Maternal Child Health Advisory Board Nevada Medicaid August 2, - - PowerPoint PPT Presentation

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Maternal Child Health Advisory Board Nevada Medicaid August 2, - - PowerPoint PPT Presentation

Jun 19, 2023 399 likes •610 views

Steve Sisolak Suzanne Bierman, JD, MPH Governor Administrator Division of Health Care Financing and Policy Maternal Child Health Advisory Board Nevada Medicaid August 2, 2019 EPSDT The Early and Periodic Screening, Diagnostic and

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Maternal Child Health Advisory Board Nevada Medicaid August 2, 2019

Steve Sisolak Governor

Suzanne Bierman, JD, MPH Administrator Division of Health Care Financing and Policy

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Division of Health Care Financing and Policy

EPSDT

  • The Early and Periodic Screening, Diagnostic and Treatment

(EPSDT) provides comprehensive and preventive health care services for children under 21 who are enrolled in Medicaid

  • Early: Assessing and identifying problems early
  • Periodic: Checking children's health at periodic, age-appropriate

intervals

  • Screening: Providing physical, mental, developmental, dental,

hearing, vision, and other screening tests to detect potential problems

  • Diagnostic: Performing diagnostic tests to follow up when a risk

is identified, and

  • Treatment: Control, correct or reduce health problems found

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Division of Health Care Financing and Policy

EPSDT, cont

  • Early and Periodic Screening, Diagnostic and Treatment

(EPSDT) services are preventive and diagnostic services available to most recipients under age 21.

  • In Nevada, the EPSDT program is known as Healthy
  • Kids. The program is designed to identify medical

conditions and to provide medically necessary treatment to correct such conditions.

  • Healthy Kids offers the opportunity for optimum health

status for children through regular, preventive health services and the early detection and treatment of disease.

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Division of Health Care Financing and Policy

LARCs

  • Medicaid has removed all barriers to family planning

counseling/education provided by qualified physicians. (e.g. Physicians, Rural Health Clinics/Federally Qualified Clinics, Indian Health Services/Tribal Clinics, and Home Health Agencies, etc.)

  • The physician must provide adequate counseling and information to

each recipient when they are choosing a birth control method.

  • If appropriate, the counseling should include the information that

the recipient must pay for the removal of any implants when the removal is performed after Medicaid eligibility ends. .

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Division of Health Care Financing and Policy

LARCs continued

  • Family planning education is considered a form of counseling intended to

encourage children and youth to become comfortable discussing issues such as sexuality, birth control and prevention of sexually transmitted disease.

  • It is directed at early intervention and prevention of teen pregnancy.
  • Family planning services may be provided to any eligible recipient of

childbearing age (including minors who may be considered sexually active).

  • Insertion of Long Acting Reversible Contraceptives (LARC) immediately

following delivery is a covered benefit for eligible recipients. LARC insertion is a covered benefit post discharge as medically necessary

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Division of Health Care Financing and Policy

Medical Necessity

103.1 MEDICAL NECESSITY Medical Necessity is a health care service or product provided for under the Medicaid State Plan and is necessary and consistent with generally accepted professional standards to:

  • A. diagnose, treat or prevent illness or disease;
  • B. regain functional capacity; or
  • C. reduce or ameliorate effects of an illness, injury or disability.

The determination of medical necessity is made on the basis of the individual case and takes into account:

  • D. the type, frequency, extent, body site and duration of treatment with scientifically based

guidelines of national medical or health care coverage organizations or governmental agencies.

  • E. the level of service that can be safely and effectively furnished, and for which no equally

effective and more conservative or less costly treatment is available.

  • F. that services are delivered in the setting that is clinically appropriate to the specific physical

and mental/behavioral health care needs of the recipient.

  • G. that services are provided for medical or mental/behavioral reasons, rather than for the

convenience of the recipient, the recipient’s caregiver or the health care provider. Medical necessity shall take into account the ability of the service to allow recipients to remain in a community-based setting, when such a setting is safe, and there is no less costly, more conservative or more effective setting.

