MississippiCAN Program - Mississippi Primary Health Care

Office of the Governor | Mississippi Division of Medicaid
Mississippi Division of Medicaid
MississippiCAN Program
M P H C A C o n f e re n c e
Goals of MississippiCAN Program
Mississippi Coordinated Access Network (MississippiCAN) implemented on January 1 2011
(MississippiCAN) implemented on January 1, 2011 is a statewide care coordination program designed to:
• Improve beneficiary access to needed medical services;;
• Improve the quality of care; and
Improve program efficiencies as well as cost
• Improve program efficiencies as well as cost effectiveness. OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID
2
Evolution of the MississippiCAN Program
• Mississippi House Bill 71 – 2009 Second Extraordinary Session
• Mississippi House Bill 421 –
Mississippi Ho se Bill 421 2012 Regular Session
2012 Reg lar Session
• Mississippi House Bill 1275 – 2014 Regular Session
•
The MississippiCAN program has evolved from January 2011 to present.
– Increased limit to 45% of total enrollment of Medicaid beneficiaries, plus the categories of beneficiaries composed primarily of persons younger than nineteen(19) years of age
– Inclusion of services, except Inpatient Hospital Services (NET now included)
OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID
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DOM Bureau of Coordinated Care
The DOM Bureau of Coordinated Care manages two statewide programs designed to improve beneficiary access to needed medical services, and to p
q
y
improve the quality of care. – Mississippi Coordinated Access Network (MississippiCAN) – Children’s Health Insurance Program (CHIP). There are two coordinated care organizations (CCOs) which provide services to these beneficiaries: – Magnolia Health Plan and – UnitedHealthcare. For questions regarding MississippiCAN, call 601‐359‐3789 or email MississippiCAN Plan@medicaid ms gov or view the website at [email protected]
or view the website at
http://www.medicaid.ms.gov/programs/mississippican/
OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID
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MississippiCAN Enrollment • Beneficiaries can enroll at any time.
• Every member will have a 90‐day window to make changes after his/her initial enrollment
his/her initial enrollment.
• During the 90‐day window, mandatory members may only switch between the plans one time.
• During the 90‐day window, optional members may dis‐enroll or u g t e 90 day
do , opt o a e be s ay d s e o o
switch between the plans one time.
• DOM will have an open enrollment period each year (October –
December) to allow members to make changes.
• Enrollment is always effective at the beginning of the month and disenrollment, for those in the optional population, is effective the last day of the month.
• Newborns born to a Medicaid mom who is currently enrolled in Newborns born to a Medicaid mom who is currently enrolled in
MississippiCAN will automatically be placed in the same plan as the mother.
OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID
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MississippiCAN Mandatory Populations
y p
Category of Eligibility
• 001 –SSI
001 SSI
• 025 ‐ Working Disabled
• 027 ‐ Breast and Cervical Cancer
• 075 – Parents and Care Takers • 088 ‐ Pregnant Women • 071 071 – Newborns
• 072 – 074 Children (Beginning SFY 2015)
Age 19 65
19‐65
19‐65
19‐65
19‐65
8‐65
0‐1
0
1
1‐19**
*088 –formerly Pregnant Women and Infants (Infants/Newborns moved to 071)
y
g
(
/
)
*085‐ formerly TANF (Parents moved to 075, and Children moved to new categories)
*087 and 091‐ formerly Children (Moved to new categories 071, 072, 073, 074)
OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID
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MississippiCAN O i
Optional Populations
l P
l i
Category of eligibility •
•
•
•
001 – SSI
019 ‐ Disabled Child Living at Home
026 DHS‐Foster Care Children
026 ‐
DHS Foster Care Children
003 ‐ DHS‐Foster Care Children
(Adoption Assistance)
Age 0‐19
0‐19
0 19
0‐19
0‐19 Note: Always check eligibility for the Date of Service to ensure submission to correct payer by methods below:
Telephone 1‐800‐884‐3222 Envision Web Portal at new address www.ms‐medicaid.com
OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID
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Beneficiaries Who Are Not Eligible for MississippiCAN
• Beneficiaries enrolled in any waiver program. (ex HCBS TBI IDDD IL MYPAC etc )
(ex. HCBS, TBI, IDDD, IL, MYPAC, etc.)
