Michigan Medicaid

1. Michigan Medicaid REIMBURSEMENT UPDATES MPAA January 24, 2014 Presenter-Catherine Caswell

2. Agenda • Buy-In Process • Hospital – Editing Changes for OPH/IPH • CHAMPS-upcoming enhancements/screen changes • Policy Updates-affecting your hospital • Suspended Claims Activity • Billing Tips • Questions & Contact Information

3. Medicare Buy-In/Medicare Savings Program

4. What is the Buy-In Program? • There is a cost to Medicare coverage that low income persons may not have enough resources to be able to afford. The Buy-In Program helps to pay for this cost. • The Medicare Savings Program may help with paying Medicare premiums for Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) and also for deductibles, coinsurance and copayments. • The Medicare.Gov-the official U.S. Government Site for Medicare explains the 4 different plans available and the income requirements etc. • http://www.medicare.gov/your-medicare-costs/help-paying-costs/medicare-savings-program/medicare-savings-programs.html

5. Why does Michigan Medicaid have a Buy-In Program? • Federal laws and regulations require all states to ensure Medicaid beneficiaries use all other resources available to them to pay for all or part of their medical care before turning to Medicaid. • When a Medicaid beneficiary becomes eligible for Medicare it is cheaper overall to provide for Medicare coverage even if the premiums are paid for by Medicaid for this coverage. • All of the states (and US territories) have their own Buy-In Programs and contracts with the Social Security Administration to help people with limited income and resources pay their Medicare costs.

6. When does a beneficiary apply for the Buy-In Program? • The Social Security Administration (SSA) determines if a beneficiary should be enrolled in Medicare. Everyone who is 65 years old and has lived in the United States for five years qualifies for Medicare. Beneficiaries may enroll through the SSA. • Providers working with patients that appear to be eligible for Medicare coverage, but do not have it, need to be aware that Medicaid will not cover any expenses that would have otherwise been covered by Medicare if coverage had been obtained. • In checking coverage (prior to rendering services to a beneficiary), if it is found that they have not obtained the coverage, the facility should encourage the beneficiary to go to the SSA and apply for benefits as soon as possible. • The Buy-In may be made for up to 2 years of retroactive Medicare coverage.

7. When does a beneficiary apply for the Buy-In Program? • There is no “open enrollment” for a Medicaid beneficiary that needs to sign up for Medicare coverage through the SSA. The beneficiary needs to inform the SSA that they have Medicaid coverage and are interested in the Buy-In Program. • The Medicaid beneficiary should tell the SSA how far back their bills go and try to get retro-active coverage if needed. • When a person is receiving Social Security Disability benefits for 24 months they become eligible for Medicare coverage. • When a person is receiving Social Security benefits because they have End Stage Renal Disease their Medicare coverage usually starts the fourth month of dialysis treatments.

8. How long does it take to apply for the Buy-In Program? • The Department of Human Services(DHS) determines if a beneficiary is eligible for the Buy-In Program. It is still up to the beneficiary to go to the SSA and apply for the coverage. If the patient is deceased the DHS caseworker must make the application for the coverage. • Medicaid has an agreement with the Social Security Administration and files are shared on a monthly basis that are continuously compared to our Medicaid eligibility files to determine if accretions or deaths need to have changes made within the billing cycles. We also receive information from Providers and Beneficiary’s to add Medicare coverage through the Buy-In Process. • The initial Buy-In process takes approximately 120 days to occur. The beneficiary may receive a reimbursement of premiums that were deducted from their Social Security check during this period.

9. Are there special rules for Aliens regarding the Buy-In Program? • When Aliens apply for Medicaid coverage their DHS caseworker should be coding their coverage appropriately so that the 5 year residency requirements are tracked. When DHS staff enters the Alien information within BRIDGES this generates the OI code 50 in CHAMPS. • The SSA keeps track of Alien Status. • The MDCH Buy-In Unit has a data base where Medicaid tracks Alien Status also.

10. Are there special rules for Aliens regarding the Buy-In Program? • The MDCH Buy-In Unit also accepts leads from Providers regarding Alien Status. • If an Alien Medicaid beneficiary is age 65 or older their Medicaid other insurance coverage file needs to be coded appropriately so that claim rejections do not occur during the 5 year residency requirement period. • Only the Buy-In Unit staff can update the Carrier Payer ID Code 7’s in CHAMPS.

