Posts Tagged Medicaid

Preparing for Alabama’s Medicaid Unwinding Process

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Preparing for Alabama’s Medicaid Unwinding Process

By: Alli Swann and Kelli C. Fleming, Esq. – Burr & Forman LLP

Over the past three years, Medicaid recipients have benefitted from uninterrupted coverage, contributing to one of the lowest periods of U.S. uninsurance. However, with the public health emergency’s (“PHE”) end reintroducing traditional Medicaid redetermination plans, Alabama providers should prepare for a potential spike in uninsured patients.

In 2020, Congress passed the Families First Coronavirus Response Act (FFCRA), which sought to bolster health insurance access during the PHE. To accomplish this goal, Congress provided increased federal funding for states to activate measures focused on maintaining access to health coverage. The package offered states additional federal funding in exchange for ensuring that low-income individuals would retain their health coverage during the pandemic. States had to meet several conditions to obtain federal funds, including a continuous coverage requirement. Under the continuous coverage requirement, Medicaid enrollees could not lose eligibility unless they requested in writing to be removed, moved out of state, or died. Continuous coverage eligibility also protected an enrollee’s coverage despite income or family size changes.

Medicaid enrollments rose substantially in response to the continuous coverage requirement. Nationally, Medicaid enrollment rose from approximately 64 million in February 2020 to 86 million by February 2023. In Alabama, approximately 800,000 people were on the Medicaid roll before the PHE’s onset. This number increased to 1.2 million people during the pandemic. However, with this “unwinding” period underway, the Robert Wood Johnson Foundation and the Urban Institute estimate that approximately 61,000 Alabamians could lose Medicaid coverage by June 2024.

The Consolidated Appropriations Act, 2023, separated the continuous enrollment condition from the PHE, ending the continuous enrollment provision on March 31, 2023. On April 1, Alabama resumed verifying eligibility information for current enrollees and slowly dis-enrolling individuals based on income or household size changes.

So, what does the Medicaid unwinding process mean for providers? 

Reducing the information gap is a critical first step in mitigating coverage loss. Medicaid providers should prepare to advise patients about the unwinding process and counsel those who have lost Medicaid coverage. 

Alabama Medicaid’s Partner Toolkit outlines important steps providers should take when talking with patients who are Medicaid recipients:

  • First, providers should ask the patient to verify their contact information with Medicaid. Providers should emphasize the importance of ensuring up-to-date information. 
  • Second, providers should ask the patient if they received a letter about their coverage from Medicaid. If so, providers should advise their patients to complete and return the included form to Medicaid, as failure to do so could result in termination.
  • Finally, providers should be prepared to advise their patients on other health coverage options if they no longer qualify for Medicaid.

Dr. Shawn Cecil, MD, Pediatrician and Assistant Professor at the University of Alabama Medical Center and College of Community Health Sciences, emphasized the importance of offices verbally communicating with patients, encouraging them to update their contact information with Medicaid. Dr. Cecil also recommends that offices train a Medicaid Application Assister to help patients complete their online Medicaid application, which helps lead to a quick turnaround time for redetermination results.

With Alabama’s uninsured population anticipated to rise, Dr. Cecil advises that physicians prepare for a change in the types of medical care patients will seek. “Studies have shown that patients without health insurance have more preventable visits to the Emergency Room compared to those with health insurance. Higher levels of ER utilization leads to higher costs and can also lead to delayed medical treatment for those with serious needs.”

As the Medicaid unwinding process continues in Alabama, providers can stay up-to-date on Alabama Medicaid’s  Alerts Webpage.

 Kelli Fleming is a Partner at Burr & Forman LLP and practices exclusively in the firm’s Healthcare Practice Group. Kelli may be reached at (205) 458-5429 or kfleming@burr.com.

Alli Swann is a law student at the University of Alabama School of Law.

