healthy connections checkup - sc dhhs · • beginning aug. 1, 2014, healthy connections checkup...
TRANSCRIPT
Healthy Connections Checkup
South Carolina Healthy Connections Medicaid
Overview and Enhancement
Overview
• What is Checkup? • Healthy Connections Checkup is a Medicaid limited benefit
program. This program was previously called “Family Planning”.
• Who is Eligible for Checkup? • Men and Women in South Carolina with an income at or below
194% FPL who are ineligible for any other Medicaid program.
• Why the New Name? • Beginning Aug. 1, 2014, Healthy Connections Checkup will include
benefits that enable a more holistic and comprehensive provision of not only Family Planning and Family Planning-related services, but also new preventive health screenings.
• The new name helps communicates the enhancement in addition to the importance of preventive health care for the eligible population.
Introducing Healthy Connections Checkup
Enhancement
• Enhancement • Update the benefit structure for the current Family Planning-Only
benefit category to include a comprehensive biennial (once every two years) physical examination and screenings/labs recommended by the U.S. Preventive Services Task Force
• Goals • Enable providers to make informed decisions regarding the
selection of an appropriate contraceptive method • Promote the utilization of preventive health care in order to
improve health outcomes for families in South Carolina • Expected Outcomes
• Regular preventive screening of members • Identification of health problems that may negatively impact
members in this eligibility category • Strong referral network to connect members to systems of care
Enhanced Benefit for Healthy Connections Checkup
New Screenings Behavioral & Mental Health screenings Cholesterol abnormalities screening Diabetes screening Hepatitis C virus infection screening Obesity screening and counseling Breast cancer screening (mammography) Abdominal Aortic Aneurysm screening Colorectal cancer screening Lung cancer screening for smokers
*Please refer to the U.S. Preventive Services Task Force guidelines (Grade A & B) for preventative screening standards. Screenings vary
by age, gender and risk factor.
Cards
Healthy Connections Checkup Cards
Goals
Goals
Increase the number of beneficiaries enrolled in Checkup
• Estimated eligible ~ 447,000 • Currently enrolled ~ 110,000 • Target is to raise total enrollment to
~ 200,000 by end of SFY15
Goals
Ensure that Healthy Connections Checkup members have access to and
receive biennial, comprehensive physical examinations and appropriate
screenings
(according to U.S. Preventive Services Task Force recommendations by age, gender and risk
factor)
Goals
Connect Healthy Connections Checkup members to systems of care (including
FQHCs, RHCs, free clinics, hospital clinics etc.) by strengthening the referral system that serves this population
Goals
Identify the health status of Healthy Connections Checkup members in order
to gain a better understanding of the existing conditions/problems in the uninsured population in the state
Data Needs
Data
• Enrollment • Total number enrolled • Newly enrolled • % of total eligible enrolled • Utilization of those enrolled
• Referrals • Number of referrals made • Number of referrals attended
• Screenings • Prevalence per disease/positive screen • Incidence per disease/positive screen
Data
• Providers • Type (PA, NP, MD/DO) • Practice structure (FQHC, RHC, free
clinic etc.) • Location • Patient volume
• Pregnancy • Incidence • Medicaid status
Referral Process
Referrals
• Importance of Referrals • Checkup members have Medicaid coverage for certain preventive
screenings. • Checkup members do NOT have coverage for follow-up
care/treatment. • Where to Refer Checkup Patients
• Providers that can offer care based on the patient’s income. • Examples include free clinics, FQHCs, RHCs, Hospital clinics that
provide charity care, etc. • Referral Procedures
• SCDHHS allows provider to bill for referrals (face-to-face and phone).
• This process was established to compensate providers for administrative costs associated with referrals AND to collect important data on the health status of the Checkup population.
Referral Process for Healthy Connections Checkup
Referral Process for Healthy Connections
Checkup Providers
Referral Types
Referral Type 1
Preventive health screening performed during physical exam
Provider receives screening results
immediately
*Referral made immediately (or same day) following exam
* Referral code billed on the same claim as
the physical exam
Same-Day Referral
Examples Include: • A1C (Instant) • HIV (Instant) • Mental / Behavioral Health Screening
Referral Type 2
Different Day Referral
Preventive health screening performed during physical exam
Provider receives screenings results 1 or
more days after the physical exam is
performed (i.e. no lab on site)
*Referral made on a different day than exam
* Referral billed on a separate claim that contains ONLY the referral code and
diagnosis code (V70.0)
Examples Include: • Hepatitis C • Cancer screenings • Other non-instant blood tests (diabetes / lipid)
Referral Type 3
Referral for Another Preventive Screening
Physical performed
Provider does not have the ability to perform
certain preventive, age-specific health
screenings
*Provider refers patient to a different provider who has the ability to
perform the preventive health screening
* Providers cannot bill for this type of referral
Examples Include: • Mammography • Colonoscopy • AAA Screening • Lung Cancer Screening
Billing for Referrals
Billing for Referrals
• Telephone Referral • Can be performed by RN or above • Does not require the patient to
come back to receive test results • Can be used for the following:
– Same-Day Referrals – Different-Day referral where
patient results can be explained over the phone
– Examples include referrals for instant results, referrals for different day diabetes, etc.
• In-Person Referral • Can be performed by NP/PA or
above • Requires face-to-face interaction
with the patient • Can be used for the following:
– Different-Day referral where patient results must be explained in-person before a referral to a new provider is made
– Examples include referrals for positive cancer screen, referrals for positive HIV screen, etc.
S0320 – Telephone Referrals S0316 – Face-to-Face Referrals
Referral Codes
Billing for Referrals
Referral Code Modifiers • Both Referral Codes (S0320 & S0316) must contain the
diagnosis code (V70.0) and 1 or more modifiers • Claims without at least 1 modifier will be rejected • Modifiers are required to specify the type of positive
screenings that resulted in a referral to a new provider • Up to 4 modifiers can be used with the referral code
Billing for Referrals
• P1 = Referral made for Diabetes Screening • P2 = Referral made for Cardiovascular Disease • P3 = Referral made for results of any cancer screening
(breast, colon, lung) • P4 = Referral made for any mental health / behavioral
health / substance abuse screening • P5 = Referral for other condition
Referral Code Modifier Options
Timeline
Timeline
Aug. 1, 2014: Effective date of benefit enhancement
• Provider education and training • Current member education • Strengthen referral network