What’s So Interesting About Medical Necessity?

1. What’s So Interesting About Medical Necessity? Interesting Case Presentation Saint Francis Hospital & Medical Center Dept. of Pediatrics October 30, 2009 Jay E. Sicklick, Esq. Center for Children’s Advocacy Hartford, Connecticut mlpp

2. Interesting Case – The Parameters • Patient is a Medicaid Recipient • Medicaid = HUSKY= Title XIX • Patient is birth through 20 • Patient’s pediatric/family medicine/psychiatric, etc. clinician has requested a medically related treatment, care or service o/b/o patient • This request is subject to some sort of review by the insurance carrier/primary payer mlpp

3. What is Medical Necessity?

4. AN Interesting Case

5. AN Interesting Case • 7 y.o. girl - seen in primary care since birth. • Primary diagnosis is Pervasive Developmental Disorder (PDD). • Autistic tendencies & very low IQ • Diet is extremely limited – like sweet and salty foods only (chips, etc.) • PCP believes that nutrition is compromised • Would like to prescribe an OTC nutritional supplement (Ensure/Pediasure) • R/Q made to MCO • R/Q “denied” as not “medically necessary” • It this “medically necessary” care and treatment? mlpp

6. ANOTHER Interesting Case

7. ANOTHER Interesting Case • 14 y.o. boy with dx of spina bifida • Mobility in h/h is at issue • Lives alone with mother • Treating provider and PT believe “track” system in house will provide better mobility in h/h • Request made to MCO as a DME • Request DENIED? • Is this “medically necessary?” mlpp

8. Medical Necessity:The Threshold Questions • What is Medical Necessity (“MN”)? • Is there a standard for defining MN? • Are pediatric patients evaluated under the same MN standard as adults? • What is the definition of MN? • Who/What is the gate keeper for MN? • Is there anything I (the pediatric provider) can do to ensure my medical judgment is deferred to in the “ask” for MN care? mlpp

9. Medical Necessity:The Threshold Questions • If my “ask” is denied, what is my recourse for the patient? • Can legal assistance be helpful in the event the request is denied? • What is the “appeal” process? • Are appeals usually successful? • What can I do next time to ensure that the original request is granted (if anything)? mlpp

10. Medicaid: A Refresher

11. Medicaid: A Refresher • Title XIX of the Social Security Act for = Medical Assistance for the Poor • Not Medicare - Title XVIII = Federal Health Insurance Linked to Social Security • Categorical Eligibility = Elderly, Blind, Disabled, Pregnant women & Children • De-linked from Cash Assistance & Resources

12. Medicaid: A Refresher • Vendor Payment System - hospitals, nursing homes, pharmacies, doctors & dentists are reimbursed • Participation by provider voluntary • No cost sharing allowed - theoretically

13. How Medicaid Works:The Federal-State Partnership

14. How the Partnership Works:The Federal Side • Federal oversight through central agency = CMS • Promulgates regulations, guidelines & statutes • Issues waivers • Reimburses from 50% to 83% of state costs • Legal principles = due process

15. The Partnership: State Administration • State Agency - Designated in Conn. As DSS • The “Medicaid Plan” • Must conform to federal law and apply statewide • Medicaid Advisory Committee req’d (MMCC)

16. Managed Care: Medicaid’s Panacea • State’s may contract with managed care entities to provide services (per CMS waiver): • PCCM – case management w/monthly fee by M.D.’s, group practices, APRN’s, PA’s or nurse midwives • MCO’s – contracts w/HMO’s, etc. w/capitation payment per enrollee • State’s can r/q most individuals to enroll in managed care programs (need choice of at least 2 entities

17. Managed Care Players

18. The Return to Managed Care:Connecticut’s Grand Experiment • Children eligible for MA coverage must elect MCO for “coverage” or may be part of a PCCM practice through DSS • MCO’s contract with State DSS • Three MCO’s presently provide managed care coverage for state’s HUSKY population: • CHN • AETNA Better Health • AmeriChoice by United Healthcare

19. The Return to Managed Care:Connecticut’s Grand Experiment • PCCM available in: • Waterbury • Windham • Hartford & New Haven expansion planned • MCO’s are at-risk. • Approve or deny coverage for services pursuant to DSS contract and state and federal regulations. • Fee for service (“Straight Title XIX”) still available in limited circumstances …