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Proposed 2023 physician pay schedule deepens Medicare’s instability

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Proposed 2023 physician pay schedule deepens Medicare’s instability

The Medical Association is working with the AMA and many national specialty societies to analyze and comment on CMS proposed 2023 fee schedule. The following article was prepared by the AMA and outlines efforts to address problems that have been identified with the proposed fee schedule:

After a thorough analysis, the AMA has weighed in with detailed comments (PDF) on the Centers for Medicare & Medicaid Services’ (CMS) proposed policies for the 2023 Medicare physician payment schedule.

The proposed 2023 Medicare physician payment schedule (PDF) shows the agency must work with Congress to avert budget-neutrality cuts and implement an inflationary update for doctors who now are in line to see a 4.42% pay cut in January.

“The AMA is deeply alarmed about the growing financial instability of the Medicare physician payment system due to a confluence of fiscal uncertainties physician practices face related to the ongoing pandemic, statutory payment cuts, lack of inflationary updates, and significant administrative barriers,” says the AMA’s comment letter to CMS.

“The payment system is on an unsustainable path that is jeopardizing patient access to physicians. The resulting discrepancy between what it costs to run a physician practice and actual payment, combined with the administrative and financial burden of participating in Medicare, is incentivizing market consolidation,” the letter adds.

The AMA is asking Congress to:

  • Extend the congressionally enacted 3% temporary increase in the Medicare fee schedule.
  • Provide relief for an additional 1.5% budget-neutrality cut that is planned for 2023.
  • End the statutory annual freeze and provide an inflation-based update for the coming year.
  • Waive the 4% pay-as-you-go sequester necessitated by passage of legislation unrelated to Medicare.

In addition, physicians are urging CMS to work with Congress to extend the 5% incentive payment physicians can earn for participating in an Advanced Alternative Payment Model. Congress also needs to extend the $500 million in funding for the “exceptional performance” payments that physicians can earn under the Merit-based Incentive Payment System (MIPS).

Earning theses bonuses in 2022 will affect payment adjustments in 2024. The CMS proposal does not include estimates for these incentives and bonuses in 2023 as they are set to expire under current law.

The lapse of these incentives, coupled with the 4.42% pay cut, threatens patient access to Medicare-participating doctors and undermines the sustainability of physician practices. The AMA is strongly advocating that Congress avert the significant conversion-factor cut. Instead, Congress should extend the 3% increase that is set by law to expire at the end of this year, prevent the additional 1.5% budget neutrality cut for 2023, and provide a positive update to account for inflation as measured by the Medicare Economic Index (MEI).

In nearly 100 pages of detailed comments, the AMA sets out its response to CMS proposed rule. Here are some key steps the AMA is advising CMS to take as it assembles the final version of the 2023 Medicare physician payment schedule.

The agency should:

Continue its current coverage and payment policies for telephone visits and audio-visual telehealth services until the joint Current Procedural Terminology®-RVS Update Committee (RUC) Telemedicine Office Visits Workgroup determines accurate coding and valuation, as needed, for office visits performed via audiovisual and audio-only modalities.

Pause consideration of other sources of cost data for use in the MEI until the AMA’s extensive effort to collect practice-cost data from physician practices is complete.

Apply the office E/M visit increases to the office visits, hospital visits and discharge-day management visits included in surgical global payment, as it has done historically.

Conduct a demonstration to determine the financial and operational efficiencies for Medicare patients with underlying medical conditions who require integral dental services as a condition of their covered, primary Medicare Part A service.

Separate the funding source to cover dental services from—and have no impact on—the Medicare physician payment schedule. 

Adopt the RUC’s recommended work relative value units and direct practice-expense inputs for vaccine administration services. The AMA supports CMS’ proposal to annually update the payment amount for administration of Part B preventive vaccines to account for changes in the cost of administering those vaccines.

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Get Text Updates from Alabama Medicaid

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Get Text Updates from Alabama Medicaid

Providers and recipients now have a new way to receive important information from the Alabama Medicaid Agency. The Text Messaging Service provides immediate and/or important communication directly to you. Examples of information shared with providers includes:  approaching deadlines, new program announcements, required provider agreements, Medicaid meetings and training, office closures, or other vital information which may impact your practice.

