Fall Provider Workshops 2017 West Virginia Department of Health - - PowerPoint PPT Presentation

Fall Provider Workshops 2017

West Virginia Department of Health and Human Resources Bureau for Medical Services (BMS)

Sarah Young, Deputy Commissioner Joy Dalton, Director of Provider Services Dee Ann Price, Quality Unit Director

September 18-Flatwoods, WV

September 19-Charleston, WV September 20-Huntington, WV September 21-Beckley, WV September 25-Martinsburg, WV September 26-Morgantown, WV September 27-Wheeling, WV September 28-Vienna, WV

West Virginia Medicaid Enrollment Update

As of August 20, 2017, West Virginia Medicaid covered 555,402 individuals - approximately 30% of West Virginia’s population:

• Fee-for-service (FFS), i.e., traditional/regular Medicaid:
• 133,135 members are currently enrolled
• Includes foster care children, Medicaid Waiver recipients, nursing

facility residents, elderly/disabled, and those who receive Medicare

• Mountain Health Trust (MHT), the State’s Medicaid Managed Care Program:
• 422,267 members are currently enrolled
• Includes most children, pregnant women, adult expansion, parents

and caretaker relatives

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Managed Care Update: Carved Out Services

What benefits are NOT included in the Managed Care Plans?

• Transplants
• Nursing Facility Services
• Medicaid Waiver Services
• Aged and Disabled Waiver (ADW)
• Intellectual and Developmental Disabilities Waiver (IDDW)
• Traumatic Brain Injury Waiver (TBIW)
• Non-Emergency Medical Transportation (NEMT)*
• Personal Care Services
• Pharmacy

For these services, providers will continue to send claims to Molina for all members (FFS and MCO). *NEMT services are provided and paid for by Medical Transportation Management (MTM).

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Managed Care Update: Contacts

MCO Contact Information:

• Aetna Better Health of West Virginia (formerly CoventryCares)

Michelle Coon, Chief Operations Officer, phone: 304-348-2017, email: mcoon@aetna.com

• The Health Plan

Christy Donohue, Director, Medicaid, phone: 304-720-4923, email: cdonohue@healthplan.org

• UniCare Health Plan of West Virginia

Terri Roush, Manager, Network Relations, phone: 304-989-5471, email: terri.roush@anthem.com

• West Virginia Family Health

Jason Landers, President, phone: 304-424-7738, email: Jason.landers@highmark.com

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Medicaid 1115 Waiver Proposal – SUD Services

West Virginia Medicaid is in the final approval stages of the section 1115 waiver application submitted to the Centers for Medicare and Medicaid Services (CMS) that describes an approach to addressing the Substance Use Disorder (SUD)

• epidemic. Implementation is tentatively scheduled to begin January 1, 2018.

Medicaid benefit expansions under the waiver include:

• Statewide adoption of the screening, brief intervention, and referral to

treatment (SBIRT) method to ensure a consistent and effective diagnosis and enrollment process.

• Expanded coverage of withdrawal management in regionally identified settings.
• Coverage of a set of clinical and peer recovery support services and recovery

housing supports designed to promote and sustain long-term recovery.

• Short term, residential substance abuse treatment for MCO members.
• Enhanced access to outpatient treatment, as appropriate, when residential

treatment is not required.

• Coverage of methadone and methadone administration as part of the state’s
• pioid treatment program.
• A comprehensive initiative for distributing naloxone and cross-training staff on

administration of naloxone as part of the effort to reduce overdose deaths.

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BMS Program Updates

Take Me Home, West Virginia:

• Supports eligible Medicaid members to transition from

facility-based, long-term services and supports to their own homes and apartments in the community.

• Has two transition navigator partner agencies:
• Metro Area Agency on Aging (AAA)
• Coordinating Council for Independent Living (CCIL)
• Has approximately 11 full-time equivalent (FTE) transition

navigators across West Virginia.

• For more information about Take Me Home, West Virginia:
• Website: www.dhhr.wv.gov/bms/Programs/Takemehome
• Phone: 304-356-4926

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BMS Program Updates (Cont.)

BMS Quality Unit:

• CMS Adult Quality Measures (AQM) Grant extended to December

2017.

• Reporting to CMS Quality Core Measures.

Quality Improvement Projects (QIPs):

• Prenatal behavioral health risk assessment and postpartum care

visit.

• Implemented in the MCOs January 2017.
• Increasing follow-up rate after hospitalization for mental illness.
• Implemented in pilot hospital June 2016 – November 2016.
• Rate of members keeping follow-up appointment after discharge from the

pilot hospital increased by 23.46%. Look for the “Quality Corner” in Medicaid Provider Newsletter updates.