20. HUSKY Basics • Connecticut’s Children’s Medicaid Plan (“A”) • Birth up to 19 y.o. • Income based (family or self) – no resource test • 98% Insured through MCO’s (BCFP, Health Net & CHN) • Straight Title XIX available

21. HUSKY Basics (cont) • No co-pays or premiums • “Medically necessary services” must be covered • EPSDT requires periodic screening, diagnosis & treatment • Rights of appeal & legal challenges inviolate

22. Who is NOT Eligible for HUSKY? • Children in U.S. on vicarious visas (e.g. parent work visas) • Undocumented (illegal) Immigrant children • Families income > 185% FPL

23. Immigrants and HUSKY • Eligibility based on residency status: • Lawful Permanent Resident (LPR) • Refugees and asylees • Certain battered spouses & children • Application Process • Same for legal immigrants as they are for US Citizens • CT Resident • Income guideline (185% child, 150% parent • Will NOT be considered Public Charge

24. Changes in the AIR

25. Medical Necessity:Defining The Playing Field • Two Part Analysis of Medical Necessity: • Definition of MN in State Regulations • Definition of MN in EPSDT

26. Medical Necessity – State Regulations Previous Definitions (before 10/1/09): • "Medical Necessity or Medically Necessary" means health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition; or prevent a medical condition from occurring. • "Medical Appropriateness or Medically Appropriate" means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate medical setting; and is the least costly of multiple, equally‑effective alternative treatments or diagnostic modalities.

27. Medical Necessity – State Regulations • Language change – October 2009 • Definition is: “Medically necessary services” means those health services required to prevent, identify, diagnose, treat, rehabilitate or ameliorate a health problem or its effects, or to maintainhealth and functioning, provided such services are: • consistent with generally accepted standards of medical practice • clinically appropriate in terms of type, frequency, timing, site and duration; • demonstrated through scientificevidence to be safe and effective and the least costly among similarly effective alternatives, where adequate scientific evidence exists; • efficient in regard to the avoidance of waste and refraining from provision of services that, on the basis of the best available scientific evidence, are not likely to produce benefit.

28. PRE-CHANGE: to assist an individual in attaining or maintaining an optimal level of health POST CHANGE: to prevent, identify, diagnose, treat, rehabilitate or ameliorate a health problem or its effects, or to maintainhealth and functioning demonstrated through scientificevidence to be safe and effective and the least costly among similarly effective alternatives, where adequate scientific evidence exists; efficient in regard to the avoidance of waste and refraining from provision of services that, on the basis of the best available scientific evidence, are not likely to produce benefit. Tracking the Changes

29. What Does It All Mean? • MCO’s & DSS (fee for service cases) review each request pursuant to the MN standards • Provide a written response to the patient if denied • Allow opportunity for an internal review and, if necessary, an impartial hearing pursuant to Due Process requirements • Requests must also be reviewed pursuant to federal EPSDT standard

30. EPSDT The problem is to discover, as early as possible, the ills that handicap our children. There must be continuing follow-up treatment so that handicaps do not go untreated. . . . We must enlarge our efforts to give proper eye care to a needy child. We must provide health to strengthen a poor youngster’s limb before he becomes permanently disabled. We must stop tuberculosis in its first stages before it causes serious harm. - - President Lyndon B. Johnson Introducing the EPSDT Legislation 90th Cong., 1st Sess. (1967).

31. What is EPSDT, or; Why does it make better pediatricians? • Early periodic screening, diagnosis, and treatment • Federal mandates for screening at periodic intervals • Medical, vision, hearing & dental, immunizations, lab tests (including PB), health education • Mandate for coverage of treatment to “correct or ameliorate” physical/mental illness during the periodic or interperiodic screens • Outreach & transportation

32. Medical Necessity Under Federal Law • Medical necessity Definition requires coverage of • “necessary health care, diagnostic services, treatment, and other measures . . . to correct or ameliorate defects and physical and mental illnesses and conditions[.] 42 U.S.C. § 1396d(r)(5) • Applies to physical and behavioral health

33. EPSDT Scope of Benefits42 U.S.C. §§ 1396d(r)(5), 1396d(a) • Mandatory services: • Inpatient hospital services • Outpatient hospital services • Rural health clinic services • Federally-qualified health center services • Laboratory and X-ray services • Nursing facility services for adults • EPSDT services • Physician services • Family planning services and supplies • Physician services • Medical and surgical services furnished by a dentist (with limitation) • Nurse-midwife services • Pediatric nurse practitioner or family nurse practitioner services • Home health services for persons eligible to receive nursing facility services