• B
Beneficiaries who are dually eligible. fi i i
h
d ll li ibl
(Medicare/Medicaid)
• Beneficiaries who at the time of application are institutionalized (ex Nursing Facility ICF MR
institutionalized. (ex. Nursing Facility, ICF‐MR, Correctional Facilities, etc.)
OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID
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New Medicaid and CHIP Eligibility Income Calculation
Effective January 1, 2014, a new methodology based on Modified Adjusted Gross Income (MAGI) will be used for determining CHIP eligibility. As a result of a conversion to MAGI, children in households with income limits up to 133 percent of the federal p
poverty level will be transitioning from CHIP to traditional y
g
Medicaid. Federal authority for the change in the Medicaid limit that affects Federal
authority for the change in the Medicaid limit that affects
CHIP is Section 2001 (a)(5)(B) of the Affordable Care Act implemented through federal regulations for the Medicaid program at 42 CFR § 435.118.
at 42 CFR §
435 118
OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID
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MississippiCAN 2014 Contract Changes
The renewed MississippiCAN contract will be effective July 1, 2014, which may be viewed at www medicaid ms gov under request for bids/proposals. Below are viewed at www.medicaid.ms.gov
under request for bids/proposals Below are
some changes in new contract:
PCP assignment
• The member has thirty (30) calendar days to select a Primary Care Provider Th
b h thi t (30) l d d
t
l t P i
C
P id
(PCP). The Contractor must inform PCPs of Member assignments via web portal unless the PCP requests an alternate format (e.g., surface mail, secure fax) when completing the provider contract. If the Contractor elects to notify PCPs via web portal, the Contractor must confirm that the PCP received and
PCPs via web portal, the Contractor must confirm that the PCP received and has acknowledged receipt of the Member listing and acknowledges receipt of list of Members assigned to them. Pharmacy
• The Contractor must use the most current version of the Medicaid Program The Contractor must use the most current version of the Medicaid Program
Preferred Drug List (PDL), which is subject to periodic changes. The Contractor must use the Medicaid PDL developed by the Division or its Agent and may not develop and use its own PDL.
OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID
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MississippiCAN 2014 Contract Changes
Non­Emergency Transportation
• The Contractor shall provide Non‐Emergency Transportation for its M b
Members to access Medically Necessary Services, in compliance with t
M di ll N
S i
i
li
ith
minimum Federal requirements for the provision of transportation services and according to DOM policies, which are outlined in Mississippi Administrative Code, Title 23, Part 201 . Non‐Emergency Transportation ,
,
g y
p
shall be provided to Members who require transportation to and from Medicaid covered non‐emergency services
Prior Authorization
• The Contractor shall have the capability and established procedures to receive Prior Authorization requests via secure web‐based submissions and facsimile from providers. The Contractor must make standard authorization decisions and provide notice within three (3) calendar authorization decisions and provide notice within three (3) calendar days or two (02) business days following receipt of the request for services. OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID
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MississippiCAN 2014 Contract Changes
Provider Network Requirements­PCP providers
Urban‐two within fifteen (15 ) minutes or thirty (30) miles ( )
y( )
Rural‐one within thirty (30) minutes or thirty (30) miles
Credentialing • The Contractor shall credential all completed application packets Th C
h ll
d i l ll
l d
li i
k
within ninety (90) calendar days of receipt. In cases of network inadequacy, the Contractor shall credential all completed application packets within forty‐five (45) calendar days of receipt
Claims:
• The Contractor shall encourage providers to submit claims as soon as possible after the dates of service. Providers shall be provided a minimum of ninety (90) calendar days and a maximum
of ninety (90) calendar days and a maximum of six (6) of six (6)
months to submit claims from the date of service. Claims filed within the appropriate timeframe but denied may be resubmitted to the Contractor within ninety (90) calendar days from the date of denial.
OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID
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MississippiCAN Contact Information
Payer
Card Color
Type Service
Blue (new cards)
Green (old cards)
Medicare
Red/White/Blue
1 800 633 4227
1‐800‐633‐4227
Purple
(same card)
(same card)
(same card)
1‐800‐884‐3222(*) 1‐800‐421‐2408
1‐866‐912‐6285
1‐866‐912‐6285
1‐866‐912‐6285
1‐800‐460‐8988
MississippiCAN
UnitedHealthcare
UBH­OptumHealth OptumRx
CHIP
UnitedHealthcare
White
(same card)
(same card)
White
Medical
Behav Hlth
DME
Pharmacy
Medical
Behav Hlth
Pharmacy
Multiple
1‐800‐884‐3222
DOM
Mississippi Medicaid
MississippiCAN
Magnolia Health Plan
Cenpatico
Univita US Script
Multiple
Telephone
1‐800‐421‐2408
1‐800‐884‐3222(*) 1‐800‐421‐2408
1‐877‐743‐8731
1‐877‐305‐8952
1‐800‐884‐3222
1 877 743 8731
1‐877‐743‐8731
1‐800‐421‐2408
OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID
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Contact Information for the MississippiCAN program
Mississippi Division of Medicaid
Phone: 601‐359‐3789
Toll‐free: 1‐800‐421‐2408
http://www.medicaid.ms.gov/progr
ams/mississippican/
/
/
Inquiry/Complaint Form available
Magnolia Health Plan
g
Toll‐free: 866‐912‐6285
Toll
free: 866 912 6285
www.magnoliahealthplan.com
United Healthcare
Toll‐free: 877‐743‐8731
www.uhccommunityplan.com
OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID
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FQHC Encounter Rate • Rule 1.3: Covered Services • A. Medicaid defines an encounter as services provided by A Medicaid defines an encounter as services provided by
physicians, physician assistants, nurse practitioners, clinical psychologists, dentists, optometrists, ophthalmologists and clinical social workers. A clinic’s encounter rate covers the b
beneficiary’s visit to the clinic, including all services and fi i ’ i i
h li i i l di
ll
i
d
supplies, such as drugs and biologicals that are not usually self‐administered by the patient, furnished as an incident to a p
professional service. When services, supplies, drugs or , pp ,
g
biologicals are included in the clinic’s encounter rates, the clinic cannot send the beneficiary to another provider that will bill Medicaid for the covered service, supply, drug or biological. http://www.medicaid.ms.gov/wp‐content/uploads/2014/01/Admin‐Code‐Part‐211.pdf
OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID
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340B Drug Pricing
Background: The 340B Drug Pricing Program resulted from enactment of the Veterans Health Care Act
of 1992, which is Section 340B of the Public Health Service Act. Section 340B of the Public Health Service
Act limits the cost of covered outpatient drugs to certain federal grantees, federally
federally‐qualified
qualified health center
look‐alikes, and qualified hospitals. These providers purchase, dispense and/or administer
pharmaceuticals at significantly discounted prices. The significant discount applied to the cost of these
drugs make them ineligible for the Medicaid drug rebate. State Medicaid programs are mandated to
ensure that rebates are not claimed on these drugs.
drugs Providers who are enrolled as 340B providers with
the U.S. Department of Health and Human Services (DHHS), Health Resources and Services Administration
(HRSA) are referred to as 340B providers. 340B providers appear on the Office of Pharmacy Affairs
Database, http://www.hrsa.gov/opa/.
Reason for change: In an Office of the Inspector General (OIG) June 2011published report, the OIG
recommended that CMS direct states to create written 340B policies regarding reimbursement of 340b
g in Medicaid. As a follow‐up
p to the OIG’s recommendations, CMS directed that states clarify
y
drugs
reimbursement policies for 340B entities in the approved state plan. DOM has submitted a state plan
amendment consistent with the regulations, including those found at 42 CFR 447.502 and 447.512, to
detail how these covered entities are reimbursed. This state plan amendment will enable MS to be in
compliance with CMS regulations and clarify billing /reimbursement for 340B entities.
entities
OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID
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Program changes, effective July 1, 2014
•
DOM will allow providers to ‘opt in’ or ‘opt out’. The Division of Medicaid
defines opt‐in as the election by a covered entity to purchase and
dispense/administer covered 340B drugs to Medicaid beneficiaries. The DOM
d fi
defines
opt‐out
t t as the
th election
l ti
b a covered
by
d entity
tit nott to
t purchase
h
and
d
dispense/administer covered 340B drugs to Medicaid beneficiaries. Covered
entities may change their opt‐in or opt‐out election by completing, signing and
submitting the Medicaid 340B Covered Entity Attestation and Election Form to
the Division of Medicaid.
