2017 Medicaid Update Ohio Department of Medicaid External

2017 Medicaid Update Ohio Department of Medicaid External Business Relations

OHIO DEPARTMENT OF MEDICAID Making Ohio Better External Business Relations • Ava Cottrell • Laura Gipson • Ed Ortopan • Janene Rowe • Chezre Willoughby • Manager: Meagan Grove 12/6/2020 2

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Disability Determination Redesign • Ohio has transitioned to Section 1634 of the Social Security Act that allows the states and federal government to use the Social Security Administration to determine the Medicaid eligibility for the aged, blind, and disabled population. » This means if you are eligible for Supplemental Security Income you are automatically enrolled into Medicaid and it makes coverage available to more low-income Ohioans. • August, 2016 Ohioans who are aged, blind, or disabled will no longer need to spenddown. Everyone impacted by the change will have a pathway to coverage. 12/6/2020 3

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Disability Determination Redesign • 1634 Option allows states to accept the Social Security Administrations decision for SSI » In Ohio, Opportunities for Ohioans with Disabilities will make decision that a person is eligible for SSI » SSI beneficiaries will automatically be enrolled in the Medicaid program » The state will not reconsider the determination » ODM will receive the information from the Social Security Administration daily » Individuals who are confirmed as blind or disabled will be given active Medicaid in the Ohio benefits system 12/6/2020 4

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Programs 12/6/2020 5

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Programs & Cards v Ohio Medicaid ‒ This card is the traditional fee-for-service Medicaid card ‒ Issued monthly

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Programs & Cards v Healthy Families/Healthy Start Medicaid ‒ Healthy Families is for children and parents who have household income below 90% of the Federal Poverty Level (FPL) ‒ Healthy Start is for children through age 18 years and pregnant women with household income below 200% of the FPL

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Presumptive Eligibility • Presumptive Eligibility Card: » Covers children up to age 19 and pregnant women. ─ It has expanded to provide coverage for parent and caretaker relatives and extension adults. » This is a limited benefit to allow time for full determination of eligibility for medical assistance. » If the County Department of Job and Family Services (CDJFS) determines presumptive eligibility, the consumer will receive the card. 12/6/2020 8

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Presumptive Eligibility • Presumptive Eligibility Letter: » If a state qualified entity determines presumptive eligibility, the consumer will receive a letter. 12/6/2020 9

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Presumptive Eligibility • Presumptive Eligibility Letter 12/6/2020 10

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Presumptive Eligibility • Presumptive Eligibility: » This card can be valid until the county determines the recipient is not eligible. It will close once they are found to not be eligible » If the recipient is found to be eligible the card will be valid until the end of the month and then they are moved to the appropriate Medicaid program. 12/6/2020 11

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Programs & Cards v Reinstatement of Medicaid for Public Institution Recipients (Ro. MPIR) ‒ For those who were receiving Medicaid prior to being placed in a public institution and are released from the institution within 12 months of the previous eligibility ‒ One Medicaid card good for 60 days

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Programs & Cards v Qualified Medicare Beneficiary (QMB) ‒ Issued to qualified consumers who receive Medicare ‒ Medicaid covers their monthly Medicare Part A & B premiums, co-insurance and/or deductible after Medicare has paid

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Programs & Cards v Specified Low-Income Medicare Beneficiary (SLMB) & Qualifying Individual (QI 1, QI 2) ‒ We ONLY pay their Part B premium to Medicare ‒ This is NOT Medicaid eligibility ‒ There is NO cost-sharing eligibility

OHIO DEPARTMENT OF MEDICAID Making Ohio Better DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services MLN Matters® Number: SE 1128 Revised CAUTION – What You Need to Know • The QMB program is a State Medicaid benefit that covers Medicare deductibles, coinsurance, and copayments, subject to State payment limits. (States may limit their liability to providers for Medicare deductibles, coinsurance and copayments under certain circumstances. ) Medicare providers may not balance bill QMB individuals for Medicare cost-sharing, regardless of whether the State reimburses providers for the full Medicare cost-sharing amounts. Further, all original Medicare and MA providers -not only those that accept Medicaid--must refrain from charging QMB individuals for Medicare cost-sharing. Providers who inappropriately balance bill QMB individuals are subject to sanctions. 12/6/2020 15

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Eligibility • Conditions of Eligibility for Each Application or Recipient: OAC 5160: 11 -58 » Consumers must cooperate with requests from third-party insurance companies to provide additional information needed in order to authorize coverage. » Consumers must cooperate with requests from a Medicaid provider; managed care plan; or a managed care plan’s contracted provider for additional information which is needed in order to bill third party insurances appropriately. 12/6/2020 16

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Eligibility • Conditions of Eligibility for each Application or Recipient: » Providers may contact local CDJFS offices to report non-cooperative consumers. » CDJFS may terminate eligibility if an individual fails or refuses, without good cause, to cooperate by providing necessary verification or by providing consent for the administrative agency to obtain verifications. 12/6/2020 17

Making Ohio Better OHIO DEPARTMENT OF MEDICAID MITS v Eligibility Verification Request ‒ You can search up to 3 years at a time!!

