1. Iowa Medicaid Project & CHSC Nutrition Billing Legislative Day February 16, 2010 Jody Kealey, RD/LD Nutrition Program Coordinator Jody-kealey@uiowa.edu

2. Introduction to Reimbursement 101 Patient renders Services from a Health care provider Requests reimbursement Individuals or Employers Pay premiums

3. MNT Legislation National Coverage Determination Social Security Act, November 1, 2001 CFR 410.130 - 410.134 CFR 414.64 Diabetes and Renal disease Further coverage requires act of Congress ADA Strongly works on MNT at a national level – Need Grassroots Locally Utilize ADA to support state work on MNT

4. The Difference Between Medicare Medicaid 65 and older Disability Regardless of income Federally funded MNT coverage Already have Strong ADA Leadership Children under age 21 65 and older Pregnant women Federal and State funds Limited income Multiple programs Need to include ADA leadership/support

5. History of IDA work May 2006 - Meeting with Mr. Gene Gessow June 2006 – Follow-up memo to Gene Gessow Fall 2007 – IDA Report on Medicaid Issues by Schulte and Roberts * May 2009 - Memo to Jennifer Vermeer, Director Iowa Medicaid – barriers to reimbursement *Survey “No payment” “Limited payment” “Don’t know” “MNT not covered”

6. Iowa Medicaid Meetings April 30, 2009 meeting with Jennifer Vermeer, Director and Julie Lovelady, Assistant Director of Iowa Medicaid Enterprises IDA identified disparities July 10, 2009 Medicaid response letter

7. Key Discussion Issues 1.Replace wording: MNT in place of “nutrition counseling” 2.Representation on an advisory council 3.Increase reimbursement rate ($21.57/unit (MNT- Medicare, $65.97/u PT compared to $8-Medicaid) 4.Change strict NIP criteria REQUIREMENTS TO APPLY FOR NONINPATIENT PROGRAM STATUS IN ORDER TO BE ELIGIBLE TO SUBMIT CHARGES FOR NUTRITION COUNSELING NIP criteria 5.Allow for reimbursement of nutrition counseling provided by dietitians employed by a local public health agency. 6.Remove the restrictive language in the manual Change the wording of “severity” Legislative and Regulatory Issues on Iowa Medicaid Reimbursement for Medical Nutrition Therapy By Jennifer Schulte and Susan Roberts, JD, MS, RD For The Iowa Dietetic Association Special Edition Submitted to Jennifer Vermeer, Director Iowa Medicaid

8. Medicaid Provider Manuals http://www.dhs.state.ia.us/policyanalysis/PolicyM anualPages/MedProvider.htm#All%20Provider% 20Chaptershttp://www.dhs.state.ia.us/policyanalysis/PolicyM anualPages/MedProvider.htm#All%20Provider% 20Chapters http://www.ime.state.ia.us/Providers/index.html http://www.dhs.state.ia.us/policyanalysis/PolicyManu alPages/Manual_Documents/Provman/fedqhc.pdf Regulatory Compare to Legislative

9. Barriers to Services Nutritional counseling services provided by licensed dietitians for recipients age 20 and under are covered when a nutritional problem or condition of such severity exists that nutritional counseling beyond that normally expected as part of the standard medical management is warranted.

10. Barriers to Billing Quote from screening manual the need for nutritional counseling exceeds the services available through WIC Families that are eligible for nutritional counseling through the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) must provide a statement that the need for nutritional counseling exceeds the services available through WIC. Maintain a copy of the statement in the child’s record.

11. CHSC/Medicaid Billing one example CHSC chose to access our patient population to nutrition services by billing Medicaid for our services through a MCH screening center WHO IS CHSC????

12. Who We Serve children & youth who have special health care needs birth through age 21 live in Iowa have a chronic condition (physical, developmental, behavioral, or emotional) or have increased risk for a chronic condition have a need for special services. Our Mission The Child Health Specialty Clinics (CHSC) mission is to improve the health, development, and well-being of children and youth with special health care needs in partnership with families, service providers, communities, and policymakers.

13. CHSC Regional Centers

14. One Path to Reimbursement Family stories value nutrition services White paper, “Did you know….not covered” Data outcomes, cost and cost savings Who can help me, who will listen, its who you know Begin the steps that can be done

15. Nutrition Care Process Links what RD is doing to $ Language Framework care Intervention Monitor/Evaluation Outcomes Deal Breaker!

16. Outcome data on Nutrition Billing 145 units billed for one quarter Nearly $4000 amount submitted Approved dollar amount 75% 25% paid out avg <$1000/qtr Math shows nearly $55,000 in RD salary CHSC 2010 data sampling

17. Grass Roots Obtain and Utilize Iowa Medicaid Report –By Schulte & Roberts Establish “lack of reimbursement” as an issue of quality and access (to your state, your agency, to your providers, to you clients) Show the disparity impact (be it in the interest of clients, self interest, both) Petition the support of key decision makers Go after Reimbursement