix

• Appendix B Electronic Media Claims (EMC) Guidelines

• Appendix E Medicaid Forms

• Appendix G Non-Emergency Transportation (NET)

• Appendix I Outpatient Hospital and ASC Procedures

• Appendix J Explanation of Benefit Codes

• Appendix K Third Party Carrier Codes

Appendix L AVRS Quick Reference Guide

• Appendix N Medicaid Contact Information

Come On Board!!!

• How do I become a provider?– For an enrollment application Contact

•EDS provider enrollment unit 1-888-223-3630 •Medicaid’s dental program 1-334-242-5997

– EDS issues a 9 digit provider number (effective the first day of the month the application is received)

– You must receive a provider number for each physical location where you perform services

Provider’s Rights

• Keep records for 3 years plus current

• Provide same services to Medicaid patients as all other patients

• Can bill recipients when services are non-covered or patient exceeded limits

• Can limit number of patients seen, days seen or ages

Chapter Three--EligibilityWho is eligible?

Three important questions to ask…

– Are they eligible?

– Are they under the age of 21?

– Do they have full Medicaid benefits?

Verifying Eligibility

Three Primary Ways

1. Provider Electronic Solutions Free Software provided by EDSQuick response time - one at time or in

batches

2. Automated Voice ResponseToll free Number 1-800-727-7848Available 23 hrs/day, 7 days per week

3. Point of Service DeviceSwipe cardMust be purchased from a vendor

Provider Assistance Center

Toll free number 1-800-688-7989 • Speak with a live person • Verify up to 6 recipients at a time

Remember – Must have full Medicaid

coverage and – be under age 21 (see Chapter

3/page 11 of Provider Manual)

Dental Benefit Information

• Provides last two PAID dates of service for the following codes:• Panoramic X-rays – D0330• Full Series X-rays – D0210• Oral Exams – D0120 or D0150• Prophylaxis/Fluoride – D1110, D1120,

D1201, D1203, D1204, D1205• Space Maintainers – D1510, D1515,

D1520, D1525, D1550

Third Party Liability (TPL)

• Verify at each visit

• Apply all payments received toward services rendered

• If incorrect - update recipient file by calling:A-G 334-242-5280H-P 334-242-5254Q-Z 334-242-5279

Prior Authorization

• Who…

• What…

• When …

• Where?

How to Obtain a Prior Authorization

• Use the Prior Authorization Dental Request Form (form 343) in provider manual Chapter 4 (can copy)

• Mail to: EDS PO Box 244032 Montgomery, AL 36124-4032

• Note: X-rays must be mailed in a separate sealed envelope

Prior Authorization

Some of the services requiring Prior Authorization

– Complete Bony Extractions

– Periodontics– Space Maintainers

after the first two

Inpatient and Outpatient Hospitalization

• Required for children ages 5 through 20 when medical criteria is met

• Not required for children under age 5

• Reimbursed for recipients older than 21 when dental problems have exacerbated underlying medical condition

Hospital Care

• Dentists must have all procedures loaded to prior authorization file to get paid

• Use correct place of service

• Hospitals use D9420 for payment for facility fee

• Must receive prior authorization number from dentists for children 5 or greater

Emergency Prior Authorization

• Call the Dental Program at 334-242-5997– Talk with staff or leave a voice message

with the following information:

– Recipient’s name and Medicaid number– Provider number of dentist– Phone number of dentist– Fill out Prior Authorization Request Form

343 and mail that day

Chapter 13Dental Program

• Examinations

– D0120 Periodic: Once every six months (not to the date/within the same month)

– D0140 Limited oral: Problem focused, once per recipient per provider per year and cannot be billed in conjunction with periodic or comprehensive. Need to document what done.

– D0150 Comprehensive: Once per recipient per provider, must document!

Radiology • Full mouth and panoramics are

covered every three years at age 5

• Posterior bitewing and single anterior can be taken every six months

• BW-4 Films limited to age 13 and older

• Must be of diagnostic quality

Space maintainers

• Non-covered for premature loss of primary incisors and placed greater than 180 days after the premature loss of a primary tooth

• Non-covered for permanent tooth

• Limited to one per recipient’s lifetime for a given space to be maintained

Crowns and Core Buildups

• Covered following root canal therapy ONLY

• Crowns limited to permanent teeth

• Recipients must be 15 years of age

• Cast post and core must beradiographically visible, one-half length of canal

• Must have post-op x-ray after crown inserted

What if the root canal is not in paid claims history?

• Send in for an administrative review with a clean claim and x-ray showing completed root canal therapy and crown inserted

• Only send claim with procedures needed for review

• Send to the Medicaid Dental Program

Palliative (Emergency) Treatment D9110

• This must not be billed with definitive treatment or emergency procedures

• These procedure codes include -D0210 -D0350 -D0470 -D9220 -D9610-D1110 through D7971

Non-Covered Services

• These include, but are not limited to dental implants, prosthetic treatment (bridgework, partials or dentures), esthetic veneers and adult dental care.

• Refer to Provider Manual Chapter 13 for details.

• Show me the money!

Reimbursment

Paper Claims

• Only ADA-approved claim forms are acceptable

Version 2002,2004

• OCR Scannable form recommended

• CDT2005 codes must be used (D-codes)

• Instructions located in the Provider Manual Chapter 5

When it is required to send a paper claim?