We hope you will take advantage of this service to stay up to date. Subscribing is quite simple. Text ALPROVIDERS to 888777 to receive provider notifications. You can opt-out at any time. Please note that recipients have a separate keyword and text messaging list to subscribe to in order to receive important recipient information from the Agency.

The Agency will continue to provide regular communication through the Provider Insider newsletter, the Medicaid website, the subscription-based electronic mailing list and Alerts. For additional information about the Text Messaging Service for Medicaid, please visit www.Medicaid.Alabama.gov or call (334) 353-9363.

 

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Alabama’s ACHNs Go Live Oct. 1

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Alabama’s ACHNs Go Live Oct. 1

The end date for the Patient 1st Program is approaching, and providers will be required to have completed agreements with both Medicaid and the ACHN. Primary Care Physicians (PCPs) will no longer receive Patient 1st capitation payments beginning in October 2019. The ACHN program will be implemented on October 1, 2019, and providers will need to complete ACHN agreements as soon as possible and before July 1, 2019, to avoid any delay in receiving bonus and participation payments.

Providers can visit the following link to download the PCP Enrollment Agreement with Medicaid or obtain information about the ACHNs: 
https://www.medicaid.alabama.gov/content/2.0_Newsroom/2.7_Special_Initiatives/2.7.6_ACHN.aspx

To obtain a copy of the PCP and DHCP agreement with the ACHN, contact the ACHN in your region.  Providers can visit the following link for ACHN contacts: https://www.medicaid.alabama.gov/documents/2.0_Newsroom/2.7_Special_Initiatives/2.7.6_ACHN/2.7.6_ACHN_Regional_Map_Contacts.pdf

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Alabama Medicaid Updates: Don’t Miss This Information!

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Alabama Medicaid Updates: Don’t Miss This Information!

Promoting Interoperability with Prescription Drug Monitoring Program (PDMP)

The Alabama Department of Public Health Meaningful Use team recently added new functionality where Eligible Providers who are currently participating in the PI Program can access the PDMP registry and run reports to show that they are actively engaged with this Specialized Registry during the reporting period. This documentation is required to meet the Public Health objectives and measures and can be submitted with the EP’s application for the Program Year for which they are attesting.

If you have technical issues with accessing and generating this report, please contact ADPH Helpdesk at 1-855-925-4767, Option 1.

Complete Your ACHN Agreements Before July 1

Primary Care Physicians (PCPs) will not be receiving a capitated payment in October 2019. The Alabama Coordinated Health Network (ACHN) program will be implemented on October 1, 2019, and providers will need to complete ACHN agreements as soon as possible before July 1, 2019, in order to receive bonus and participation payments. The end date for the Patient 1st Program is approaching, and providers will be required to have completed agreements with both Medicaid and the ACHN.

Providers can visit this link to download the PCP Enrollment Agreement with Medicaid or to obtain information about the ACHNs. To obtain a copy of the PCP and DHCP agreement with the ACHN, contact the ACHN in your region. Providers can visit this link for ACHN contacts.

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Medical Association Signs on to Letter Targeting PA Requirements

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Medical Association Signs on to Letter Targeting PA Requirements

The Medical Association recently joined the American Medical Association and 85 other national medical groups and state medical associations in sending a letter to the Centers for Medicare & Medicaid  Services to urge CMS to provide guidance to Medicare Advantage plans on prior authorization processes through its 2020 Call Letter. In the jointly signed letter, the groups call upon CMS to require MA plans to selectively apply PA requirements and provide examples of criteria to be used for programs such as ordering/prescribing patterns that align with evidence-based guidelines and historically high PA approval rates. Citing the CMS Patients Over Paperwork initiative, the letter stresses this new guidance will promote safe, timely and affordable access to care for patients; enhance efficiency; and reduce administrative burden on physician practices.

The letter further explains how the prior authorization process has been found to be burdensome for health care providers, health plans and even patients and that physicians and insurers have agreed that these policy changes to eliminate PAs on those services for which there is low variation in care can promote greater transparency regarding services subject to PAs and protect patients to ensure PAs do not impact the continuity of care.