Making Ohio Better OHIO DEPARTMENT OF MEDICAID MITS v Eligibility Verification Request-result

Making Ohio Better OHIO DEPARTMENT OF MEDICAID MITS v. Eligibility Verification Request-results, cont’d

Making Ohio Better OHIO DEPARTMENT OF MEDICAID MITS v Eligibility Verification Request-results, cont’d

Making Ohio Better OHIO DEPARTMENT OF MEDICAID MITS v Eligibility Verification Request-results, cont’d

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Provider Responsibilities 12/6/2020 23

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Provider Responsibilities • Consumer Liability: OAC 5160 -1 -13. 1 » A Medicaid consumer cannot be billed: ─ ─ When a Medicaid claim has been denied. Unacceptable claim submission. Failure to request a prior authorization. Retroactive Peer Review determination of lack of medical necessity. » 3 Steps must be followed in order to bill a consumer: ─ The consumer is notified in writing prior to the service being rendered that the provider will not bill Medicaid for the covered service. ─ The consumer agrees to be liable for payment of the service and signs a written statement to that effect prior to the service being rendered. ─ The provider explains to the consumer that the service is a covered Medicaid service and other Medicaid providers may render the service at no cost to consumer. 12/6/2020 24

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Provider Responsibilities 12/6/2020 25

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Ohio Medicaid Policy 12/6/2020 26

OHIO DEPARTMENT OF MEDICAID Making Ohio Better LAWriter • Medicaid Ohio Administrative Code Rules » OAC rules have been moved to La. Writer as of July 1, 2015 ─ http: //codes. ohio. gov/oac/5160 12/6/2020 27

OHIO DEPARTMENT OF MEDICAID Making Ohio Better LAWriter • Scroll to 5160 Medicaid 12/6/2020 28

OHIO DEPARTMENT OF MEDICAID Making Ohio Better LAWriter • Click on the appropriate provider type 12/6/2020 29

OHIO DEPARTMENT OF MEDICAID LAWriter Making Ohio Better Right side scroll down for additional sections in Physician chapter 12/6/2020 30

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Policy Updates New and Revised POS codes for CMS Effective January 1, 2016 Code Descriptor POS 19 Off Campus. Outpatient Hospital Descriptor: A portion of an off-campus hospital provider based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick injured person who do not require hospitalization or institutionalization POS 22 On Campus. Outpatient Hospital Descriptor: A portion of a hospital’s main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Policy Updates • Federal Sterilization Form » This form is required for all sterilization services » It has been updated with an expiration date of 12/31/2018 » It can be found on the Department of Human Services website ─ http: //www. hhs. gov/opa/pdfs/consent-for-sterilization-english-updated. pdf 12/6/2020 32

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Policy Updates • ICD-10 » New ICD-10 diagnosis codes indicate weeks of gestation of pregnancy » ODM requires all claims with a delivery procedure (mother’s claim, not child’s claim) and a date of service (outpatient and professional) or date of discharge (institutional) or after October 1, 2015 contain the weeks of gestation ICD-10 diagnosis code » On professional claims, the claim detail for the delivery procedure must point to the gestation age ICD-10 diagnosis code in one of the four diagnosis pointer fields on the delivery detail. If the gestation age ICD-10 diagnosis code is not one of the four diagnoses pointed to on the delivery detail, the detail will deny 12/6/2020 33

Making Ohio Better OHIO DEPARTMENT OF MEDICAID ICD-10 • Gestational week diagnosis codes are required on all claims indicating a delivery procedure code (both CPT and ICD) ICD-10 Diagnosis Codes Z 3 A. 00 Z 3 A. 01 Z 3 A. 08 Z 3 A. 09 Z 3 A. 10 Z 3 A. 11 Z 3 A. 12 Z 3 A. 13 Z 3 A. 14 Z 3 A. 15 not specified Z 3 A. 16 16 weeks gestation of pregnancy Less than 8 weeks Z 3 A. 17 17 weeks gestation of pregnancy 8 weeks gestation of Z 3 A. 18 18 weeks gestation of pregnancy 9 weeks gestation of Z 3 A. 19 19 weeks gestation of pregnancy 10 weeks gestation of Z 3 A. 20 20 weeks gestation of pregnancy 11 weeks gestation of Z 3 A. 21 21 weeks gestation of pregnancy 12 weeks gestation of Z 3 A. 22 22 Weeks gestation of pregnancy 13 weeks gestation of Z 3 A. 23 23 Weeks gestation of pregnancy 14 weeks gestation of Z 3 A. 24 24 Weeks gestation of pregnancy 15 weeks gestation of Z 3 A. 25 25 Weeks gestation of pregnancy Z 3 A. 26 Z 3 A. 27 Z 3 A. 28 Z 3 A. 29 Z 3 A. 30 Z 3 A. 31 Z 3 A. 32 Z 3 A. 33 Z 3 A. 34 Z 3 A. 35 26 Weeks gestation of pregnancy 27 Weeks gestation of pregnancy 28 Weeks gestation of pregnancy 29 Weeks gestation of pregnancy 30 Weeks gestation of pregnancy 31 Weeks gestation of pregnancy 32 Weeks gestation of pregnancy 33 Weeks gestation of pregnancy 34 Weeks gestation of pregnancy 35 Weeks gestation of pregnancy Z 3 A. 36 36 Weeks gestation of pregnancy Z 3 A. 37 37 Weeks gestation of pregnancy Z 3 A. 38 38 Weeks gestation of pregnancy Z 3 A. 39 39 Weeks gestation of pregnancy Z 3 A. 40 40 Weeks gestation of pregnancy Z 3 A. 41 41 Weeks gestation of pregnancy Z 3 A. 42 42 Weeks gestation of pregnancy Z 3 A. 49 Greater than 42 weeks gestation of pregnancy 34

