Program (WVCHIP) Crystal Fox, Benefit and Eligibility Specialist - - PowerPoint PPT Presentation

West Virginia Children’s Health Insurance Program (WVCHIP)

Crystal Fox, Benefit and Eligibility Specialist Fall 2017 Provider Workshop

Annual Income Guidelines for WVCHIP

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Family Size Medicaid Max WVCHIP Gold WVCHIP Blue WVCHIP Premium 2 $21,599 $24,360 $34,267 $48,720 3 $27,158 $30,630 $43,087 $61,260 4 $32,717 $36,900 $51,906 $73,800 5 $38,277 $43,170 $60,726 $86,340 6 $43,836 $49,440 $69,546 $98,800

Coverage

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Medical Services and Prescription Benefits WVCHIP Gold WVCHIP Blue WVCHIP PREMIUM Generic Prescriptions No Copay No Copay No Copay Listed Brand Prescriptions $5 $10 $15 Non-listed Brand Prescriptions Full Retail Cost Full Retail Cost Full Retail Cost Multisource Prescriptions No Copay $10 $15 Medical Home Physician Visit No Copay No Copay No Copay Physician Visit (non-medical home) $5 $15 $20 Preventive Services No Copay No Copay No Copay Immunizations No Copay No Copay No Copay Inpatient Hospital Admissions No Copay $25 $25 Outpatient Surgical Services No Copay $25 $25 Emergency Department (is waived if admitted) No Copay $35 $35 Vision Services No Copay No Copay No Copay Dental Benefit No Copay No Copay $25 Copay for some non-preventive services

PERM Audit

• Payment Error Rate Measurement (PERM) measures improper

payments in Medicaid and CHIP and produces error rates for each program.

• The current PERM cycle is reviewing Medicaid and CHIP Fee

For Service (FFS) payments made by states October 1, 2015– September 30, 2016.

• Cycle 2, which includes West Virginia, closed August 15, 2017,

and we will receive the results in November 2017.

• Our next cycle will run October 1, 2018 through September

30, 2019.

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• Eligible Medical Home provider types are General Practice, Family

Practice, Internal Medicine, and Pediatricians. Any Physician Assistant (PA) or Nurse Practitioners (NPs) practicing under these specialties is considered a “back-up” Medical Home provider and will not be assessed a copay when the supervising physician is the named Medical Home provider.

• Please note: the physician group/facility must also select to be a

Medical Home provider along with the rendering provider.

• To become a Medical Home provider, please contact Molina

Provider Enrollment at 1-888-483-0793.

• Encourage your patients to enroll in the Medical Home program,

WVCHIP will waive the copay for sick visits and increase your reimbursement by the copay amount.

• WVCHIP should not be confused with Public Employees Insurance

Agency (PEIA) who increased their Medical Home copays effective July 1, 2017.

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Medical Home

Provider Enrollment

• The Affordable Care Act requires all providers to enroll or

revalidate their enrollment information under new enrollment screening criteria. Enrollment and revalidation is mandatory for both Medicaid and WVCHIP providers. Enrollment in Medicaid does not fully enroll the provider in WVCHIP.

• Provisional enrollment will end September 30, 2017. Any

provider not fully enrolled in the WVCHIP Plan will be terminated effective September 30, 2017 and claims will no longer be paid.

• To enroll in WVCHIP, contact Molina at 1-888-483-0793, or 304-

348-3360, or online at www.wvmmis.com.

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Out-of-State Providers

• WVCHIP will waive the out-of-state prior authorization

requirement if the provider agrees to accept WVCHIP in-state fees as payment in full with no balance billing to the member.

• This agreement can be made during provider enrollment or any

time thereafter by calling the provider enrollment department at Molina.

• WVCHIP uses the PEIA fee schedules. Go to www.peia.wv.gov to

see PEIA fees.