Medicaid The change is effective thirty (30) days following the
Division of Medicaid’s receipt of the form. Covered entities changing their
enrollment status must meet the requirements in Administrative Code, Part
200, Chapter 4, Rule 4.10.E.1) or 4.10.E.2).
•
A contract pharmacy, defined by the Division of Medicaid as an agent of a
340B covered entity and ineligible to be a freestanding 340B covered entity,
cannot dispense and bill the Division of Medicaid for 340B outpatient drugs
for Medicaid beneficiaries.
Billing (please see next page for detail pharmacy billing instructions)
•
OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID
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Pharmacy Billing Instructions Pharmacy Billing instructions: These billing directions only address billing of 340B drugs. The non‐340B drugs should continue to be billed using the ‘Usual and Customary’ charge. The following section addresses only pharmacy providers who are 340B Covered Entities who have elected to ‘opt in’, that is dispense ALL of their 340B drugs to Medicaid b
beneficiaries at their 340B actual acquisition cost (340B AAC). It is understood that some 340B Covered Entities purchase fi i i
t th i 340B t l
i iti
t (340B AAC) It i
d t d th t
340B C
d E titi
h
both 340B drugs and non‐340B drugs for their patients who are ineligible to receive 340B drugs. 340B providers who are enrolled with the department as a provider type other than pharmacy shall charge DOM no more than their actual acquisition cost for the drug product.
NCPDP directions for POS billing of 340B drugs:
I fi ld ‘420 DK’ (S b i i Cl ifi i C d ) In field ‘420­DK’ (Submission Clarification Code) enter a value of ‘20’
l f ‘20’ (Description‐
(D
i i
34ØB Indicates that, prior to 34ØB ‐
I di
h i providing service, the pharmacy has determined the product being billed is purchased pursuant to rights available under Section 34ØB of the Public Health Act of 1992 including sub‐ceiling purchases authorized by Section 34ØB (a)(1Ø) and those made through the Prime Vendor Program (Section 34ØB(a)(8)). In field 423­DN (Basis Of Cost Determination) enter a value of ‘08’ (34ØB /Disproportionate Share Pricing/Public Health Service ‐
Health
Service Price available under Section 34ØB of the Public Health Service Act of 1992 including sub‐ceiling purchases Price available under Section 34ØB of the Public Health Service Act of 1992 including sub ceiling purchases
authorized by Section 34ØB (a)(1Ø) and those made through the Prime Vendor Program (Section 34ØB(a)(8)). Applicable only to submissions to fee for service Medicaid programs when required by law or regulation. )
In field 409­D9 (Ingredient Cost Submitted) the 340B actual acquisition cost must be entered.
In field 426­DQ (Usual and Customary Charge or Total Charge) the lowest net charge that a non­Medicaid , 340B eligible patient would pay for the same prescription must be entered.
Example
The total charge to a non‐Medicaid 340B‐eligible patient for a 30 day supply of Lisinopril 20 mg purchased under the p g
p
p
y
y
340Bprogram is $4.00. The same prescription for a Medicaid beneficiary must be billed with an entry of $4.00 in the ‘Usual and Customary Charge’ field.
OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID
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340B FAQs • Are MSCAN (aka coordinated/managed care) claims included? Yes
• What will happen if a 340B entity does not complete and return the attestation form to Medicaid? The new policy, including attestation form, is in alignment with CMS and OIG recommendation for Medicaid agencies. It is Medicaid’s intent g
that all 340B providers will complete the form and submit to Medicaid. If a 340B provider does not submit said attestation form, then this provider will be considered a non‐340B entity. That fact may trigger audits from 340b regulatory bodies and drug manufacturers. • I am a prescriber and I don’t know why I received the 340B letter/attestation. What am I to do with this?
OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID
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Preferred Drug List (PDL) •
•
•
•
•
•
What is a PDL? A medication list of preferred drugs selected as ‘best of the best’ clinically, safety wise and monetarily.