PA programs can create significant treatment barriers by delaying the start or continuation of necessary treatment, which may in turn adversely affect patient health outcomes. According to a 2018 AMA survey of 1,000 practicing physicians, 91 percent of physicians said PAs can delay a patient’s access to necessary care. These delays may have serious implications for patients and their health, as 75 percent of physicians reported that PA can lead to treatment abandonment, and 91 percent indicated that PA can have a negative impact on patient clinical outcomes. Most alarmingly, 28 percent of physicians indicated that PA has led to a serious adverse event (e.g., death, hospitalization, disability/permanent bodily damage) for a patient in their care.

Read the letter in its entirety

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SAME Act Could Give Alabama Second Chance at Medicaid Expansion

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SAME Act Could Give Alabama Second Chance at Medicaid Expansion

Alabama Sen. Doug Jones introduced legislation this week to give a second chance to expand Medicaid to those states that have not yet expanded their programs. The States Achieve Medicaid Expansion (SAME) Act would also give these states another opportunity to receive the same levels of federal funding that was offered in 2010.

“Alabama made a mistake by not expanding Medicaid. If I can give them an opportunity to rectify that, I’d like to do it,” Jones said in an interview with the Montgomery Advertiser. “I think it’s important for us to expand Medicaid in the state to help save our rural hospitals, get better health outcomes in those rural areas and to provide an economic boost in the state. Let’s finish this job and move forward, instead of languishing and letting our Medicaid dollars that we already pay go to other states.”

Originally in 2010, there would have been federal funds to cover the full cost of expansion for three years for those states that expanded their Medicaid program, at which time federal coverage would drop to 90 percent and states would cover the rest. Should the SAME Act pass, full funding would be offered for three years before decreasing to 95 percent funding in the fourth year, 94 percent in the fifth and 93 percent in the sixth. Federal coverage would stand at 90 percent every year thereafter.

The Medical Association remains an advocate for not only fully funding Alabama’s Medicaid program but also agrees with expansion of the program. Medicaid is a state-run program providing health coverage for about 23,000 low-income residents. To qualify for current Medicaid coverage, families with children must have a household income at or below 18 percent of the poverty level. Expanding the program would take that threshold up to 138 of percent the poverty level, offering access to as many as 325,000 Alabamians.

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New Requirements for Fee-For-Service Delivery Claims

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New Requirements for Fee-For-Service Delivery Claims

Effective for dates of services on or after Feb. 1, 2018, fee-for-service delivery claims for recipients who reside in a county not served by an Alabama Medicaid (Medicaid) Maternity Care Program must contain the date of last menstrual period and the date of first prenatal visit. This information is not required for hospital claims.

Counties not included in a Medicaid Maternity Care Program:

District 10:  Autauga, Bullock, Butler, Crenshaw, Elmore, Lowndes, Montgomery and Pike
District 12: Baldwin, Clarke, Conecuh, Covington, Escambia, Monroe and Washington

Soft Denial:
Claims without the date of last menstrual period and the date of the first prenatal visit will receive a “soft” denial.  This means the claim will process, but the provider will receive an alert to remind them to include the information.

Hard Denial:
On Feb. 1, 2019, claims that do not include the date of last menstrual period and the date of the first prenatal visit will be denied.

Some examples of what a provider can expect to see on the denied claim include:
Edit 330 – DTP SEGMENT DATE IS INVALID
Edit 331 – DATE LAST MENSTRUAL PERIOD MISSING OR IN FUTURE
Edit 332 – DATE FIRST PRENATAL VISIT MISSING OR IN FUTURE

Claims with the procedure codes below must include the date of last menstrual period and date of the first prenatal visit:

  • 59400-59410     Vaginal delivery
  • 59510-59515      Cesarean delivery
  • 59610-59622     Delivery after previous cesarean delivery

How can a fee for service provider submit a claim?

