Reimbursement Update/HPE Adult Aid Category/HIP
IHCP Quarterly Update Reimbursement Update, HPE Adult Aid Category, HIP 2.0 HP Provider Relations/March 2015 Agenda • Indiana Health Coverage Programs (IHCP) Rate Changes • HPE Adult – New Aid Category • New Healthy Indiana Plan 2 IHCP 1st Quarter Update March 2015 IHCP Rate Changes Rate Changes • As part of the HIP 2.0 implementation, the Indiana Health Coverage Programs (IHCP) announced a general increase in reimbursement rates for providers billing physician services paid on a feefor-service basis • Effective for dates of service (DOS) on or after February 1, 2015, rates for most physician services were adjusted, in aggregate, to 75% of the 2014 Medicare Physician Fee Schedule • rate changes will apply to nonphysician practitioners rates that are based on the physician fee schedule 4 IHCP 1st Quarter Update March 2015 Rate Changes Consultations As communicated in BT201504, effective for dates of service on or after February 1, 2015, consultation codes are no longer covered by the IHCP. These include CPT®1 codes 99241-99245 and 99251-99255. Although these codes are non-covered, other Evaluation and Management (E/M) codes remain covered services, including but not limited to: • • • • 1 5 99201-99205 for new patient office and other outpatient visits 99211-99215 for established patient office and other outpatient 99221-99223 for initial hospital care 99231-99233 for subsequent hospital care visits. CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association IHCP 1st Quarter Update March 2015 Rate Calculation Rate Calculation For most services, the IHCP is using the following data to calculate revised rates: • 2014 Medicare Physician Fee Schedule Relative Value Units (RVUs) • 2014 Medicare Indiana Geographic Practice Cost Indexes (GPCIs) – 2014 Medicare Practice Expense GPCI – 0.922 – 2014 Medicare Work GPCI – 1.000 – 2014 Malpractice Expense GPCI – 0.615 • 75% of the 2014 Medicare Conversion Factor of 35.8228 7 IHCP 1st Quarter Update March 2015 Note…. • While rates for physician services increased in aggregate, providers should note that rates for some services may remain the same or decrease as a result of this update 8 IHCP 1st Quarter Update March 2015 Exceptions Exceptions Exceptions to the rate-setting methodology: • Nondelivery maternity services and prenatal services will increase, in aggregate, to 100% of the 2014 Medicare rate • Reimbursement methodology for maternity delivery services is as follows: – The rates for Current Procedural Terminology (CPT®1) codes 59612 and 59620 increased to 100% of the 2014 Medicare rate – The rates for CPT codes 59409 and 59514 are now a blended rate of the two services; both services will reimburse $818.87 1 CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association 10 IHCP 1st Quarter Update March 2015 Exceptions • Behavioral health services increased, in aggregate, to 80% of the 2014 Medicare rate • Anesthesia services increased to approximately 75% of the 2014 Medicare rate Please note that IHCP reimbursement continues to reflect age and physical status units where applicable • Consultation codes are no longer covered by the IHCP effective for DOS on or after February 1, 2015 – Includes CPT codes 99241-99245 and 99251-99255 • Rates for Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) visits will increase to $87 for established patients (now $62) and $100 for new patients (now $75) – The rate will be applied based on the reported diagnosis (V20.2) as it is today • All other reimbursement methodologies and medical policies remain unchanged 11 IHCP 1st Quarter Update March 2015 HPE Adult – New Aid Category HPE Adult – New Aid Category • Effective February 15, 2015, the IHCP added a new aid category – HPE Adult • What are the differences in HPE Adult vs other Hospital Presumptive Eligibility (HPE) categories? – HPE Adult members have HIP Basic plan coverage – HPE Adult members have cost-sharing obligations – HPE Adult members are served under the managed care delivery system and must be enrolled with an IHCPcontracted managed care entity (MCE) 13 IHCP 1st Quarter Update March 2015 Eligibility Eligibility Qualifications • • • • • • • 15 Be a U.S. citizen or a qualified noncitizen Be an Indiana resident Not be currently incarcerated Not be a current IHCP member Not have Medicare coverage Be a nondisabled adult ages 19 – 64 Have a family income of approximately 138% (includes a 5% income disregard) of the federal poverty level (FPL) or less for the applicable household size IHCP 1st Quarter Update March 2015 Eligibility Services covered by HPE Adult HIP Basic: • Ambulatory patient services • Hospitalization • Emergency services • Mental health and substance abuse • Prescription drugs • Rehabilitative services • Laboratory services • Preventive care 16 IHCP 1st Quarter Update Services not covered by HPE Adult HIP Basic: • Dental services • Vision services • Bariatric surgery • Treatment for temporomandibular joint (TMJ) disorder March 2015 HPE Application Process HPE Application Process • If the individual is deemed eligible for the HPE Adult – HIP Basic aid category, the HPE application will generate a pop-up box to enter the member’s MCE selection – If a selection is not made, the member will be auto-assigned to an MCE • As with other HPE aid categories, members are only allowed one HPE eligibility period per rolling 12 months • QPs are held to the same requirements and standards that apply to other HPE aid categories 18 IHCP 1st Quarter Update March 2015 Copayments Copayments • A $4 copayment will apply to the following services: – Rehabilitative and habilitative services and devices – Ambulatory services – Laboratory services – Office and other outpatient services – Preferred drugs • Inpatient services = $75 per stay • Nonpreferred drugs = $8 • Nonemergency Emergency Department (ED) visits = $8 first visit; $25 all subsequent visits 20 IHCP 1st Quarter Update March 2015 Reimbursement Reimbursement • Services rendered to individuals covered under the HPE Adult aid category will be reimbursed through the risk-based managed care (RBMC) delivery system by the MCE with which the member is enrolled • The member’s MCE assignment is identified when verifying IHCP eligibility • During the HPE period, providers are required to submit claims for HPE Adults to the appropriate MCE using the member’s HPE identification (ID) number, which will always begin with “600” Note: Presumptive eligibility qualified providers will be expanded to include federally qualified health centers (FQHCs), rural health clinics (RHCs), community mental health centers (CMHCs), county health departments, and free-standing psychiatric hospitals. Effective date: TBD 22 IHCP 1st Quarter Update March 2015 Helpful Tools Helpful Tools • IHCP website at indianamedicaid.com • IHCP Provider Manual • Electronic Solutions Service Desk − 1-877-877-5182 (toll-free) − [email protected] • Customer Assistance − 1-800-577-1278 (toll-free) − Provider Relations field consultant − provider.indianamedicaid.com/contact-us/providerrelations-field-consultants.aspx • Written Correspondence − HP Provider Written Correspondence P. O. Box 7263 Indianapolis, IN 46207-7263 24 IHCP 1st Quarter Update March 2015 Q&A
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