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Division of Health Care Financing and Policy

Non Emergency Transportation

  • Nevada Medicaid contracts to provide non-

emergency transportation

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Division of Health Care Financing and Policy

Rates

  • Nevada FFS rates are established through the

Nevada State Plan which requires approval from the Center for Medicare and Medicaid Services.

  • Rates information

http://dhcfp.nv.gov/Resources/Rates/FeeSchedul es/

  • https://www.medicaid.nv.gov/hcp/provider/Hom

e/tabid/135/Default.aspx

  • Medicaid’s Managed Care Organizations (MCOs)

contract rates with providers.

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Division of Health Care Financing and Policy

Tubal Ligations

MSM 603.3

  • State and federal regulations grant the right for eligible Medicaid

recipients of either sex of childbearing age to receive family planning services provided by any participating clinics, physician,PA, APRN, CNM, or pharmacy.

  • Females, who are enrolled for pregnancy-related services only, are

covered for all forms of family planning, including tubal ligation and birth control implantation up to 60 days post-partum including the month in which the 60th day falls

  • Prior authorization is not required. In accordance with federal
  • regulations, the recipient must fill out a consent form at least 30

days prior to the

  • procedure. The physician is required to send the consent form to

the fiscal agent with the initial claim.

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Division of Health Care Financing and Policy

Katie Beckett

  • An eligibility option which allows the state to waive parental income and resources

for any child under 19 years of age and meets a level of care that would make the child eligible for placement in a hospital, nursing facility or Intermediate Care Facility for persons with intellectual disabilities.

  • These benefits are available to eligible children with disabilities who would not
  • rdinarily qualify for Supplemental Security Income (SSI) benefits because of

parental income or resources

  • If a child qualifies under this option, Medicaid covers all medically necessary

services as defined under the Medicaid State Plan

  • The cost of care must not be higher than the amount Medicaid would pay if the

child were institutionalized

  • There may be financial responsibility based on the parent’s income and resources

for those children qualifying under Katie Beckett Eligibility option.

  • Eligibility determinations are made the Division of Welfare and Supportive Services

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Division of Health Care Financing and Policy

Fetal Stress Test State Rates

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$- $5.00 $10.00 $15.00 $20.00 $25.00 $30.00 $35.00 $40.00 $45.00 NV Rate Oregon Idaho Wyoming Colorado New Mexico Arizona Utah Montana Surrounding State Avg.

59025 26 FETAL NONSTRESS TEST

* Based on a search of state Medicaid rates. For reference only

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Division of Health Care Financing and Policy

Vaginal Delivery Only Rates

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$- $200.00 $400.00 $600.00 $800.00 $1,000.00 $1,200.00 NV Rate Oregon Idaho Wyoming Colorado New Mexico Arizona Utah Montana Surrounding State Avg.

59409 ~ VAGINAL DELIVERY ONLY

* Based on a search of state Medicaid rates. For reference only

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Division of Health Care Financing and Policy

Comprehensive Vaginal Delivery Rates

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$- $500.00 $1,000.00 $1,500.00 $2,000.00 $2,500.00 $3,000.00 NV Rate Oregon Idaho Wyoming Colorado New Mexico Arizona Utah Montana Surrounding State Avg.

59400 ~ OB CARE ANTEPARTUM VAG DLVR & POSTPARTUM

* Based on a search of state Medicaid rates. For reference only

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Division of Health Care Financing and Policy

Cesarean Delivery Only Rates

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$- $200.00 $400.00 $600.00 $800.00 $1,000.00 $1,200.00 $1,400.00 NV Rate Oregon Idaho Wyoming Colorado New Mexico Arizona Utah Montana Surrounding State Avg.

