Navigating Nevada Medicaid & CHIP

1. NavigatingNevada Medicaid & CHIP Presentation to Access to Healthcare Summit May 22, 2012

2. Topics/Goals • General Understanding of: • Medicaid and the Children’s Health Insurance Program (CHIP)… In Nevada the CHIP program is called Nevada Check Up (NCU) • Healthcare Reform’s Potential Impact • New Initiatives in Nevada • How do I Navigate Nevada Medicaid/NCU • Policies/Responsibilities and Coverage • Fee For Service (FFS) • How do I become a provider • How do I learn about billing/payment • Managed Care

3. Program Statements • The Division of Health Care Financing and Policy administers two major health coverage programs which provide health care to Nevadan’s. • Medicaid provides health care to low-income families, as well as aged, blind and disabled individuals. Services are provided as fee-for-service and through managed care networks. • Nevada Check Up provides health coverage to low-income, uninsured children who are not eligible for Medicaid. Services are provided as fee-for-service and through managed care networks.

4. State/Federal Government Partnership • Federal Financial Participation (FFP) is provided to pay for medical services authorized by the Centers for Medicare and Medicaid Services (CMS). • Both Medicaid and CHIP have CMS Mandatory and Optional eligibility groups and services.

5. Medicaid – Unique by State • If you’ve seen one Medicaid or CHIP program, you’ve seen one Medicaid or CHIP program. • A person eligible in one State may not be eligible in another State. • Services provided by one State may differ considerably in amount, duration, or scope from services provided in a similar or neighboring State. • States may change eligibility (currently maintenance of eligibility, adults to 2014 and Children to 2019), services, and/or reimbursement during the year.

6. Medicaid – Publicly Financed but Private Sector Services • Publicly Financed but not a Government Run Healthcare Delivery System • Medicaid procures most health care and administrative services in the private market through contracts, purchasing services on a fee for service basis or through paying premiums to contracted managed care organizations.

7. General Medicaid Rules • Comparability of Services • Free Choice of Provider • Statewideness • Utilization Control • Medical Necessity • Proper & efficient administration • Payment for services furnished outside the State • Assurance of Transportation (Logisticare) • EPSDT – States are required to provide all medically necessary services to individuals under 21 years of age. This includes services that would otherwise be optional services or non state plan.

8. Health Care Reform-Background • On March 23, 2010, the President signed the Patient Protection and Affordable Care Act (PPACA) passed by the House on March 21, 2010. • On March 30, 2010, the President signed the Health Care and Education Act of 2010, making changes to the Patient Protection and Affordable Care Act.

10. Medicaid Expansion | Eligibility for under the ACA • In 2014, the Modified Adjusted Gross Income Standard (MAGI) will be used to determine eligibility: • for the premium tax credits available in the Exchanges. • Medicaid (a few exceptions) and • CHIP • Income eligibility levels will increase and cover everyone at those levels. The effective eligibility standard will be 138% (5% income disregard). • Finally, eligibility rules will seek to streamline state eligibility processes.

11. Medicaid Expansion | New Eligibles • Starting 2014, the ACA creates a new mandatory eligibility group that expands Medicaid to adults with incomes at or below 138 percent of the Federal Poverty Level (FPL); $15,415 for an individual in 2012. These individuals are considered “New Eligibles” under the Act and include those who are: • Ages 19-65; • NOT Pregnant; • NOT entitled to/enrolled for benefits under Medicare; • NOT otherwise eligible for Medicaid under the Social Security Act; and • Whose income does not exceed 138% of the FPL.

13. Medicaid Expansion | Eligibility Engine • The Eligibility Engine is an IT initiative to implement the new eligibility requirements for Medicaid, CHIP and subsidized Silver State Health Insurance exchange coverage for individuals. Key provisions of this project include: • Create a “No wrong door” process for eligibility. • The Engine will be administered by Division of Welfare and Supportive Services (DWSS)

14. Essential Health Benefits | Covered Services • The ACA requires Medicaid and the Exchange’s health plans to cover the minimum Essential Health Benefits (EHB) including: • Ambulatory services • Emergency services • Hospitalization • Maternity and newborn care • Mental health and substance use disorder services, including behavioral health treatment • Prescription drugs • Rehabilitative and habilitative services and devices • Laboratory services • Preventive and wellness services and chronic disease management • Pediatric services, including oral and vision care • Medicaid must also cover early screening for children (EPSDT), non-emergency medical transportation, FQHC and Family Planning services.

