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Medicaid Coverage for Transplantation in 2004 – Results of a National Coverage Survey by NMDP and TFCA

Medicaid Coverage for Transplantation in 2004 – Results of a National Coverage Survey by NMDP and TFCA. February 17, 2005. Medicaid Survey Background. National Marrow Donor Program (NMDP) developed and distributed survey to all US State Medicaid Plans 1 st Survey conducted Spring 2002

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Medicaid Coverage for Transplantation in 2004 – Results of a National Coverage Survey by NMDP and TFCA

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  1. Medicaid Coverage for Transplantation in 2004 – Results of a National Coverage Survey by NMDP and TFCA February 17, 2005

  2. Medicaid Survey Background • National Marrow Donor Program (NMDP) developed and distributed survey to all US State Medicaid Plans • 1st Survey conducted Spring 2002 • Focus was on blood and marrow transplants (BMT)

  3. Medicaid Survey Purpose • Better understand State Medicaid coverage of diseases and protocols approved for BMT patients • Identify key decision makers and the authorization process for BMT cases • Assess the financial barriers that limit patient access to BMT • Not a scientific study - should be viewed as an objective analysis that may identify potential issues or concerns

  4. 2002 Survey Findings • 34 of 50 states responded on the following topics: • Search, Procurement and Transplant • 39% of states do not cover the cost of unrelated donor searches • 88% of states cover donor procurement • 100% of states cover transplant • 12% of states indicated that cost of unrelated donor search is under review

  5. 2002 Survey Findings, cont. • Post transplant • 100% indicated follow up care costs are covered • 55% indicate covering patient lodging • 52% indicated covering patient meals

  6. 2002 Survey Findings, cont. • Caregiver costs • Less than half of the states that responded cover caregiver costs of meals and lodging • Lack of caregiver coverage adversely affects the patient’s ability to receive medical care

  7. 2002 Survey Findings, cont. • Non-myeloablative transplant • 52% of states indicate they cover non-myeloablative transplants • Clinical Trials • 9% of states cover Phase I • 15% of states cover Phase II • 21% of states cover Phase III

  8. 2002 Survey Findings, cont. • Disease Coverage • 80% of states cover most common type of disease (ALL, AML, CML, NHL, etc.) • 37% cover diseases for developing protocols such as Renal Cell Carcinoma • Access • 88% of states allow patients to leave state borders for transplant • Most of the states required the patient to attend a bordering state • Very few states allowed patient to go anywhere in US

  9. 2002 Survey Findings, cont. • Guidelines • 45% of states reported following Medicare guidelines regarding coverage • Authorization • 90% of states required authorization • 55% of states required the transplant center obtain prior authorization • 24% require the referring physician to obtain prior auth • None of the states require patient to obtain prior authorization

  10. 2002 Survey Findings, cont. • Criteria for Authorization • Equally divided between the following • 24% medical necessity • 24% government guidelines • 26% case-by-case basis • In 44% of states, the state plan physician committee or medical director determines the authorization • 42% of states did not respond to who determines authorization

  11. 2002 Survey Findings, cont. • Appealing Denials • 74% of states require either patient or physician to submit administrative appeal • Detailed documentation about why the disease protocol should include transplantation must be supplied • The rest of the states that responded were vague about appeals process

  12. 2004/2005 Medicaid Survey • NMDP and TFCA partnered to distribute updated survey to all 50 states. • New survey included: • Sent to all 50 states December 2004

  13. 2004/2005 Survey • To date, 13 states have returned surveys* *ID only provided info on solid organ. BMT requests are handled by another party.

  14. Kidney Liver Pancreas Live Cadaver Live Cadaver Live Cadaver AL X X X X X X CT X X X X X X DE X X X X X X GA X X X X X X ID X X X KY X X X X X X MN X X X X X X NE X X X X ND X X X X X X OK X X X X X X OR X X X X X X TX X X X X 2004/2005 Survey • Transplants Covered

  15. Lung Heart Small Bowel Multi-Visceral Live Cadaver Cadaver Live Cadaver Live Cadaver AL X X X X CT X X X X DE X X X X X X X GA X X X X X X X ID X X X X KY X X X X X X X MN X X X X X X X NE X X X ND X X X X X X X OK X X X X X X X OR x x x x x TX X X X X X 2004/2005 Survey • Transplants Covered