• When filing:– Accident Form XIX-TPD-1-76– Third Party Denial– Administrative Review/ Override

Why bill electronically?

• Less than two week turn-around on claims

• Immediate claim correction

• Enhanced online adjustment functions

• Improved access to eligibility information

Enhances effectiveness and efficiency

Enhancements

• Can now use LAN, ISP or DSL connection

• View EOP within software

• Claim status

• Send adjustments/reversals electronically

Important Facts to remember…

• Tooth numbers 1-9 must have a “0” in front when billing (example 01)

• Primary teeth - use letters

• Supernumerary teeth – NEW VALUES!

• Place of service codes include:– 11 office– 22 outpatient, requires prior authorization– 21 inpatient, requires prior authorization – 31 nursing facility, requires prior

authorization

Oral Cavity Codes

• 00 – Full Mouth

• 01 – Upper Arch

• 02 – Lower Arch

• 10 – Upper Right Quadrant

• 20 – Upper Left Quadrant

• 30 – Lower Left Quadrant

• 40 – Lower Right Quadrant

Filing Limit

• Medicaid requires all claims for Dental providers be filed within one year of date of service.

• Providers should process claimsfor payment as soon as service is completed.

• 120 days from other insuranceEOP date

• 120 days from adjustment, if past the filing limit

Administrative Review

• Must be received within 60 days of the date the claim became outdated

• Must have documentation showing attempts to get claim paid (see Chapter 7-6)

• Mail to:Alabama Medicaid AgencyDental Program Administrative ReviewPO Box 5624Montgomery, AL 36103-5624

EDS

• Common reasons for returned claims and denials

• Update on Provider Relations

• Statistics on electronic filing

Smile Alabama!

• Primary goals: – Increase number of Medicaid dental providers– Increase number of children receiving dental

care

• Other goals: – Provider training and support– Patient education– Assistance with claims processing– Patient education tools/resources

Medicaid’s Dental Outreach Initiative

Targeted Case Management

Case management by social workers and nurses available through the EPSDT program

– Assistance with patient education, follow-up on missed appointments, coordination of services, transportation. New HRSA Grant received to evaluate the effectiveness

Contact Medicaid for the social worker in your area

Available Tools

• Alabama Medicaid Provider Manual– “The Book” to have/ also on CD-Rom– Policy/procedure information on all Medicaid Programs

• Provider Insider Newsletter– Published bimonthly– Policy changes and clarification on existing policy

• Alert Bulletins– “Urgent” information published as needed

• Dental Messenger– Published through Smile Alabama! initiative– Issues related to the Medicaid Dental Program for

dentists

More Tools

Mini Messages– Part of EOP statements– Gives status of system problems/claims issues

– Notice of any recoupments/re-processing of claims

Medicaid Web site (www.medicaid.state.al.us)– Contains contact information– Forms– Provider Notices– Fee Schedules

Important Numbers To Remember

• Medicaid– Dental Program (Policy Questions) 334-242-5997

Fax 334-353-5027– Recipient Inquiry Unit (Toll-free) 1-800-362-1504– Outreach/Education (Educational Materials)

334-353-5203

• EDS– Provider Assistance Center (Billing Issues)

1-800-688-7989– Provider Enrollment (Enrollment Issues)

1-888-223-3630– EMC (Electronic Claims Submission Issues)

1-800-456-1242

NETNon-Emergency Transportation

• Requires Prior Authorization • Provides transportation vouchers to

patients (like a check)• Vouchers must be signed by dentist• Covers one escort for recipients under 21• Must be done 5 days prior to appointment,

unless urgent• Call 1-800-362-1504, press #3

Things to look forward to….

Program Integrity

• Medicaid will insure that payments are made to legitimate providers for legitimate services for legitimate recipients.

• Medicaid has enhanced efforts to recover inappropriately paid funds, overpayments and address fraud, waste, and abuse.

Appropriate Payments

• Medicaid is working with Health Watch Technologies (HWT) to further insure payment integrity.

• HWT will provide a cross functional team to include professionals in medicine, law, public policy, hospital administration, nursing, mental health, and data analysis.

Review Algorithms

Examples of review algorithms

• CDT and HCPC coding guidelines to insure appropriate billing of comprehensive codes, mutually exclusive codes, and modifier use

• Regulation and policy based rules to include coverage limitations and non-covered services

• Unbundling review of lab and ER services, surgical procedures and procedures

Review Algorithms

Examples continued:

• Unreasonable volume to indicate excessive units of a service

• Duplicate billings of the same claim or same service by multiple providers

• Recipient utilization of narcotics, or other services that indicate potential drug seeking behavior

Benefits for Providers

• Clarifies billing rules and policies that may be confusing

• Reduces need to resubmit claims and additional documentation

• Reduces the number of on-site audits

National Provider Identifier…NPI

• Covered providers can begin applying for NPIs May 23, 2005

• Compliance date applicable to most entities is May 23, 2007– By this date, covered

entities must use only the NPI to identify providers in standard electronic transactions.

– http://nppes.cms.hhs.gov– www.ada.org

NPI: The Concept

• Provides the ability to bill all health plans uniformly – no longer necessary to use different identifiers for different health plans, contracts, locations

• Billing will be simplified

• COB payments will come sooner

• If 100% paper, does not apply

Healthy Smiles for

Healthy Children

It’s All About

Questions….