15. Essential Health Benefits | Benefit Packages

16. Medicaid Expansion | Service Delivery • Urban Nevada • Medicaid Managed Care Organizations (MCOs) • Coverage of ACA-related groups: Childless adults; Parents/Caretakers; Pregnant women; Infants and children under age 19. • CHIP • Fee-For-Service • All other groups including MAABD, dual eligibles, HCBS waiver clients, child welfare or juvenile justice system groups. • Rural Nevada • Fee-For-Service

17. Care Management/Health Home in Fee For Service • The health home and the care management programs integrate the medical care, behavioral health and long term care needs of the patient into one coordinated plan of care through a medical team all focused on the needs of the patient. • They monitor and manage provision of patient care through case management and health information technology. • They utilize national benchmarks to track outcomes (hospital re-admit rates, ER use, well child visits)

18. Care Management Organization • 1)Provide integrated Care Management; and/or • 2) Develop a cost-effective infrastructure to help small medical practices meet the requirements of a health home, thereby promoting the expansion of health homes in Nevada.

19. Medicaid Waiver Request • Use innovative care delivery models including per person per month type provider payments, shared savings options and pay for performance. • Tailor some programs to specific populations or age groups (health home specific to children with cardiac conditions or adults with severe diabetes pre end stage renal disease). • Initially limit some programs to Medicaid and not the dual Medicaid/Medicare population. • To mandatorily enroll or exclude specific groups. • To act expeditiously when opportunities present.

20. What Services and What Requirements Does Nevada Have? • In all but a few instances the NCU benefit plan, regulations, utilization and service policy is the same as Medicaid. • Medicaid Benefit Plan is developed in conjunction with CMS in an amendment to the Medicaid State Plan (SPA) • Benefit Plan, Regulation, Utilization and Policy is in the Nevada Medicaid Service Manual • https://dhcfp.nv.gov/MSM%20Table%20of%20Contents.htm?Accept

21. Medicaid Service Manual (MSM) • All providers must be familiar with the Medicaid Service Manual Chapters • 100 Medicaid Program…..guidance for all providers • Many Chapters are organized by provider type • Other chapters by an activity or function: • Rates and Cost Containment • Healthy Kids (EPSDT) • Hearings • Program Integrity • School Based Health Services • Managed Care • The Addendum includes definitions that apply in all areas.

22. MSM Changes and Updates • All Medicaid Regulation and Policy Change goes through a public hearing process. • https://dhcfp.nv.gov/publicnotices.htm • Providers should monitor and review the upcoming public workshops and hearings to ensure they have input and knowledge of program changes that affect their service.

23. How Do I Become a Provider in the Fee For Service Program • Provider Qualifications and Service Requirements are in the MSM • Provider Enrollment Information and Process is Listed on the Web in the Provider Tab at: • http://www.medicaid.nv.gov/ • Billing Information, Training Opportunities are also listed in the provider tab on this website.

24. How Do I Become a Provider in the Managed Care Program • Nevada contracts with two managed care organizations, Amerigroup and Health Plan of Nevada. You must contact each MCO to inquire about being a provider for their Nevada Medicaid Program. • Amerigrouphttps://providers.amerigroup.com/Pages/Home.aspx?ReturnUrl=%2fsecure%2fPages%2fHome.aspx • Health Plan of Nevada • http://www.healthplanofnevada.com/Body.cfm?id=9

25. Questions? Contact: Betsy Aiello, Deputy Administrator Division of Health Care Financing and Policy 1100 E. William St. Ste 101 Carson City, NV 89701 PH: 775-684-3679 Email: eaiello@dhcfp.nv.gov