  16. 2004/2005 Survey Findings • BMT Donor search • 6 states cover related and unrelated search costs (AL, CT, KY, NE, ND, OR) • 5 states do not cover related and unrelated search costs (DE, GA, MN, TX, UT) • 1 state indicated they have not considered covering search costs (OK) • 1 state did not respond to the question (ID)

  17. 2004/2005 Survey Findings, cont. • BMT Donor Procurement • 7 states indicated they cover procurement (AL, CT, KY, MN, NE, ND, OR) • 1 state indicated they cover procurement for bone marrow only, they do not cover procurement for PBSC or cord (DE) • 4 states do not cover procurement costs (GA, OK, TX, UT) • 1 state did not respond (ID)

  18. 2004/2005 Survey Findings • Services Covered in Payment Rate • Initial Consultation • Facility Fee • AL, ND • Physician Fee • KY, AL, ND, OK • Pre-Transplant Workup • Facility Fee • DE, KY, AL, ND • Physician Fee • KY, AL, ND, OK

  19. 2004/2005 Survey Findings • Services Covered in Payment Rate • Organ Procurement • Facility Fee • DE, KY, AL, ND, UT • Physician Fee • KY, AL, ND, OK, UT • Transplant Inpatient Stay • Facility Fee • DE, KY, AL, OK, MN, UT • Physician Fee • KY, AL, OK

  20. Transportation Lodging Meals Parking All but All but DE, KY, Patients All AL, AL, CT, MN, OK, CT,GA GA, OR TX Donor ND, MN ND, MN ND, MN MN All* but CT, GA All but All but KY, MN, *AL only for minors Caregivers CT,GA CT,GA OK, TX going to out of state transplant center 2004/2005 Survey Findings • BMT Services

  21. Transportation Lodging Meals Parking DE,KY, Patients All All All ID, MN, OK,TX Donor ID, ND, MN ID, ND ID, ND ID DE, KY, DE, ID, ID, NE, Caregivers All but AL All but ND KY, OK, ND, OK, TX UT, TX 2004/2005 Survey Findings • Solid Organ Services * ID indicated that prior authorization is required for all services

  22. 2004/2005 Survey Findings • Authorization Guidelines • Prior Authorization • All states indicated that prior authorization was required on all types of transplants • All states (except MN) said that it was the responsibility of the transplant center/ specialist to obtain authorization • MN indicated that the Primary Care Physician is responsible to obtain transplant auth

  23. 2004/2005 Survey Findings, cont. • Follow-up care for Solid Organ • 6 states say the length of coverage period for solid organ transplant is greater than 120 days (CT, GA, KY, ND, OR, UT) • In MN it is up to 90 days • In TX it is less than 60 days • In DE & ID they do not predetermine a coverage period • Follow-up care for Solid Organ Donors • 6 states said they do not cover long term follow up care for the donor (AL, CT, GA, KY, OK, OR) • 6 states said they do cover long term follow up care for the donor (DE, ID, MN, ND, TX, UT)

  24. 2004/2005 Survey Findings, cont. • Follow-up care for BMT • 12 states indicated they cover the transplant and follow-up care (AL, CT, DE, GA, KY, MN, NE, ND, OK, OR, TX, UT) • Prescription Coverage Limitations • 3 states indicated that they have prescription limitations • TX- limited to 3 prescriptions per month • OK- Age 0-20: must be on formulary • OK- Age 21+: limited to 6 prescriptions per month, 3 of which can be name brand • GA- limited to 5 prescriptions per month (PA for >5)

  25. 2004/2005 Survey Findings, cont. • Transplant out of state (BMT and Solid Organ) • 8 states responded that they allow transplants out of state (AL, CT, DE, KY, MN, ND, NE,OK, TX) • Most of them indicated they need to either have a contract with the facility or prior authorize • 2 states indicated that patients could not go out of state for BMT (NE, OR) • 2 states indicated this is under review (GA, UT) • 1 state did not respond (ID)

  26. 2004/2005 Survey Findings • Reimbursement– Facility Fees • 5 states said they reimburse based on DRG (CT, GA, NE, TX, UT) • 4 states said they reimburse based on a discounted percentage of charges (ID, ND, OK, OR) • AL said they reimburse based on a global rate • DE said they reimburse on “payment per discharge” • KY said they reimburse based on capitation • MN did not respond • Physician charges are reimbursed by fee for service in most states

  27. 2004/2005 Survey Next Steps • NMDP/TFCA will continue to try to obtain results from the remaining states • More information to be presented at the UNOS meeting in Memphis. • Repeat survey again in 2006?

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