SoonerCare in Your Tribal Community CMS I/T/U Outreach and Education Event

1. SoonerCare in your Tribal Community CMS I/T/U Outreach and Education Event May 2018 Johnney Johnson and Stephanie Mavredes

2. Disclaimer This presentation was compiled by OHCA Tribal Government Relations and OHCA Provider Services. The information contained within this presentation is intended as a reference only and is current as of April 30, 2018. Content is subject to change. Stay current with up-to-date information on the OHCA public website: www.okhca.org

3. Agenda • Indian Health and SoonerCare • Tribal Government Relations (TGR) Updates • Policy and Billing • Provider Enrollment • I/T/U SoonerCare Updates • Web Alerts

4. Indian Health and SoonerCare

5. Indian Health and SoonerCare • 16 percent of the SoonerCare population is American Indian (AI) or Alaskan Native (AN) • 130,157 total AI enrollment • 81 percent are children • 4 percent are SoonerPlan • 1 percent are Insure Oklahoma • 61 percent of AI/AN SoonerCare members have been verified AI/AN through claim’s data American Indian Fast Facts March 2018 www.okhca.org/fast-facts

6. Indian Health and SoonerCare • There are 39 tribal governments in Oklahoma • 54 Indian Health Service/tribal/urban (I/T/U) outpatient clinics • 10 I/T/U hospitals • 14 tribes and all of IHS are SoonerCare providers American Indian Fast Facts March 2018 www.okhca.org/fast-facts

7. Tribal Government Relations Updates

8. TGR Website www.okhca.org/tribalrelations

9. TGR Annual Report

10. TGR Action Plan

11. TGR Action Plan, cont.

12. TGR Action Plan, cont. • Access to Care: Increased support for tribal health programs to address health care for tribal citizens • Elder Care: Create partnerships to successfully address the growing needs of the tribal elder population.        • SoonerCare Outreach, Education and Linkage: Effectively connect tribal communities to the SoonerCare program. 

13. Proposed Changes Blog • The proposed changes website provides an online forum for proposed rule changes and consultation. • The site gives readers the opportunity to view or make comments on upcoming proposed policy, state plan, and/or waiver changes. • All comments regarding proposed administrative rules will be considered during the rulemaking process and become a part of the official work folder. www.okhca.org/proposed-changes

14. Proposed Changes Blog, cont.

15. Public Comments

16. Legislative Update Medicaid work requirements: • The governor’s executive order directs the Oklahoma Health Care Authority (OHCA), which manages the state’s Medicaid program, to file any federal waivers and state plan amendments within six months to the governor and the Legislature.

17. Legislative Update, cont. Act to Restore Hope: • This bill requires OHCA and the Oklahoma Department of Human Services (DHS) to verify eligibility information prior to awarding assistance under Medicaid. • It allows the information to include: earned and unearned income, employment status immigration status, residency status, enrollment in other assistance programs, financial resources, incarceration status, death records, and information relating to identity fraud and theft, and more.

18. Policy and Billing

19. Indian Health and SoonerCare FMAP: Federal Medical Assistance Percentage AIR: All-Inclusive Rate OMB: Office of Management and Budget

20. Policy • OHCA’s policies and rules are located on the public website at www.okhca.org:

21. Policy, cont. • I/T/U policies and rules can be located by following these steps:

22. Outpatient Encounters • “An I/T/U encounter means a face to face or telehealth contact between a health care professional and an IHS eligible SoonerCare member for the provision of medically necessary Title XIX or Title XXI covered services through an IHS or Tribal 638 facility or an urban Indian clinic within a 24-hour period ending at midnight, as documented in the patient's record.” 317:30-5-1098 I/T/U outpatient encounters

23. Outpatient Encounters, cont. Examples include but are not limited to: • Medical and diagnostic services • Behavioral health services • Dental services • Vision services • Physical, occupational and speech therapy • Podiatry • Visiting nurse services • Smoking and tobacco use cessation counseling 317:30-5-1098 I/T/U outpatient encounters

24. Outpatient Encounters, cont. • “More than one outpatient visit with a medical professional within a 24-hour period for distinctly different diagnosesmay be reported as two encounters.” • “I/T/U outpatient encounters for IHS eligible SoonerCare members whether medical, dental, or behavioral health, are not subject to prior authorization.” 317:30-5-1098 I/T/U outpatient encounters

25. Encounter Rate • The annual OMB rate for covered encounters paid to contracted I/T/U providers is established by the Office of Management and Budget (OMB), and is published in the Federal Register.

26. I/T/U Revenue Codes • Contracted I/T/U providers bill with revenue codes for compensable services: • 512: Dental • 513: Behavioral Health • 519: Medical

27. Services Outside of the Encounter Rate • If the I/T/U facility chooses to provide other SoonerCare State Plan-covered health services which are not included in the I/T/U encounter definition, those service providers must:

28. Services Outside of the Encounter Rate, cont. Examples include but are not limited to: • Durable medical equipment • Glasses • Ambulance • Home health • Inpatient practitioner services • Non-emergency transportation • Behavioral health case management • Psychosocial rehabilitative services • Psychiatric residential treatment facility services 317:30-5-1090 Provision of other health services outside of the I/T/U encounter

29. Fee Schedule • Fee-for-service reimbursement rebates are available at www.okhca.org under the “Claim Tools” option:

30. Fee Schedule, cont. • Fee-for-service rates are also accessible on the provider portal using the “Search Fee Schedule” feature:

31. Fee Schedule, cont. • Benefit Package – Select the members eligibility plan. • Procedure code – Enter the procedure code. • Date of Service – Enter the date of service. • Age – Enter age of member. • Modifiers – Use for pricing of procedures.

