Presentation to the House Appropriations Committee Tamela Griffin - - PowerPoint PPT Presentation

Presentation to the House Appropriations Committee

Tamela Griffin

Acting Deputy Associate Commissioner for Policy & Program, Medicaid & CHIP Services

Victoria Grady

Deputy Director, Rate Analysis

March 21, 2018

3/19/2018 2

Timeline of Therapy Policy and Rate Changes

2016-17 GAA, Rider 50

• Directed agency

to achieve $150 million in GR savings over the biennium related to therapy services

Therapy Medical Policy Changes

• Clarified medical

necessity criteria

• Defined therapy

functional goals to align with modern best practices

• Began tracking

services provided by therapy assistant with use of a modifier

Reimbursement Rate Change

• Changed fee-for-

service rates for therapy services

Rate and Policy Changes

• As directed by 2018-

19 GAA, Rider 59, partial rate restoration

• Changed speech

therapy reevaluation reimbursement rate

• Standardized billing

across provider types according to national coding guidelines

• Clarified policy on

untimed speech therapy visit

Rate Change

• Reduction of

therapy assistant rate to 85 percent

• f the rate for

licensed therapists *

September 1, 2015 May 1, 2016 December 15, 2016 September 1, 2017 December 1, 2017

* Rider 59 directed a reimbursement rate reduction for therapy assistants at 85% on December 1, 2017 and 70% on September 1, 2018.

Rider 59: 25% Reduction Restoration Reimbursement Rate Equalization

Rate Effective on 12/15/16

Home Health Agency Therapy Services

$135.14 $100.34 $109.04 $109.04

$39.78

Per 15 min unit

Billing Unit Standardization**

Comprehensive Outpatient Rehabilitation Facilities/Outpatient Rehabilitation Facilities (CORF/ORF) Therapy Services

$111.65

Independent Therapy Services

$104.09

Unit 1

Prior to 12/15/16 $107.78 ***

$28.67

Per 15 min unit

$31.45

Per 15 min unit

$31.25

Per 15 min unit

$28.67

Per 15 min unit

$29.32

Per 15 min unit

$159.12

Total allowable fee

$114.68

Total allowable fee

$125.80

Total allowable fee

$125.00

Total allowable fee

$114.68

Total allowable fee

$117.28

Total allowable fee

** In accordance with federal standards and coding guidelines, policy changes were implemented to standardize each code’s billing unit, either as a 15-minute or encounter unit. *** Rider 59 directed a reimbursement rate reduction for therapy assistants at 85% on December 1, 2017 and 70% on September 1, 2018.

Fee-for-Service Medicaid Therapy Reimbursement Rate Example*

Rate Effective on 9/1/17

Unit 1 Unit 1 Unit 2 Unit 2 Unit 2 Unit 3 Unit 4 Unit 4 Unit 4 Unit 3 Unit 3 Unit 1 Unit 2 Unit 3 Unit 4 Unit 1 Unit 2 Unit 3 Unit 4 Unit 1 Unit 2 Unit 3 Unit 4

* Example is based on CPT code 92507, a speech therapy code. The same process was used for all Physical, Occupational, and Speech Therapy codes.

Monitoring Implementation

Access to care has been monitored closely since the December 2016 rate reductions

• Monitor and address member and

provider complaints

• Review utilization trends by

service delivery area and by provider type

• Monitor provider enrollment and

terminations

4

5

Provider Enrollment Has Stabilized

6,832 6,913 5,999 6,008 6,159 6,251 6,191 6,303 6,223 6,144 6,234 6,212 6,260 5,400 5,600

5,800 6,000 6,200 6,400 6,600 6,800 7,000

All Enrolled Therapy Providers

December 2016 – December 2017

Decline in early 2017, primarily due to the ACA re-

• enrollment. Enrollment numbers increased and

are stable since April 2017.

Stabilized

Continue Monitoring Implementation

Rider 57

Requires HHSC to submit quarterly reports that include:

• Provider and member complaints by disposition received

by the Office of the Ombudsman and HHSC;

• Provider and member complaints by disposition reported

by Medicaid Managed Care Organizations (MCOs);

• The number of pediatric acute care therapy provider

terminations and the reason for identified terminations;

• The utilization of pediatric acute care therapy services;
• The number of members on a waiting list, unable to

access pediatric acute care therapy services due to insufficient network capacity; and

• The number of pediatric acute care therapy providers no

longer accepting new clients.

6

Continuing Monitoring Efforts

• Monitor MCO compliance with network

adequacy standards quarterly

• Conduct onsite MCO operational

reviews

• The Acute Care Utilization Review unit

participates in operational reviews and looks at MCO policies, procedures, and prior authorization practices, including clinical documentation

7 Provider Type Distance in Miles Travel Time in Minutes Metro Micro Rural Metro Micro Rural

Occupational, Physical, or Speech Therapy

30 60 60 45 80 75