11. Providers Contacting the Buy-In Program • Providers are to continue to relay information to the Buy-In Unit (BIU) when they have a beneficiary with a need for Medicare coverage. This is their contact info: • Address: • Michigan Department of Community HealthMedicare Buy-In UnitCapital Commons Center, 6th floor400 South PineLansing, MI  48933 • Email: buyinunit@michigan.gov • Phone: TPL Medicare Buy-In Main Line: (517) 335-5488

12. What information does the Buy-In Unit need from Providers? • This is a list of the necessary information that needs to be included with a BIU request: • * Beneficiary’s name, date of birth, and Medicaid identification (ID) number; • * Health insurance claim number (HICN); • * Inpatient hospital admission date; and • * Hospital name, address, and provider NPI number

13. Aliens age 65 and older • ALIENS: The BIU will accept leads from providers about Alien Status in relation to Medicare eligibility. Alien status can be verified by: • Alien Registration Receipt Card (I-551) • I-94 form stamped "Processed for I-551", "Cuban/Haitian Entrant (Status Pending)", "parole", "212(d)(5)", or "Form I-589 Filed" • I-94 form indicating admission into the United States from Cuba or Haiti and letter or notice from the U.S. Citizenship and Immigration Services (USCIS) indicating ongoing (not final) deportation, exclusion or removal proceedings • Passport stamped "Processed for I-551 Temporary Evidence of Lawful Admission for Permanent Residence"

14. The work flow? • The phone number for the Buy-In Unit is currently trunked to the general 800 number for provider inquiries (1-800-292-2550) • The worker should take all of your information and will write up a service request (SR) so we can track the issue. The service request will be sent internally to the Buy-In Unit. The BIU worker will review and research the case for possible action and will put notes within the SR. A normal BIU request is worked in 20 days and the SR is closed. (I have seen several done in a 5 day turnaround time)

15. Checking the Status of your Buy-In Request • If you want to know what was done by the BIU staff you will no longer be calling the BIU or emailing them directly for that follow-up information, however, you are welcome to contact Provider Support Services for this information at either at our 1-800-292-2550 number or via e-mail to ProviderSupport@Michigan.Gov. • As I said above if you call the TPL Medicare Buy-In Main Line: (517) 335-5488 you are really calling the 800 line. • If you call or write to us at PSS we can look up the notes that the BIU worker has indicated within the SR and that should tell you what information you need. • The BIU will not be directly responding to providers in most cases but have moved that responsibility to Provider Support Services.

16. Other questions about Buy-In? • How much does the SOM pay for the Medicare Buy-In Program per month?  (Approximately). • Part A $8 million and Part B $25 million.  • What is the monthly premium per individual? • Part A premiums $426 and Part B $104.90. • Why does DHS give Medicaid coverage if they are eligible for but did not enroll in Medicare? • It is DHS policy that Medicaid coverage is processed even if they are eligible for but not enrolled in Medicare. • How many Alien Medicaid Beneficiaries are over age 65 and not eligible to be enrolled in Medicare? • 4,255

17. Other questions about Buy-In? • When the Buy-In Unit receives a request from a hospital to see if the SOM will purchase Medicare coverage for a specific individual does the worker contact the DHS office to see if they have done the correct MBA coding or to see if their budget needs to be reevaluated?  • The Buy-In Unit does not contact the DHS case worker when we receive a request for a Buy-In review.  • Generally, when the DHS worker does a recipient’s budget they will select the Cost Saving Program in Bridges.  This opens the benefit period and assigns a MBS code. • In most cases determining Buy-In eligibility between Bridges and CHAMPS and submitting the Medicare Buy-In file for premium payments is automated.   

18. Other Buy-In Scenarios? • If upon review of the buy-in request, it is found that the beneficiary was not picked up by the month’s automated process, and there is Buy-In eligibility on Bridges and the scope/coverage in CHAMPS meets buy in requirements, staff will process buy-in.   If the case is not coded for Buy-In, staff closes the SR noting that the beneficiary is not eligible for Buy-In and that the provider can bill the beneficiary.  • The beneficiary may contact DHS to reevaluate the case and make sure the coding is correct.  In this scenario the DHS worker contacts the Buy-In Unit regarding coding in CHAMPS. 

19. CHAMPS-Upcoming Enhancements/Corrections Hospital Claims

20. APC updates-OPH claims to recycle • New APC software has been loaded to CHAMPS to adjudicate with October 2013 quarterly updated information. All paid claims with dates of service from 10/01/2013 will be adjusted and should start to appear on Pay-Cycle 5 (01/30/2014). • APC software for the January 2014 quarterly update will be implemented soon after the late March release.