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Policy Updates Effective January 1, 2017 • Additional payment for multiple births • Will recognize acupuncture as a covered service » Limited to provider types already in our system » Accupuncturist provider type will be added in the spring • Co-Surgery modifier 62 will be recognized » 2 physicians can add the modifier and be paid appropriately instead of 1 paid at 100% and the other at 25%. Physicians must have unique and different specialties 12/6/2020 35

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Policy Updates Effective July 1, 2017 • Enhanced Ambulatory Patient Grouping System (EAPG) » Webinar held 1 -23 -17 and saved recording on OHA website » Questions: EAPG@Medicaid. ohio. gov • Addition of behavioral health and substance use disorder services to outpatient hospital benefit • National drug Codes will be required » 6 months post and pay » 1 -1 -18 claims will begin to deny if missing or invalid » Included in the EAPG rule 12/6/2020 36

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Policy Updates • First, there were specific DRG’s that were added/deleted to the grouper for Version 34 that 3 M did not make us aware of until after October 1 st. Claims that grouped to these DRG’s were denied for being ungroupable. We have established relative weights for the new DRG’s and added them to the MITS. HHTL 3352 -1608, details the DRGs that were deleted or added and their associated relative weights. It is available on our web site. • At this time, being cognizant of how a resubmission/adjustment of this size could adversely affect the cash flow of a hospital, we plan on releasing the reprocessed claims over a period of several weeks. We ask for the patience of the members while we complete the process and would ask that they refrain from resubmitting claims on their own. We will notify OHA when all processing is complete. If at that time, a member hospital believes that there are still claims that have not properly paid, the hospital may resubmit them. • 12/6/2020 37

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Payment Innovation • Episode Based Payment » A new health care delivery payment system that rewards providers for the value of the service and not the volume » The episodes cover a 12 month period and will determine if a provider is eligible for an incentive payment » The performance period for incentive payments for 2017 began January 1, 2016 12/6/2020 38

Making Ohio Better OHIO DEPARTMENT OF MEDICAID Payment Innovation Transforming Payment for a Healthier Ohio: Episode-based Payment Performance period is from 2016 -17 for incentive payments in 2017 Episode Principal Accountable Provider Perinatal Physician/group delivering the baby Asthma-Acute Exacerbation Facility where trigger event occurs COPD Exacerbation Facility where trigger event occurs Acute Percutaneous Intervention Facility where PCI performed Non-acute PCI Physician Total Joint Replacement Orthopedic surgeon

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Managed Care Bureau of Managed Care bmhc@medicaid. ohio. gov 614 -466 -4693 http: //medicaid. ohio. gov/PROVIDERS/Managed. Care 12/6/2020 40

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Managed Care/My. Care Ohio v New populations moving into Managed Care ‒ The Managed Care population will continue to grow so always check eligibility prior to providing services § Foster children - transitioning in phases by 7/1/17 § Breast and Cervical Cancer Patients (BCCP)- 1/1/17 § Bureau of Children with Medical Handicaps (BCMH) - 1/1/17 § Adoption children - 1/1/17

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Managed Care/My. Care Ohio v Individuals with optional enrollment in Medicaid Managed Care Plan ‒ Native Americans that are members of federally recognized tribes ‒ Home and Community Based waivers thru DODD 1/1/17

OHIO DEPARTMENT OF MEDICAID Making Ohio Better Managed Care • Provider Complaints: » Work directly with the plan first. » If not resolved, submit a complaint to ODM. http: //www. medicaid. ohio. gov/PROVIDERS/Managed. Care/Provider. Complain t. aspx » Certification issues, work with the Area Agency on Aging (AAA) or Ohio Department of Medicaid (ODM) for My. Care Ohio waiver providers. » Provider Credentialing concerns can be sent to Ohio Department of Insurance (ODI). 12/6/2020 43

Making Ohio Better OHIO DEPARTMENT OF MEDICAID Ohio Medicaid Services • Helpful phone numbers: » IVR ─ 1 -800 -686 -1516 » Prior Authorization (PA) ─ 1 -800 -686 -1516 » Enrollment ─ 1 -800 -922 -3042 » Adjustments ─ 614 -466 -5080 » Permedion ─ 1 -800 -772 -2179 » Coordination of Benefits Section ─ 614 -752 -5768 ─ 614 -728 -0757 (fax) » OSHIP (Ohio Senior Health Insurance Information Program) ─ 1 -800 -686 -1578 12/6/2020 44