Payer of Last Resort-Requirements Medicaid Third Party Verification. Charles Henley, MSW June 16, 2017

Transcription

1 -Requirements Medicaid Third Party Verification Charles Henley, MSW June 16, 2017

2 (PoLR) (DSHS policy ) By statute, the RWHAP funds may not be used for any item or service for which payment has been made or can reasonably be expected to be made by another payment source (Sections 2605(a)(6), 2617(b)(7)(F), 2664(f)(1) and 2671(i) of the Public Health Service (PHS) Act.).

3 Responsibilities (6.0) DSHS HIV Care Services Staff ensures RW/B & State Services funds are used as PoLR for eligible services and eligible clients (6.1). Administrative Agency (AA) monitors provider billing of third party payers to determine compliance with PoLR requirements (6.3). Providers implement policies & procedures to ensure DSHS funds are used as PoLR (6.4).

4 Screening for Other Payment Sources (7.0) Providers/Subs must have effective methods for screening clients for health insurance currently held or available including public benefits Vigorously Pursue enrollment Must document efforts to enroll clients in benefits Clients who refuse to enroll must receive continued counseling on their eligibility at each recertification opportunity or more often if needed

5 Verification of Coverage (8.0) Must verify 3 rd party coverage for eligible services at every visit Providers of 3 rd party reimbursable services must have an effective electronic health benefits verification system in place for all contracts beginning 4/1/18 and thereafter (i.e. contracts with 9/1/18 start dates) Client Refusal to Enroll (9.0) Clients who refuse enrollment may not be refused RW services

6 Area/Admin Agency AA has electronic 3 rd party verification capability for monitoring purposes Austin TGA (Part A only) No No Dallas (Parts A & B) No No Ft. Worth (Parts A & B) No Yes AA requires Subs to have electronic 3 rd party verification capability Houston (Part A only) Yes (ChangeHealthcare) Yes (varies by provider) Bexar Co. (Part A & B) Yes (Emdeon Capario) Yes (Emdeon Capario) BVCOG The Resource Group StarCare STDC

7 Service Provider Enrollment (10.0) A contracted provider who delivers Medicaid eligible services must be enrolled as a Medicaid provider (10.1). Contracted providers that provide services typically covered by health insurance must be included in a broad spectrum of private health plans that PLWHA may enroll in through the Marketplace (10.2)

8 Effective 4/1/18 Medicaid and Medicare provider certification must be documented before an AA issues contracts for the following services: Always OAHS LPAP Home Health Hospice Mental Health Substance Use Outpatient Care Substance Use Services/Residential Home & Community-based Services When Applicable* Oral Health* (if covered by Medicaid) Medical Nutritional Therapy* Early Intervention Services* Rehabilitation Services* *discuss with Services Consultant

9 Client Charges (11.0) Funded agencies that provide OAHS, LPAP, Mental Health, Medical Nutrition, Home & Community based Services, Home Health, Hospice, EIS and Substance Use Outpatient services must implement a sliding fee discount program that includes 1. A Schedule of Fees for services 2. Corresponding Sliding Fee Disc0unt Schedule 3. Policy to waive/reduce fees to ensure receipt of care 4. Policies that prohibit refusal of services if clients refuse or are unable to pay 5. A limit on annual Aggregate Charges based on the client s household income that applies to all service providers

10 Program Income (12.0) Income resulting from payments for HIV services by clients or from insurance companies is considered program income. Service providers must retain program income derived from DSHS-funded services and must follow DSHS rules on reporting and use of such income. Providers must also follow any additional requirements of DSHS-funded AAs specified in contract or policy. See PCN for more info.

11 Financial Eligibility Financial eligibility is determined locally In Part B-only HSDAs determined by AA with community input In Part A/B HSDAs determined by the Planning Council Must be uniform across the HSDA May vary depending on the service category AA must publish financial and other eligibility information in an easily understood format

12 Next Steps Survey/assess your funded agencies 3 rd party billing capacity Means of verifying coverage Medicaid/Medicare provider enrollment Credentialing of providers/back office capacity Identify service categories that may need to be rebid to procure qualified agencies/providers TA needs Potential service gaps under PoLR requirements

13 Questions/Technical Assistance What are your area s Technical Assistance needs in implementing PoLR requirements? Route comments, questions and requests for TA through your DSHS consultant What expertise can your area offer to other areas? Share best practices and lessons learned Collaborate with other areas to standardize eligibility and enrollment policies & procedures Links