21. Correction needed • If using CHAMPS to manage a hospital paid claim (adjusting transaction) the system will not let the user blank out an NPI#. Current work around until this is corrected is to put in another valid type one NPI#. Projected fix date 4.11 03/28/2014 • If CHAMPS has approved hospital claim with a RENDERING NPI# posted within the claim when that same rendering physician bills for their services on a professional claim it sets erroneous duplicate edit. This professional service should not edit against the institutional charges and a defect has been filed. Projected fix date 4.11 03/28/2014 • Electronic claims received in CHAMPS will be editing for association of the providers NPI to their billing agent. The editing will be set as informational for a period of time. Billing Agents will be receiving communications regarding this issue prior to go live. (Planning to set CARC 96 with RARC=N55) Projected fix date 4.11 03/28/2014

22. Correction needed • Crossover claims reported with negative payments and or negative Claim Adjustment Reason Codes (CARC) do not process correctly. Currently also allowing claims that do not balance to enter system and they also do not process correctly. Projected 4.11 Fix Date 03/28/2014 • Direct Data Entry (DDE) claims screens will not allow entry of an invalid CARC Projected 4.11 Fix Date 03/28/2014 • Paper claims must be reported with appropriate ICD-9 qualifier in field locator 66. Claims will be returned if not using the appropriate code qualifier according to National Uniform Billing Committee (NUBC) standard completion instructions. Effective 03/22/2014

23. News-future changes to look forward to! • Needs working bypass for admit source = 5 (transferred from SNF) within our Patient Pay Logic. Per policy when patient is living in a Skilled Nursing Facility and is transferred to an In-Patient Hospital setting we should normally bypass deducting the PPA from the first month service however currently we are immediately taking the PPA Future (CQ 50883) Projected 4.11 Fix Date 03/28/2014 • Co-Pay Deducted ($50.00) when transfer in's, per policy system should not deduct a copayment. Provider may see CARC 3. (CQ 50883) Projected 4.11 Fix Date 03/28/2014

24. New Discharge Status Codes • Effective 10/01/2013 per NUBC there will be 15 new discharge status codes (re: planned readmissions) • We are in the process of updating to allow all 15 • Projected 4.11 Fix Date 03/28/2014

25. Policy Clarification/Hospital-Proposed Medicaid Changes

26. MSA Policy Bulletin 13-42Standards of Coverage/PA Requirements for Genetic Testing • Issued on 11/26/2013- Explains criteria for determining if genetic testing coverage is available through the prior authorization process. • This policy is meant to cover all categories of genetic tests and becomes effective 01/01/2014. (see MSA Bulletin 12-70 for a list of some of the new genetic codes)

27. MSA Policy Bulletin 13-43Claim Void Process, Subrogation Process and Billing Beneficiaries • Issued 11/26/2013 to be effective 01/01/2014 Medicaid has a process when it is determined that the provider did not hold another resource liable for payment after Medicaid has paid the claim: 1. TPL Sends provider a notice (copies are located in your facility In-Box. 2. Notice gives providers 30 days to appropriately adjust claim to report the other insurance action. 3. If provider does not adjust the claim within this 30 day period the department voids the TCN’s indicated on the notice.

28. MSA Policy Bulletin 13-43Claim Void Process, Subrogation Process and Billing Beneficiaries- cont. • As a condition of Medicaid eligibility, beneficiaries must assign MDCH the right to seek recovery of other resource payments made on their behalf. In certain cases the department will bill the other resource for direct reimbursement. • Providers are reminded that the General Information for Providers chapter of the Medicaid Provider Manual provides information regarding when the beneficiary may not be billed. Providers are required to abide by this agreement for the duration of their enrollment in the Medicaid Program.

29. MSA Policy Bulletin 13-44Medicaid Cost Sharing (Co-Payment) Exemptions. • Issued 12/02/2013 to be effective 01/01/2014 • ACA has special cost sharing regulations for Native American Indians/Alaska Natives. Also exemptions for enrollees in the Breast and Cervical Cancer Control Program. • These two groups will be added to the list of Medicaid beneficiaries who are exempt from any Medicaid co-payments. This information will be referenced in the Medicaid Provider Manual located at www.michigan.gov/medicaidproviders >> Policy and Forms >> Medicaid Provider Manual.

30. MSA Policy Bulletin 13-44Medicaid Cost Sharing (Co-Payment) Exemptions.- Continued • Due to system constraints claims processed through March, 2014, may continue to show the co-payment deductions, however, once the system is updated all affected claims will automatically be adjusted by MDCH and appropriate funds will be returned to providers.