  • For claims submitted through 5010 X12 837P:
    1. Enter the date of the patient’s last menstrual period in a DTP segment in loop 2300 with a qualifier of 484
    2. Enter the date of the patient’s first prenatal visit in a DTP segment in loop 2300 with a qualifier of 454
  • For claims submitted on the Medicaid Interactive Web Portal:
    1. Enter the date of the patient’s last menstrual period in the field labeled “last menstrual period date”
    2. Enter the date of the patient’s first prenatal visit in the field labeled “first prenatal visit date”
  • For paper claims submitted on a CMS form 1500:
    1. Enter the patients last menstrual period in block 14
    2. Enter QUAL the value “484” to identify the information in block 14 as the date of the last menstrual period.
    3. Enter QUAL the value “454,” which identifies the information entered as the date of the first prenatal visit in block 15
    4. Enter the date of the patient’s first prenatal visit in block 15
    5. If no prenatal care was received, the date entered in block should be the date of the first contact during the pregnancy.

*Reminder:  Medicaid requires all claims be filed electronically unless they are required to be submitted on paper.

  • PES does not currently allow claims to be submitted with this information, but a software upgrade will be available prior to claims denying for not containing the information.

Note:
Providers within the Maternity Care Program must continue to follow guidelines outlined in the April 13, 2017 ALERT. Please visit http://medicaid.alabama.gov/alert_detail.aspx?ID=12209 for a copy of the ALERT.

Please direct questions to the Fiscal Agent, Provider Assistance Center at (800) 688-7989.

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MEDICAID ALERT: Federal Rule Change for Prenatal Claims

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MEDICAID ALERT: Federal Rule Change for Prenatal Claims

The passage of the Bipartisan Budget Act of 2018 requires states to “cost avoid” claims for prenatal services when there is a known liable third party. Prior to this change, states were federally required to “pay and chase” claims with a designated prenatal procedure or diagnosis code. The federal “pay and chase” provision enabled providers to bill Medicaid for prenatal care and receive payment without having to bill the other third party. Medicaid was required to seek reimbursement from the other liable third party. Because of this federal change, the Alabama Medicaid Agency will implement changes within its claims processing system to require providers to bill other known insurance coverage prior to receiving Medicaid payment for prenatal services.

Effective Jan. 1, 2019, for prenatal services claims received for dates of services on or after Feb. 9, 2018, Alabama Medicaid will deny claims when there is other insurance coverage, but no payment or denial by the other insurance is indicated on the claim. Once the provider has billed the third-party carrier, if a denial is received or a balance remains, the provider may then submit the claim to the Alabama Medicaid Agency for consideration of payment.

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Alabama Medicaid Alert: Short-Acting Opioid Naïve Limits

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Alabama Medicaid Alert: Short-Acting Opioid Naïve Limits

Effective Nov: 1, 2018, the Alabama Medicaid Agency will begin implementing limits on short-acting opiates for opioid naïve recipients. The Agency defines “opioid naïve” as a recipient with no opioid claim in the past 180 days.

Edit Details:

  • A 7-day supply limit for adults age 19 and older
  • A 5-day supply limit for children age 18 and younger
  • A maximum of 50 morphine milligram equivalents (MME) per day allowed on a claim for an opioid naïve recipient
  • Any claim for a short acting opioid for an opioid naïve recipient exceeding the maximum days’ supply limit or MME limit will be denied.
  • Claims prescribed by oncologists will bypass the edit.
  • Long term care and hospice recipients are excluded.
  • Refills of remaining quantities and/or new prescriptions filled within 180 days of the initial opioid naive claim will require an override.
  • Refills of remaining quantities of prescriptions that are partially-filled will be allowed per State and federal law* but will require an override through Medicaid. See below for more details from the State Board of Pharmacy.
  • For adults, the refill of the quantity remaining on the partial fill will not count towards the prescription limit if filled within 30 days of the original prescription. Monthly maximum unit quantities still apply.
  • Overrides for quantities exceeding the maximum days’ supply limit or MME limit may be submitted to Health Information Designs (HID). Please see the Pharmacy Override External Criteria Booklet for information about override requirements. Please refer to the following link for more information regarding overrides for opioid naïve patients:http://www.medicaid.alabama.gov/content/4.0_Programs/4.3_Pharmacy-DME.aspx.
  • A Recipient Information Sheet for prescribers and pharmacists to provide to recipients can be found athttp://www.medicaid.alabama.gov/content/4.0_Programs/4.3_Pharmacy-DME.aspx.