32. Fee Schedule, cont. • If a service is non-covered, based on the criteria entered, the following message will appear:

33. Fee Schedule, cont. • If a service is covered, based on the criteria entered, the following information will appear: • Allowed amounts • Prior authorization requirements • Units • Restrictions

34. Provider Enrollment

35. Provider Enrollment • “To receive SoonerCare reimbursement, an I/T/U must be contracted with the OHCA and appear on the IHS maintained listing of recognized IHS-operated and Indian health care facilities under a 638 agreement.” 317:30-5-1086 Eligible I/T/U providers

36. Provider Enrollment, cont. • “The facility is required to contract with OHCA all professional staff employed by the I/T/U.” • Contracts for all practitioners working within the I/T/U facility should be submitted via Oklahoma’s Electronic Provider Enrollment (EPE) web-based system. • “Only professional staff listed as eligible providers in OAC 317:30-5 are recognized by OHCA.” 317:30-5-1088 I/T/U provider participation requirements

37. New Provider Contracts • New provider contracts should be submitted online at www.okhca.org/providerenrollment:

38. Contract Renewals • Updates to current provider contracts are made through the Update Provider File option on the administrative log-in for the provider portal:

39. Contract Renewals, cont. • Renewal letters are emailed to the “official contact” on the provider account 75 days prior to the contract expiration date and then again 45 days prior to contract expiration date. • Global Messages are posted to the Provider Portal and OHCA website.

40. Provider Enrollment Risk Level • In 2011, the Affordable Care Act (ACA) required states to place health care providers into a categorical risk level based on the risk for fraud, waste or abuse. • Limited-risk, moderate-risk, and high-risk level providers • 42 CFR Part 455 requires some on-site screening visits for moderate-risk and high-risk level providers • An OHCA representative conducts these visits for providers who are not already screened by another state or federal agency.

41. Limited-Risk Provider Screenings • Limited-Risk Provider Screenings include: • Licensure/Accreditation (when applicable) • System for Awards Management/Excluded Parties List System • TIBCO (PECOS: Medicare Enrollment System) • Social Security Master Death File • National Plan and Enumeration System (NPI) • CMS MedFile • Obtain disclosures regarding ownership (when applicable) • Office of Inspector General

42. Moderate-Risk Provider Screenings • Moderate-Risk Provider screenings include: • All limited-risk screenings • Conduct on-site visits to confirm accurate of providers application • Moderate-Risk Provider Types include: • Ambulance services, behavioral health agencies, behavioral health groups, individual behavioral health providers, hospice, independent diagnostic testing facilities, laboratories, physical therapy groups, physical therapists

43. High-Risk Provider Screenings • High-Risk Provider screenings include: • All limited- and moderate-risk screenings • Fingerprinting requirement: owners with 5 percent or greater ownership interest (providers enrollment by Medicare may be exempt from this requirement). • This requirement is part of the enhanced screening provisions contained in Section 640 if the ACA (42 CFR §455.434) • High-Risk Provider Types include: • Durable medical equipment (DME) and home health

44. Site Visit Requirements • Moderate- and High-Risk provider types • On-site screening visits may be conducted without prior notification. • During the visit, the OHCA representative will ask the provider questions, review various aspects of the provider's business and view the facility. • Non-cooperation with the OHCA representative could affect the provider's enrollment.

45. Application Fees • As of January 1, 2018, institutional providers are now responsible for application fees at the time of new and renewal contracts. • Includes the following I/T/U-specific contracts: • IHS hospital and outpatient clinics • Tribal hospital and outpatient clinics • Urban Indian outpatient clinics

46. Application Fees, cont. • The application fee for institutional providers enrolling in Medicare or Medicaid for Calendar Year (CY) 2018 is $569.00 • This fee is required with any enrollment application submitted on or after January 1, 2018, and on or before December 31, 2018. • Resources: • Provider Letter 2018-05 • Federal Register/ Vol. 82, No. 231/Monday, December 4, 2017 / Notices

47. I/T/U SoonerCare Updates

48. Behavioral Health Updates Effective September 1, 2017: • The 45-50 minute face-to- face requirement for a behavioral health encounter was removed from policy. • I/T/U providers are required to append procedure code(s) when billing for a behavioral health encounter. Provider Letter 2017-21

49. Behavioral Health Updates, cont. 317:30-5-1094 Behavioral health services provided at I/T/Us (b) Behavioral health professional therapy services are covered when provided in accordance with a documented individualized treatment plan, developed to treat the identified mental health and/or substance use disorder(s). Behavioral health services must be billed on an appropriate claim form using appropriate Current Procedural Terminology (CPT) procedure code and guidelines. The time indicated on the claim form must be the time actually spent with the member.

50. Behavioral Health Updates, cont. • Procedure codes appended to the 513 revenue code are “informational” only. • Reimbursement for services billed with the 513 revenue code will continue to be paid at the encounter rate.