Does Medicaid still cover non­preferred drugs? Yes, but prior authorization is needed
h
d d
Why should we use the PDL? Every time a non‐preferred drug is used for a Medicaid beneficiary, MS Medicaid and the State of Mississippi lose money. Is every drug on the PDL? No. A drug class is not included if there are limited cost savings for that class of drugs, if there is little use of the drug, or if the class is mostly generic. This is monitored closed and DOM may decide to add or delete a class from the PDL as needed. How many classes on the PDL? Over 75‐80 drug classes are on DOM’s PDL.
Where can we find the PDL? On Medicaid
On Medicaid’ss webpage at webpage at
http://www.medicaid.ms.gov/providers/pharmacy/preferred‐drug‐list/
OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID
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Advantages of PDL • Goal of the PDL is to have as many cost effective drugs available as possible. • Preferred drugs do not need a prior authorization
• Adult beneficiaries (< 21) can get more than two branded drugs if the branded drugs are on the PDL.
PDL
• Save Medicaid and the MS taxpayers money
OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID
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What is the Uniform PDL? • Medicaid and MSCAN are working together g g
to have a uniform or the same Preferred g
(
)
Drug List (PDL) for Medicaid, UHC, and Magnolia.
• Start Date 10
Start Date 10‐1‐2014
1 2014
• Will help providers and beneficiaries OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID
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Helpful Tips • Bookmark the Pharmacy Services webpage for your easy reference http://www.medicaid.ms.gov/providers/pharmacy/
reference http://www.medicaid.ms.gov/providers/pharmacy/
• Here are some examples of what can be found on this page: •
•
•
•
•
•
•
•
•
PDL ‐ updated
Billing Tips (other insurance, hospice)
Medicaid Cough and Cold quick List
Medicaid Cough and Cold quick List
90 Day Maintenance List
72 Hour Emergency Prescription
Prior Authorization Forms
Prior Authorization Forms Latest Pharmacy News
ICD9 codes at Point Of Sale
Over The Counter (OTC) Formulary
Over The Counter (OTC) Formulary
OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID
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MSCAN Pharmacy Information Magnolia • Return POS Message :
Return POS Message :
• BILL MSCAN PLAN: Magnolia
• 1‐800‐460‐8988; BIN#008019
• This is their PBM or US Script’s Pharmacy Helpdesk number
p
y
p
• If you need to contact the Plan, call 1‐866‐912‐6285
UHC or UnitedHealthcare
• Return POS Message:
• BILL MSCAN PLAN: UHC • 1‐877‐305‐8952; BIN#610494 GROUP: ACUMS
• This is their PBM or RX Solutions’ Pharmacy Helpdesk number
Thi i th i PBM RX S l ti
’ Ph
H l d k
b
• If you need to contact the Plan, call 1‐877‐743‐8731
OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID
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Why does Medicaid do that? F d
Federal Regulations and Drug Coverage l R
l i
d D
C
Medicaid covers most drugs and drug classes, but not all. Why is that? From the inception of Medicaid (early 1970’s) to the early 90s, every state had its own Medicaid state‐specific pharmacy formulary. States had the authority and ability to control and monitor pharmacy costs. 1990, OBRA ’90 abolished state specific Medicaid drug formularies which caused Pharmacy budgets to skyrocket. Every prescription drug had to be covered (other than federal specified exclusions—see below) if manufacturer participates in (
p
)
p
p
rebate program. That means, that Medicaid does not cover the drugs listed below or we only cover some of the drugs listed below.
Federal Exemptions: commonly know as ‘1927s’ are found in Section 31.07
• drugs used for cosmetic purposes; d
df
ti
• drugs for weight gain or weight loss; • drugs for fertility; • drugs to treat cough and colds; • Over The Counter (OTC) drugs; O
Th C
t (OTC) d
• DESI (less than effective drugs as determined by the FDA) drugs; and
• RX vitamins.
OFFICE OF THE GOVERNOR | MISSISSIPPI DIVISION OF MEDICAID
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Occasionally the overall cost for a Brand may be less than for the Generic
Medicaid payment to
payment to pharmacies is higher for brand
Federal rebate
Supplemental rebates l
Medicaid overall Medicaid
overall
cost after rebates is lower for brand
Overall cost
Brand
G
Generic
i