IMPORTANT: A recipient may not pay cash for the remaining amount over 7 days for the same prescription of a Medicaid-paid opioid claim (ie a single fill/dispense/claim may not be ‘split billed’ to both Medicaid and cash). If the prescription to be paid by Medicaid exceeds the drug’s limit allowed, an override may be requested. Only if the override is denied, then the excess quantity above the maximum unit limit is deemed a non-covered service, and the recipient can be charged as a cash recipient for that amount in excess of the limit. A prescriber must not write separate prescriptions, one to be paid by Medicaid and one to be paid as cash, to circumvent the override process. FAILURE TO ABIDE BY MEDICAID POLICY MAY RESULT IN RECOUPMENTS AND/OR ADMINISTRATIVE SANCTIONS. Source: Provider Billing Manual 27.2.3 

Morphine Milligram Equivalents (MME) Information/Examples

Higher doses of opioids are associated with higher risk of overdose and death. Even relatively low dosages (20-50 MME per day) increase risk.1

Examples of MME calculations/day include:

  • 10 tablets per day of hydrocodone/acetaminophen 5/325 = 50 MME/day
  • 6 tablets per day of hydrocodone/acetaminophen 7.5/325 = 45 MME/day
  • 5 tablets per day of hydrocodone/acetaminophen 10/325 = 50 MME/day
  • 2 tablets per day of oxycodone 15 mg = 45 MME/day
  • 3 tablets per day of oxycodone 10 mg = 45 MME/day
  • 10 tablets per day of tramadol 50 mg = 50 MME/day
  • 1 patch per 3 days of fentanyl 25mcg/hr = 60 MME/day

A link with more information regarding MME calculations is https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf.

*Partial Filling of Schedule II Medication: Per the Alabama State Board of Pharmacy website, there has been a change in federal law regarding partial filling of Schedule II controlled substance (CS). The Comprehensive Addiction and Recovery Act (CARA) of 2016 passed the United States Senate and was signed into law on July 22, 2016. CARA allows pharmacists to partially fill Schedule II CS. According to CARA, a prescription may be partially filled if: it is written and filled according to state and federal law; the partial fill is requested by the patient or prescribing practitioner; and the total quantity dispensed does not exceed the quantity prescribed. Remaining portions of partially filled prescriptions must be filled within 30 days of the original written prescription date. There is no single specified way to fill or bill prescriptions under the CARA update.2

1 https://www.cdc.gov/drugoverdose/prescribing/guideline.html
2 http://www.albop.com/FAQ.aspx

Override Requests
Pharmacy override requests for quantities exceeding the maximum days’ supply limit or MME limit may be submitted to Health Information Designs (HID). Please see the Pharmacy Override External Criteria instructions for information about override requirements at:

http://medicaid.alabama.gov/content/9.0_Resources/9.4_Forms_Library/9.4.13_Pharmacy_Forms.aspx.

The Override Request Form is to be used by the prescriber or the dispensing pharmacy when requesting an override. The form can be found at:

http://medicaid.alabama.gov/content/9.0_Resources/9.4_Forms_Library/9.4.13_Pharmacy_Forms.aspx.

Providers requesting overrides by mail or fax should send requests to:

Health Information Designs (HID)
Medicaid Pharmacy Administrative Services
P. O. Box 3210 Auburn, AL 36832-3210
Fax: 1-800-748-0116
Phone: 1-800-748-0130

Incomplete requests or those failing to meet Medicaid criteria will be denied. If the prescriber believes medical justification should be considered, the prescriber must document this on the form or submit a written letter of medical justification along with the override form to HID. Additional information may be requested. Staff physicians will review this information.

Any policy questions concerning this provider ALERT should be directed to the Pharmacy Program at (334) 242-5050. Questions regarding override procedures should be directed to the HID help desk at 1-800-748-0130.

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