59514 ~ CESAREAN DELIVERY ONLY

* Based on a search of state Medicaid rates. For reference only

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Division of Health Care Financing and Policy

Physician Rate Overview

Procedure Code Modifier Code Description Paid Svc Count NV Rate Oregon Idaho Wyoming Colorado

59025 26 FETAL NONSTRESS TEST 2,198

$ 29.73 $ 21.02 $ 25.20 $ 16.03 $ 28.16

59409 ~ VAGINAL DELIVERY ONLY 1,748

$ 840.57 $ 916.06 $ 689.05 $ 905.65 $ 736.92

59400 ~ OB CARE ANTEPARTUM VAG DLVR & POSTPARTUM 1,051 $ 2,144.73 $ 2,346.15 $ 1,759.34 $ 2,329.18 $ 1,214.86 59514 ~ CESAREAN DELIVERY ONLY 883

$ 945.68 $ 1,030.27 $ 774.77 $ 1,019.17 $ 863.78

59025 ~ FETAL NONSTRESS TEST 778

$ 48.06 $ 33.87 $ 40.19 $ 53.44 $ 35.46

59510 ~ OB ANTEPARTUM CARE CESAREAN DLVR & POSTPARTUM 538

$ 2,371.93 $ 2,598.00 $ 1,946.30 $ 2,574.30 $ 1,458.18

59410 ~ VAGINAL DELIVERY ONLY W/POSTPARTUM CARE 195

$ 1,070.75 $ 1,169.96 $ 878.89 $ 1,154.45 $ 804.34

59425 ~ ANTEPARTUM CARE ONLY 4-6 VISITS 142

$ 465.62 $ 510.64 $ 381.97 $ 508.29 $ 341.00

59515 ~ CESAREAN DELIVERY ONLY W/POSTPARTUM CARE 136

$ 1,297.11 $ 1,419.30 $ 1,064.74 $ 1,400.31 $ 934.35

59426 ~ ANTEPARTUM CARE ONLY 7/> VISITS 90

$ 832.98 $ 913.83 $ 684.86 $ 909.70 $ 610.39

15 * Based on a search of state Medicaid rates. For reference only

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Division of Health Care Financing and Policy

Rate Overview, Cont

Code Description NV Rate New Mexico Arizona Utah Montana

FETAL NONSTRESS TEST

$ 29.73 $ 32.14 $ 27.99 $ 23.49 $ 38.45

VAGINAL DELIVERY ONLY

$ 840.57 $ 968.26 $ 842.80 $ 801.52 $ 1,050.58

OB CARE ANTEPARTUM VAG DLVR & POSTPARTUM

$ 2,144.73 $ 1,909.67 $ 1,749.93 $ 2,029.33 $ 2,659.13

CESAREAN DELIVERY ONLY

$ 945.68 $ 1,142.71 $ 949.33 $ 801.52 $ 1,186.27

FETAL NONSTRESS TEST

$ 48.06 $ 40.70 $ 45.04 $ 60.07

OB ANTEPARTUM CARE CESAREAN DLVR & POSTPARTUM

$ 2,371.93 $ 2,164.73 $ 1,940.43 $ 2,029.33 $ 2,963.34

VAGINAL DELIVERY ONLY W/POSTPARTUM CARE

$ 1,070.75 $ 1,080.18 $ 1,075.81 $ 1,022.79 $ 1,341.44

ANTEPARTUM CARE ONLY 4-6 VISITS

$ 465.62 $ 368.78 $ 426.45 $ 437.85 $ 573.25

CESAREAN DELIVERY ONLY W/POSTPARTUM CARE

$ 1,297.11 $ 1,286.17 $ 1,306.69 $ 1,022.79 $ 1,634.89

ANTEPARTUM CARE ONLY 7/> VISITS

$ 832.98 $ 646.10 $ 763.99 $ 780.92 $ 1,020.26

16 * Based on a search of state Medicaid rates. For reference only

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Division of Health Care Financing and Policy

