Maternal Child Health Advisory Board Nevada Medicaid August 2, - PowerPoint PPT Presentation

Steve Sisolak Suzanne Bierman, JD, MPH Governor Administrator Division of Health Care Financing and Policy Maternal Child Health Advisory Board Nevada Medicaid August 2, 2019

EPSDT • The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) provides comprehensive and preventive health care services for children under 21 who are enrolled in Medicaid  Early: Assessing and identifying problems early  Periodic: Checking children's health at periodic, age-appropriate intervals  Screening: Providing physical, mental, developmental, dental, hearing, vision, and other screening tests to detect potential problems  Diagnostic: Performing diagnostic tests to follow up when a risk is identified, and  Treatment: Control, correct or reduce health problems found 2 Division of Health Care Financing and Policy

EPSDT, cont • Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services are preventive and diagnostic services available to most recipients under age 21. • In Nevada, the EPSDT program is known as Healthy Kids. The program is designed to identify medical conditions and to provide medically necessary treatment to correct such conditions. • Healthy Kids offers the opportunity for optimum health status for children through regular, preventive health services and the early detection and treatment of disease. 3 Division of Health Care Financing and Policy

LARCs Medicaid has removed all barriers to family planning • counseling/education provided by qualified physicians. (e.g. Physicians, Rural Health Clinics/Federally Qualified Clinics, Indian Health Services/Tribal Clinics, and Home Health Agencies, etc.) The physician must provide adequate counseling and information to • each recipient when they are choosing a birth control method. If appropriate, the counseling should include the information that • the recipient must pay for the removal of any implants when the removal is performed after Medicaid eligibility ends. . 4 Division of Health Care Financing and Policy

LARCs continued Family planning education is considered a form of counseling intended to • encourage children and youth to become comfortable discussing issues such as sexuality, birth control and prevention of sexually transmitted disease. It is directed at early intervention and prevention of teen pregnancy. • Family planning services may be provided to any eligible recipient of • childbearing age (including minors who may be considered sexually active). Insertion of Long Acting Reversible Contraceptives (LARC) immediately • following delivery is a covered benefit for eligible recipients. LARC insertion is a covered benefit post discharge as medically necessary 5 Division of Health Care Financing and Policy

Medical Necessity 103.1 MEDICAL NECESSITY Medical Necessity is a health care service or product provided for under the Medicaid State Plan and is necessary and consistent with generally accepted professional standards to: A. diagnose, treat or prevent illness or disease; B. regain functional capacity; or C. reduce or ameliorate effects of an illness, injury or disability. The determination of medical necessity is made on the basis of the individual case and takes into account: D. the type, frequency, extent, body site and duration of treatment with scientifically based guidelines of national medical or health care coverage organizations or governmental agencies. E. the level of service that can be safely and effectively furnished, and for which no equally effective and more conservative or less costly treatment is available. F. that services are delivered in the setting that is clinically appropriate to the specific physical and mental/behavioral health care needs of the recipient. G. that services are provided for medical or mental/behavioral reasons, rather than for the convenience of the recipient, the recipient’s caregiver or the health care provider. Medical necessity shall take into account the ability of the service to allow recipients to remain in a community-based setting, when such a setting is safe, and there is no less costly, more conservative or more effective setting. 6 Division of Health Care Financing and Policy

Non Emergency Transportation • Nevada Medicaid contracts to provide non- emergency transportation 7 Division of Health Care Financing and Policy

Rates • Nevada FFS rates are established through the Nevada State Plan which requires approval from the Center for Medicare and Medicaid Services. • Rates information http://dhcfp.nv.gov/Resources/Rates/FeeSchedul es/ • https://www.medicaid.nv.gov/hcp/provider/Hom e/tabid/135/Default.aspx • Medicaid’s Managed Care Organizations (MCOs) contract rates with providers. 8 Division of Health Care Financing and Policy

Tubal Ligations MSM 603.3 State and federal regulations grant the right for eligible Medicaid • recipients of either sex of childbearing age to receive family planning services provided by any participating clinics, physician,PA, APRN, CNM, or pharmacy. Females, who are enrolled for pregnancy-related services only, are • covered for all forms of family planning, including tubal ligation and birth control implantation up to 60 days post-partum including the month in which the 60th day falls Prior authorization is not required. In accordance with federal • regulations, the recipient must fill out a consent form at least 30 • days prior to the procedure. The physician is required to send the consent form to • the fiscal agent with the initial claim. 9 Division of Health Care Financing and Policy

Katie Beckett An eligibility option which allows the state to waive parental income and resources • for any child under 19 years of age and meets a level of care that would make the child eligible for placement in a hospital, nursing facility or Intermediate Care Facility for persons with intellectual disabilities. These benefits are available to eligible children with disabilities who would not • ordinarily qualify for Supplemental Security Income (SSI) benefits because of parental income or resources If a child qualifies under this option, Medicaid covers all medically necessary • services as defined under the Medicaid State Plan The cost of care must not be higher than the amount Medicaid would pay if the • child were institutionalized There may be financial responsibility based on the parent’s income and resources • for those children qualifying under Katie Beckett Eligibility option. Eligibility determinations are made the Division of Welfare and Supportive Services • 10 Division of Health Care Financing and Policy

Fetal Stress Test State Rates 59025 26 FETAL NONSTRESS TEST $45.00 $40.00 $35.00 $30.00 $25.00 $20.00 $15.00 $10.00 $5.00 $- NV Rate Oregon Idaho Wyoming Colorado New Mexico Arizona Utah Montana Surrounding State Avg. * Based on a search of state Medicaid rates. For reference only 11 Division of Health Care Financing and Policy

Vaginal Delivery Only Rates 59409 ~ VAGINAL DELIVERY ONLY $1,200.00 $1,000.00 $800.00 $600.00 $400.00 $200.00 $- NV Rate Oregon Idaho Wyoming Colorado New Mexico Arizona Utah Montana Surrounding State Avg. * Based on a search of state Medicaid rates. For reference only 12 Division of Health Care Financing and Policy

Comprehensive Vaginal Delivery Rates 59400 ~ OB CARE ANTEPARTUM VAG DLVR & POSTPARTUM $3,000.00 $2,500.00 $2,000.00 $1,500.00 $1,000.00 $500.00 $- NV Rate Oregon Idaho Wyoming Colorado New Mexico Arizona Utah Montana Surrounding State Avg. * Based on a search of state Medicaid rates. For reference only 13 Division of Health Care Financing and Policy

Cesarean Delivery Only Rates 59514 ~ CESAREAN DELIVERY ONLY $1,400.00 $1,200.00 $1,000.00 $800.00 $600.00 $400.00 $200.00 $- NV Rate Oregon Idaho Wyoming Colorado New Mexico Arizona Utah Montana Surrounding State Avg. * Based on a search of state Medicaid rates. For reference only 14 Division of Health Care Financing and Policy