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BMS Program Updates (Cont.)

West Virginia Health Homes:

• The first Health Homes Program, launched July 1, 2014, for Medicaid

members with bipolar disease who have or are at risk of having Hepatitis B

• r C, was expanded statewide in April 2017.
• Second Health Homes Program launched April 1, 2017 in 14 counties to

address the co-occurring conditions of diabetes, pre-diabetes, obesity and have or are at risk of anxiety/depression.

• To participate in either of these Health Homes Programs, please list your

contact information on the workshop evaluation.

• Additional Health Homes Program information is available on the BMS

website: www.dhhr.wv.gov/bms/ and the KEPRO website: www.kepro.com.

• Questions/concerns - contact KEPRO at 304-343-9663 or 1-800-461-0655.

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BMS Program Updates (Cont.)

Medicaid NEMT Broker is MTM (Medical Transportation Management): Recent NEMT statistics:

• Trips scheduled:
• July 2017 = 112,537
• Calendar Year 2017 to date = 867,789

BMS is currently in the process of reprocuring a vendor to provide NEMT Broker services and hopes to have the new contract awarded by early 2018.

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BMS Policy Update

July 13, 2017:

• Final rule 42 CFR 484 for Home Health in effect, to be

implemented by January 2018. August 29, 2017:

• Chapter 527 Managed Care Program was posted for Public
• Comment. Comments will be processed and posted with final

policy update. Upcoming Changes to Provider Enrollment:

• Direct Care Workers

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Provider Enrollment Update

June 1, 2017:

• West Virginia Medicaid must be in compliance with the Fingerprint

Based Criminal Background Check (FCBC) requirement of the February 2, 2011, federal regulations on provider enrollment and screening.

• FCBC requirement applies to certain provider types enrolled on and

after August 1, 2015, including, but not limited to:

• Home Health
• Durable medical equipment, prosthetics, orthotics and supply

providers (DMEPOS)

• Providers who have been excluded in the past 10 years
• Any other providers designated as “high risk” by BMS or CMS
• Providers enrolled in Medicare or another state’s Medicaid or Children’s

Health Insurance Program (CHIP) and who have already had a FCBC do not have to undergo another check.

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Provider Enrollment Update (Cont.)

• West Virginia Medicaid working with West Virginia Clearance for

Access, Registry and Employment Screening (WV CARES) Program to implement FCBC process.

• Providers are responsible for FCBC-related fees. Check must be

mailed to Molina prior to fingerprinting.

• Providers will have 30 days from date of notice to complete FCBC.

August 1, 2017:

• New EFT forms are available on the State Auditor’s Website

(https://www.wvsao.gov/) to be completed with new enrollment and maintenance. December 31, 2017:

• All current MCO providers must be enrolled with West Virginia

Medicaid or the MCO will terminate the provider contract.

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Provider Enrollment Update (Cont.)

January 1, 2018:

• Molina will begin screening new MCO network providers who must

have a participation agreement in effect with the State Medicaid agency, even if they do not plan to participate in the Medicaid FFS program.

• Managed Care Federal Rule (March 2016) stated Medicaid has ultimate

responsibility for screening, enrolling, and periodically revalidating all Medicaid MCO network providers.

• MCO network providers will also be subject to revalidation.

June 1, 2018:

• Cycle 2 Provider Revalidation will begin for West Virginia Medicaid

providers which will include MCO providers, as applicable.

• Provider Revalidation is required at least every five years for Medicaid

providers under 2011 Federal regulations for Provider Screening and Enrollment.

• Revalidation date is based on most recent effective date.

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Provider Enrollment Update (Cont.)

Since August 2015, specific West Virginia Medicaid enrolled providers have the

• pportunity to determine presumptive eligibility:
• Hospitals
• Federally qualified health centers
• Rural health clinics
• Comprehensive community behavioral health centers
• Free clinics

Entities interested in becoming an approved presumptive eligibility provider must:

• Be a Medicaid enrolled provider,
• Submit a presumptive eligibility enrollment package to BMS, and
• Complete an online training course.

Medicaid Presumptive Eligibility Program information: http://www.dhhr.wv.gov/bms/Pages/default.aspx

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Unenrolled Prescriber Edit:

• West Virginia Medicaid has opted for a phased-in approach for

remaining unenrolled prescribers to mirror Medicare’s approach.

• Unenrolled Prescriber Edit means that prescriptions (new or refill)

written by providers who are not enrolled with West Virginia Medicaid on January 1, 2019, will be denied. This edit applies to all providers who prescribe, including those newly eligible to enroll as part of revalidation (i.e., hospital residents, physician assistants).

