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Medicaid Coverage for the Diabetes Prevention Program: The Process to Make and Implement the Policy Change Sarah Brokaw, MPH Montana Diabetes Program Montana.

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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:

1 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

2 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

3 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

4 Examples of Provider Notices * Note that these provider notices are currently being updated with information from the next slide

5 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

6 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.

7 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


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