34. EPSDT Scope of Benefits – cont. • Optional services (for adults, mandatory under EPSDTwhen necessary to correct or ameliorate an illness or condition): • Home health care services (includes nursing services, home health aides, • medical supplies and equipment, physical therapy, occupation therapy, • speech pathology, audiology services) • Private duty nursing services • Clinic services • Dental services • Physical therapy and related services • Prescribed drugs • Dentures • Prosthetic devices • Eyeglasses • Other diagnostic, screening, preventive, and rehabilitative services, including any medical or remedial services recommended for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level • Intermediate care facility for the mentally retarded services • Inpatient psychiatric hospital services for individuals under age 21 • Hospice care • Case-management services • TB-related services • Respiratory care services • Personal care services • Primary care case management services • Any other medical care, and any other type of remedial care recognize under state law, specified by the Secretary (of DHHS)

35. So – What Does it All Mean?

36. Advocacy Strategies:Making the Case for Medical Necessity • Three part strategy: • Anticipate • Advocate • Appeal

37. 7 y.o. girl - seen in primary care since birth. Primary diagnosis is Pervasive Developmental Disorder (PDD). Autistic tendencies & very low IQ Diet is extremely limited – like sweet and salty foods only (chips, etc.) PCP believes that nutrition is compromised Would like to prescribe an OTC nutritional supplement (Ensure/Pediasure) R/Q made to MCO R/Q “denied” as not “medically necessary” It this “medically necessary” care and treatment? ANTICIPATE Reminder – AN Interesting Case

38. MN Advocacy – Anticipate • What Do you Need to do to make sure your patient receives the care/treatment requested? • What are the facts that make this patient’s case compelling? • Previous treatments tried, results produced, etc. • Think of alternatives and how you can address those (HMO response) • Document successes in other patients • Think about how this case might be unique/special

39. MN Advocacy – Advocate • Write a Letter Advocating for Your Request • Explain who you are • State the language of the law … i.e. why this service/treatment is medically necessary • “Pat Patient needs this nutritional supplement because I expect that it will enable her to maintain health an functioning, it is consistent with generally accepted standards of practice, and it is clinically appropriate in terms of type, frequency, etc … • Include specifics & details relating to the patient’s illness or disability

40. MN Advocacy – Advocate • Write a Letter Advocating for Your Request • The details: • Explain how the treatment will prevent an illness or disability, or • Explain how it will ameliorate a health problem or its affects, or • Explain how it will maintain health or functioning (maintain functional capacity) • Conclude by indicating the medical consequences which you believe will result if the care/treatment/prescription is denied.

41. Sample Letter MN Letter October 30, 2009 Community Health Network 11 Fairfield Boulevard Wallingford, CT 06492 Re: Pat Patient, 2/22/2004, Plan # 11111 Greetings: I am writing to request authorization for Pat Patient to receive Pediasure for the diagnosis of failure to thrive. This request is medically necessary because: KEY FACTS FOR PP INCLUDED HERE … The provision of this important supplement will, or is reasonably expected to allow Pat to maintain health and functioning at her present level. Specifically (INCLUDE FACTS ABOUT PAT’s DIET ETC.) If you need any further information, please do not hesitate to call me at (860) 714-1000. Very truly yours, PCC Provider License # 123456789 Phone Fax

43. MN Advocacy – Appeal Responses to Denials: • HMO’s • Informally advocate with the UR rep. • Informally advocate with the medical director (usually not a pediatrician) • Advise family to request an informal review • Refer the family to the MLPP for formal appeal • Formal appeal with DSS hearing officer (fair hearing)

44. MN Advocacy – Appeal • Responses to Denials: • DSS • Call the Medical Director (Rob Zavoski) • Refer the case to the MLPP • Initiate process of formal appeal (fair hearing)

45. Medical Necessity – A Review • The standard by which Medicaid care and treatment is judged • NOT a subjective standard – but subject to clinical judgment • Clinician has tools to advocate before the decision is made • Advocacy shifts burden to the decision maker • Make your case based on facts & details – don’t assume a denial is appropriate