Provider Enrollment Edits

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Program Integrity Update

Provider Screening of Employees and Contractors:

• West Virginia Medicaid is required by CMS to direct providers to:
• Screen employees and contractors for excluded persons to

prevent Medicaid payments for items/services furnished or

• rdered by excluded individuals and entities.
• Search the Office of Inspector General’s List of Excluded

Individuals and Entities (LEIE) monthly to capture new exclusions or reinstatements that occurred since the last search.

• LEIE’s online searchable database:

https://exclusions.oig.hhs.gov/.

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Medicaid ID Cards

Goals and Objectives:

• Achieve administrative savings
• Maximize investment in eligibility verification technology
• MMIS web portal: www.wvmmis.com
• Molina Automated Voice Response System (AVRS)

(1-888-483-0793)

• Aligns with feedback from Spring 2017 Provider Workshops
• 99% report having access to the internet
• 89% indicate they already use portal and/or AVRS
• 75% indicate that less than 50% of members bring cards to

appointments

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BMS Resources

West Virginia Department of Health and Human Resources, Bureau for Medical Services (West Virginia Medicaid) Mailing address: 350 Capitol Street, Room 251 Charleston, WV 25301 Telephone: 304-558-1700 Website: http://www.dhhr.wv.gov/bms Medicaid Fee-for-Service (FFS) Molina – Fiscal Agent: https://www.wvmmis.com/default.aspx KEPRO (formerly APS Healthcare) – UM Contractor: http://wvaso.kepro.com HMS – TPL Contractor: http://www.wvrecovery.com Medicaid Managed Care (Mountain Health Trust) Maximus – Enrollment Broker: https://www.mountainhealthtrust.com MCOs – Aetna Better Health of WV, The Health Plan, UniCare, & WV Family Health Scion – Dental Benefits Manager: www.sciondental.com FFS & Managed Care MTM – NEMT Broker: https://www.mtm-inc.net/west-virginia Phone: 1-844-549-8353 Fax: 1-844-239-5970

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Pharmacy Program Update

West Virginia Department of Health and Human Resources Bureau for Medical Services (BMS)

Vicki Cunningham, Director of Pharmacy Services Bill Hopkins, Pharmacy Operations Manager Brian Thompson, Drug Utilization Coordinator

Medicaid Pharmacy Services Benefit

On July 1, 2017, Pharmacy Services were carved out of Managed Care Benefit.

• Prior Authorization Vendor - Rational Drug Therapy Program

Phone: 800-847-3859 FAX: 800-531-7787

• Provides prior authorization service for prescriptions written for

self-administration or to be administered in the home setting (home infusion).

• Billed by the pharmacy with a National Drug Code (NDC).
• Cannot provide prior authorization services for drugs to be

administered in an infusion center or a prescriber’s office and billed with a J Code (known as Buy and Bill).

• BMS maintains that prescribers have the right to determine the

most appropriate site of administration for their patients’ medications to assure safe and effective treatment.

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Medicaid Pharmacy Service Benefit: Exceptions

FFS Covers:

• Prescriptions dispensed by a pharmacy to be administered at

home AND obtained by the member ONLY with a prescription

• Clotting Factor for Hemophilia
• Spinraza

MCO Covers:

• Drugs administered in an office setting, facility, or infusion

center, billed with J-Codes/HCPCS code.

• Administration of these drugs

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Medicaid Pharmacy Service Benefit: Exceptions

If a prescription is written for the following drugs, they will be covered by the FFS Pharmacy Program, but can be administered in the prescriber’s

• ffice. If prescribers choose to buy and bill these products with a J Code,

they should check with the MCO first to assure coverage.

• Depo-Testosterone
• Injectable Progestin Contraceptives
• Vaccines
• Synagis
• Remicade
• Lupron Depot
• IVIG
• Neulasta
• Neupogen
• Oncology Agents
• Makena

NOTE: Drugs billed as medical claims with a J Code must be billed to the

• MCOs. Prescriptions written for a pharmacy to fill are billed to the FFS

Pharmacy Program.

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Medicaid Pharmacy Services Benefit: Contacts

West Virginia Medicaid Pharmacy Services Office: Email: DHHRMedicaidPharm@wv.gov Prior Authorization Vendor - Rational Drug Therapy Program: Phone: 800-847-3859 FAX: 800-531-7787 Molina Provider Services: Phone: 888-483-0793 Molina Pharmacy Help Desk: Phone: 888-483-0801

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