PA/APRN Rate Overview

Procedure Code Code Description Paid Svc Count NV Rate Oregon Idaho Wyoming

59025 FETAL NONSTRESS TEST 44

$ 37.94 $ 33.87 $ 34.16 $ 48.10

59409 VAGINAL DELIVERY ONLY 30 $

663.61 $ 916.06 $ 585.69 $ 815.09

59400 OB CARE ANTEPARTUM VAG DLVR & POSTPARTUM 23 $ 1,693.21 $ 2,346.15 $ 1,495.44 $ 2,096.26 59425 ANTEPARTUM CARE ONLY 4-6 VISITS 5 $

367.59 $ 510.64 $ 324.67 $ 457.46

59410 VAGINAL DELIVERY ONLY W/POSTPARTUM CARE 5 $

845.33 $ 1,169.96 $ 721.56 $ 1,039.00

59426 ANTEPARTUM CARE ONLY 7/> VISITS 3 $

657.61 $ 913.83 $ 582.13 $ 818.73

59430 POSTPARTUM CARE ONLY SEPARATE PROCEDURE 2 $

148.67 $ 207.00 $ 131.89 $ 185.77

59025 FETAL NONSTRESS TEST 1

$ 23.47 $ 21.02 $ 21.42 $ 14.43

59612 VAGINAL DELIVERY AFTER CESAREAN DELIVERY 1 $

745.02 $ 1,029.78 $ 657.48 $ 914.61

17 * Based on a search of state Medicaid rates. For reference only

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Division of Health Care Financing and Policy

PA/APRN Rate Overview, Cont

Procedure Code Code Description Paid Svc Count NV Rate New Mexico Arizona Montana

59025 FETAL NONSTRESS TEST 44 $

37.94 $ 36.63 $ 40.54 $ 54.06

59409 VAGINAL DELIVERY ONLY 30 $

663.61 $ 871.43 $ 758.52 $ 945.52

59400 OB CARE ANTEPARTUM VAG DLVR & POSTPARTUM 23 $

1,693.21 $ 1,718.70 $ 1,574.94 $ 2,393.22

59425 ANTEPARTUM CARE ONLY 4-6 VISITS 5 $

367.59 $ 331.90 $ 383.81 $ 515.93

59410 VAGINAL DELIVERY ONLY W/POSTPARTUM CARE 5 $

845.33 $ 972.16 $ 968.23 $ 1,207.30

59426 ANTEPARTUM CARE ONLY 7/> VISITS 3 $

657.61 $ 581.49 $ 687.59 $ 918.23

59430 POSTPARTUM CARE ONLY SEPARATE PROCEDURE 2 $

148.67 $ 127.44 $ 155.90 $ 207.68

59025 FETAL NONSTRESS TEST 1 $

23.47 $ 28.93 $ 25.19 $ 34.61

59612 VAGINAL DELIVERY AFTER CESAREAN DELIVERY 1 $

745.02 $ 977.16 $ 854.67 $ 1,072.12

18 * Based on a search of state Medicaid rates. For reference only

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Division of Health Care Financing and Policy

Rates

  • Nevada Medicaid rates are established in the Medicaid State Plan and are

approved by the Centers for Medicare and Medicaid Services (CMS) http://dhcfp.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/AdminSupport/ Manuals/MSP/Sec4/5%20- %204.19%20Attach%20B%20Pay%20for%20Med%20Care(1).pdf

  • The specific language for OB services provided by a Physician is found on 4.19-B,

page 1c, paragraph 5, part e:

  • e. Obstetrical Service Codes 59000 – 59999 will be reimbursed at 95% of the

Medicare non-facility rate.

  • The specific language for OB services provided by an Advanced Practitioner of

Nursing/ Physician Assistant/ Nurse Midwife is found on 4.19-B, page 1d, paragraph 6, part d.4:

  • 4. Obstetrical Service Codes 59000 – 59999 will be reimbursed at 75% of the

Medicare non-facility rate

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Division of Health Care Financing and Policy

Questions

Jodi Patton, MPA-HA Chief I, Medical Programs jpatton@dhcfp.nv.gov 775-684-3778

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