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
Timeline of Therapy Policy and Rate Changes September May December September December 1, 2015 1, 2016 15, 2016 1, 2017 1, 2017 2016-17 GAA, Therapy Medical Reimbursement Rate and Policy Rate Change Rider 50 Policy Changes Rate Change Changes • As directed by 2018- • Directed agency • Clarified medical • Changed fee-for- • Reduction of 19 GAA, Rider 59, to achieve $150 necessity criteria service rates for therapy assistant partial rate restoration million in GR therapy services rate to 85 percent • Defined therapy • Changed speech savings over the of the rate for functional goals therapy reevaluation biennium related licensed to align with reimbursement rate to therapy therapists * modern best • Standardized billing services practices across provider types according to national • Began tracking coding guidelines services provided • Clarified policy on by therapy untimed speech assistant with therapy visit use of a modifier * Rider 59 directed a reimbursement rate reduction for therapy assistants at 85% on December 1, 2017 and 70% on September 1, 2018. 3/19/2018 2
Fee-for-Service Medicaid Therapy Reimbursement Rate Example* Rate Effective on Prior to Rate Effective on 9/1/17 12/15/16 12/15/16 Billing Unit Rider 59: 25% Reduction Reimbursement Standardization** Restoration Rate Equalization $135.14 $100.34 $109.04 $109.04 Home Health Agency Therapy Services Unit 1 Unit 1 Unit 1 $39.78 $28.67 $31.45 Unit 4 Unit 2 Unit 4 Unit 2 Unit 4 Unit 2 Per 15 Per 15 Per 15 min unit min unit min unit Unit 3 Unit 3 Unit 3 $159.12 $114.68 $125.80 $111.65 $107.78 Total allowable Total allowable Total allowable fee fee fee *** Comprehensive Outpatient Rehabilitation Facilities/Outpatient Rehabilitation Facilities (CORF/ORF) Therapy Services Unit 1 Unit 1 Unit 1 $31.25 $28.67 $29.32 Unit 4 Unit 2 Unit 4 Unit 2 Unit 4 Unit 2 Per 15 Per 15 Per 15 min unit min unit min unit Unit 3 Unit 3 Unit 3 $104.09 $114.68 $125.00 $117.28 Total allowable Total allowable Total allowable fee fee fee Independent Therapy Services * Example is based on CPT code 92507, a speech therapy code. The same process was used for all Physical, Occupational, and Speech Therapy codes. ** In accordance with federal standards and coding guidelines, policy changes were implemented to standardize each code’s bil ling 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.
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
Provider Enrollment Has Stabilized Decline in early 2017, primarily due to the ACA re- enrollment. Enrollment numbers increased and are stable since April 2017. All Enrolled Therapy Providers December 2016 – December 2017 7,000 6,913 6,832 6,800 6,600 Stabilized 6,400 6,303 6,234 6,212 6,260 6,251 6,191 6,223 6,159 6,144 6,200 5,999 6,008 6,000 5,800 5,600 5,400 5
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 Provider Distance in Miles Travel Time in Minutes Type Metro Micro Rural Metro Micro Rural Occupational, Physical, or 30 60 60 45 80 75 Speech Therapy • 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
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