Presentation on theme: "Medicaid Coverage for the Diabetes Prevention Program: The Process to Make and Implement the Policy Change Sarah Brokaw, MPH Montana Diabetes Program Montana."— Presentation transcript:
Medicaid Coverage for the Diabetes Prevention Program: The Process to Make and Implement the Policy Change Sarah Brokaw, MPH Montana Diabetes Program Montana Incentives to Prevent Chronic Disease Grantee Conference Call March 4, 2015
Background Meeting with Montana Medicaid and Diabetes Program staff in 2010 (Administrators, Bureau Chiefs, program staff) – Made case for Medicaid coverage for the DPP – Showed evidence for health outcomes improvement using our own data and from the DPP literature (Tuomilehto et al. 2001, Knowler et al. 2002, Knowler et al. 2009) – Demonstrated cost neutrality/cost savings based upon our own funding levels and from the cost-effectiveness literature (Herman et al. 2005, Herman 2011) CMS Medicaid Incentive to Prevent Chronic Disease Grant – MT Medicaid and Diabetes Program applied together in May 2011 – Received the grant in September 2011 – Formalized partnership and our timeline and workplan to obtain Medicaid coverage from September 2011 to April 2012 – Continued to work together closely on implementing this coverage – Added ongoing support such as national recommendations from CDC
Montana Medicaid Policy Change Administrative Rules of Montana rule change – Rule 37.85.206 amended: Services Provided by General Medicaid Services – Rule 37.86.5401-5404 added: Preventive Services by Medicaid Primary Care Services – Source: http://www.mtrules.org/http://www.mtrules.org/ State Plan Amendment to Preventive Services Section – Draft began in 11/2011 and approved 4/13/2012 – Effective 2/2/2012 – Source: http://www.medicaid.gov/State-resource-center/Medicaid-State-Plan- Amendments/Downloads/MT/MT-12-003.pdfhttp://www.medicaid.gov/State-resource-center/Medicaid-State-Plan- Amendments/Downloads/MT/MT-12-003.pdf Reimbursement set according to fee schedule rates – S9460 @ $21.88 weekly (Total for completion of all 16 weekly sessions = $350) – S9455 @ $25.00 monthly (Total for completion of all 6 monthly sessions = $150) – Total reimbursement of $500 per Medicaid member for 22-session DPP – Source: http://medicaidprovider.mt.gov/enduserprovidershttp://medicaidprovider.mt.gov/enduserproviders
Examples of Provider Notices * Note that these provider notices are currently being updated with information from the next slide
DPP – Claims Submission Public Health Use the contracted NPI Bill as 837P or CMS-1500 Must bill separate lines for each date of service S9455: will pay $25.00 after co-pay S9460: will pay $21.88 after co-pay Hospital Use the contracted NPI Bill as 837I or UB-04 Must bill separate lines for each date of service S9455: will pay $25.00 after co-pay S9460: will pay $21.88 after co-pay
System Errors Being Corrected Medicare Crossover Claims – Xerox will update the claims system to include Revenue code 500 which will allow claims for members receiving Medicare and Medicaid to pay correctly and a Medicare denial will not be required. Critical Access Hospital (CAH) – Xerox will update the claims system to allow CAHs to be paid at the same rate as all other facilities for S9455 and S9460. NPI – Medicaid is working with Public Health and Xerox to update any inactive NPIs that were contracted to allow claims to pay correctly.
The Good News Providers are currently being paid for their DPP services for DPP claims that are: – submitted with an active NPI contracted with Public Health – for Medicaid members only (not Medicare crossover) – for all facilities excluding CAHs *Providers have 365 days from date of service to submit claims