• Dental fees can be found at:

http://www.dhhr.wv.gov/bms/FEES/Pages/default.aspx

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Orthodontic Treatment

• Comprehensive orthodontic treatment is payable once per lifetime.
• Coverage is not automatic and must be prior authorized to be
• covered. Information should be mailed to:

WVCHIP – Orthodontic PA Request 350 Capitol Street, Room 251 Charleston, WV 25301

• Information required for review:
• Panoramic film
• Cephalometric x-ray
• A standard series of 5 Intra and 3 Extra Oral photographs that meet

the American Board of Orthodontic standards

• Treatment plan including findings, prognosis, length of treatment,

and phases of treatment

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Procedures Requiring Prior Authorization

• Abortion
• Nonemergency ambulance transport and hospital-to-hospital transport
• All inpatient admissions to hospitals/facilities (in-state and out-of-state)
• All admissions to rehabilitation or skilled nursing facilities
• Any potentially experimental/investigational procedure, medical device, or

treatment

• Applied Behavioral Analysis treatment
• Chelation therapy
• Chiropractic services for children under age 16
• Continuous glucose monitors
• Cosmetic/reconstructive surgery as a result of accident or birth defects
• CT scan of sinuses or brain - outpatient
• CTA (CT angiography) - outpatient
• Dental ridge reconstruction
• DEXA scans (dual energy x-ray absorptiometry)
• Dialysis services - outpatient

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Procedures Requiring Prior Authorization (cont.)

• Durable medical equipment purchases of $1,000 or more, or rental more

than 3 months

• Endoscopic treatment of Gastro-esophageal Reflux Disease (GERD)
• Hearing aids
• Heart Perfusion Imaging
• Home health care: exceeding 12 skilled nursing visits
• Hospice care
• IMRT (intensity modulated radiation therapy) - outpatient
• Hyperbaric Oxygen Therapy (HBOT)
• I.V. therapy in the home
• MRI scan of the breast, knee or spine (cervical, thoracic, and lumbar)
• Orthotics/prosthetics over $1000
• Oral surgeries including orthognathic surgery
• Outpatient therapy services including occupation, physical, speech, and

vision therapy beyond 20 visits

• PET Scans
• Sleep apnea services and equipment

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Procedures Requiring Prior Authorization (cont.)

• SPECT (single photon emission computed tomography) of brain and

lung

• Stereotactic Radiation Surgery and Stereotactic Radiation Therapy
• All inpatient surgical procedures
• Outpatient surgeries as listed below:
• cataract
• cochlear implants
• colonoscopy
• hysterectomy
• implantable devices including, but not limited to: implantable

pumps, spinal cord stimulators, neuromuscular stimulators, and bone growth stimulators

• knee arthroscopy
• septoplasty or submucous resection
• spinal surgery including artificial disc, laminectomy, and/or fusion
• uvulopalatopharyngoplasty

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Procedures Requiring Prior Authorization (cont.)

• Transplants and transplant evaluations (including, but not

limited to: kidney, liver, heart, lung and pancreas, small bowel, and bone marrow replacement or stem cell transfer after high dose chemotherapy)

• (TTE) Transthoracic Echocardiogram
• Submit Prior Authorization Requests to:
• HealthSmart

PO Box 2451 Charleston, WV 25329-2451 1-800-356-2392 www.healthsmart.com

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Resources

• Eligibility, application status, renewals and general information:

WVCHIP HelpLine at 1-877-982-2447

• Claims, benefits, and eligibility: Molina at 1-800-479-3310
• Prior-authorizations: HealthSmart at 1-800-356-2392
• Prescription drug benefits: CVS at 1-800-241-3260
• Provider enrollment: Molina at 1-888-483-0793

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Contact

Crystal Fox Benefits & Eligibility Specialist WVCHIP West Virginia Department of Health and Human Resources 350 Capitol Street, Room 251 Charleston, WV 25301 Phone: 304-957-7862 Fax: 304-558-2741 Email: Crystal.D.Fox@wv.gov Follow DHHR on Facebook and Twitter for WVCHIP related announcements and information.

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