31. MSA Bulletin 13-45Diagnosis Related Group (DRG) Grouper Update, DRG Rate Update, Rehabilitation Per Diem Rate Update • Issued 11/26/2013 to become effective 01/01/2014 • Effective January 1, 2014, claims for inpatient hospital discharges using the DRG methodology will be processed using Medicare DRG Grouper Version 31.0. • Cost Data for Medical/Surgical Hospitals-cost reported data from Hospitals FY 09/01/2007-08/31/2009 is being used to complete the DRG Rate rebasing amounts for 01/01/2014 DRG rate updates. • Cost Data for Distinct Part Rehabilitation Units and Rehabilitation Hospitals-cost reported data from Hospitals FY ending between 09/01/2008-08/21/2010 will be used to complete the 01/01/2014 per diem rate updates. • TO NOTE: These rates for all hospitals are posted on our web-site at: www.Michigan.Gov/MedicaidProviders >> Billing and Reimbursement >> Provider Specific Information >> Inpatient Hospitals

32. MSA Policy Bulletin 13-46Update on Enrollment of CSHCS/ Medicaid Beneficiaries into a Medicaid Health Plan (MHP), MHP Exclusion of Beneficiaries Authorized for Private Duty Nursing (PDN) • Issued 11/26/2013 to be effective 01/01/2014 • This bulletin updates 3 policies delineated in MSA 12-46. • Continuity of care/authorizations-when patient has change in enrollment status how long the PA in place at that time must be honored (30 days) • Beneficiaries authorized for PDN will be disenrolled retro to 1st day of the month in which services are received.

33. MSA Policy Bulletin 13-46Update on Enrollment of CSHCS/ Medicaid Beneficiaries into a Medicaid Health Plan (MHP), MHP Exclusion of Beneficiaries Authorized for Private Duty Nursing (PDN)- Continued 3. Excluded Services for CSHCS/Medicaid beneficiaries- All services specifically excluded from the Medicaid Health Plan contract remains excluded for CSHCA/Medicaid beneficiaries enrolled in a MHP. MHPs are not required to provide transportation for services excluded from the MHP contract. In-state approved intensive feeding clinic(s) are excluded from the MHP contract. Drugs in the categories listed on the MHP carve-out list found at https://michigan.fhsc.com/ >> Providers >> Drug Information are also excluded from the MHP contract.

34. MSA Bulletin 13-48Updates to the Medicaid Provider Manual; ICD-10 Project Update • Issued 11/26/2013 • The MDCH has updated the January 2014 quarterly update of the Michigan Medicaid Provider Manual. The manual is maintained on the MDCH website. A compact disc version of the manual is available to enrolled providers upon request. • MDCH encourages providers to participate in scenario-based testing and assign ICD-10 diagnosis codes to medical scenarios that apply to their practice areas. Scenario-based testing can be accessed on the MDCH website at www.michigan.gov/5010icd10. Full-scale Business-to-Business (B2B) testing of ICD-10 coded claims and encounter transactions, including adjudication in the B2B Test environment, will begin in January 2014. These activities are designed to help providers ensure that their remediation efforts to prepare for the transition to ICD-10 have resulted in the creation of transactions that can be processed successfully.

35. MSA Bulletin 13-49Outpatient Prospective Payment System and Ambulatory Surgical Center Reduction Factor • Issued 12/02/2013 effective 01/01/2014 • To maintain budget neutrality for the Medicaid program, the Medicaid OPPS and ASC reduction factor will be adjusted from 54.3% to 53.4% effective for dates of services on or after January 1, 2014 in accordance with the CMS final rule.

36. MSA Bulletin 13-50Rural Access Pool • Issued 12/23/2013 effective 02/01/2014 • MDCH will continue its Rural Access Pool(RAP) in Fiscal Year 2014 for hospitals that provide Medicaid services to low-income rural residents. • Eligibility criteria is defined as well as how the allocation is calculated. Calculation of FY 2014 pool will be derived by hospital cost reports with FYs ending between 10/01/2011 and 09/30/2012. • Payments made from the RAP will be applied against hospitals inpatient and outpatient settlement limits.

37. MSA Bulletin 13-54Healthcare Common Procedure Coding System (HCPCS) Code Updates • Issued 12/20/2013 • This policy bulletin notifies all provider types of any “new” code coverage, any existing code that we are going to start covering and also the list of codes that coverage is being discontinued as of 12/31/2013. • For Out-Patient Hospitals the intent is to remain in alignment with Medicare coverage explained within Addendum B and the policy shall only define the codes paid/not paid differently therein. • The wrap around codes list for January 2014 quarter was posted and PSS sent an alert to the area that posted the wrap list that on the last page it needs to be updated.

39. Code Changes Per MSA Bulletin 13-54 • A Biller B Aware was posted: • January 14, 2014: Attention OPH Providers: Effective January 1, 2014, the CMS has implemented their guidelines regarding HCPCS code G0463 and MDCH will be following those CMS guidelines:  G0463 “(Hospital outpatient clinic visit for assessment and management of a patient), for hospital use only representing any clinic visit under the OPPS and to assign new HCPCS code G0463 to new APC 0634. This replaces CPT codes 99201 through 99205 and 99211 through 99215.” • Please keep in mind that MDCH is currently adjudicating Outpatient Hospital claims with October 2013 quarter version APC software. MDCH, upon receipt of the CMS finalized January 2014 quarter APC software, will test and load the new software in late March. MDCH will claim adjust any claims that may be impacted by a delayed quarterly update implementation.The Medicare Addendum B is posted on the following CMS website: • http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html

40. Policy on our web site • All of our policy may be accessed on our web-site: www.Michigan.Gov/MedicaidProviders • >>Policy and Forms • From this page you find the Medicaid Provider Manual, Approved Policy Bulletins dating back to 2001, and Michigan Medicaid Proposed Policy • >>Michigan Medicaid Proposed Policy • From this page you find policy’s that are under current comment

41. Proposed Policy-how to be heard! • >>Proposed Medicaid Changes • These documents inform interested parties of proposed changes in Michigan Medicaid policy. Proposed new policy and changes to existing policy must undergo a 30-day public comment period before it becomes final. • The page will explain the Comment Due Date, the project number and subject. Within the project number paper is the contact information to use for your comment.

42. Proposed Policy-1354-Waiver Comments Due 02/16/2014 • Subject: Phase-out of the Plan First! Family Planning Waiver • The waiver is due to expire 06/30/2014 and will not be renewed. • Under the ACA women currently enrolled in Plan First! Must apply for comprehensive healthcare coverage under the Healthy Michigan Plan or through other options on the Federally Facilitated Marketplace. • Enrollment will continue until 03/31/2014 after which no new applications will be accepted.

43. Proposed Policy-1402-ADA-Comments Due 02/20/2014 • Subject: Implementation of Updated Paper Claim Forms • Conversion from the ADA 2002 to the ADA 2012 and from the CMS 1500 (08/05) to the CMS 1500 (02/12) • Effective 03/22/2014 MDCH will implement HARD cut-over to new formats. Paper claims received using previous formats will be returned. • Policy describes instructions significant to MDCH claim adjudication. • New Adjudication Rule for UB 04=the appropriate ICD-9 qualifier must be reported in field locator 66.

44. Suspended Claims ActivityBILLING TIPS!

45. IPH Suspended Claims Status Top Rejects for In-Patient Hospital Claims • Patient Is Enrolled In A Medicaid Health Plan CARC 24 • Other Insurance/Medicare Reported Errors CARC 22/45 • Timely Filing Guidelines Not Met CARC 29 • Ineligible CARC 31 • PACER Missing CARC 15 • Total Claims Suspending for Manual Review=4500+ TCNs

46. OPH Suspended Claims Status Top Rejects for Out-Patient Hospital Claims • Possible Duplicate CARC 18/B5 • Other Insurance/Medicare reported errors CARC 22/45 • Attending NPI not enrolledCARC 206/208 • Claim does not group to APC Payment CARC A8 • Adjustment claim completion error CARC 125 w/M47 • Total Number Claims Suspending for Manual Review=20,000+

47. Claim Tips! • Claims processing wants us to remind providers to always use a new clean form when advising patient of Voluntary Sterilization or Hysterectomy information. The MSA 1959 and MSA 2218 are found on our web-site at: • www.Michigan.Gov/MedicaidProviders next click on Policy and Forms. • When submitting the Consent For Sterilization form to the area that reviews this document please ensure that the date of service on the cover letter matches the date of service within the MSA 1959 form.

48. Questions ? • CALL our hotline staff at 800-292-2550 Mon-Fri 8-5. • E-MAIL You may also address any questions in writing to our staff that answers e-mail at: ProviderSupport@Michigan.gov • WRITTEN inquiries Provider Research & Analysis PO BOX 30731 Lansing, MI 48909

49. THANK YOU FOR PARTICIPATING IN THE MICHIGAN MEDICAID PROGRAM REIMBURSEMENT UPDATES MPAA January 24, 2014