Medicaid and the Risks to Providers Ivan J. Punchatz, Esq. Shareholder, Healthcare Section Buchanan Ingersoll & Rooney Rich Skorupski, CIC, CRM, CPCU Senior Vice President Meeker Sharkey & Hurley
Medicaid Background Medicaid (Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq.) enacted at same time as Medicare (Title XVIII, 42 U.S.C. § 1395 et seq.). Social Security Act Amendments of 1965, P.L. 89-97 (July 30, 1965). Unlike Medicare, which is 100 percent federally funded and administered, Medicaid is a cooperative federal-state program, voluntary and jointly funded by the federal government and participating states. – United States Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) – Single State Medicaid Agencies 2
Medicaid Background (cont.) States must comply with federal Medicaid standards, including requirements as to the contents of their state plans, to qualify for federal financial participation (FFP). There are significant variations in state Medicaid programs in terms of: – Eligibility for benefits; – Covered services; and – Program administration ( e.g. , reimbursement). 3
Medicaid Background (cont.) Some contrasts with Medicare: – Eligibility: Elderly (Medicare) Indigent, Disabled, Special Needs population (Medicaid) – Funding and administration: 100% federal (Medicare) via insurance Federal-state collaboration (Medicaid) via public benefits – Coverage: Broader post-acute coverage in Medicaid (long-term care services) 4
Medicaid Background (cont.) Mandatory Optional – Physician services – Prescription drugs – Lab and x-ray services – Clinic services – Inpatient hospital – Dental services, dentures – Outpatient hospital – Physical therapy and rehab – EPSDT for individuals under 21 – Prosthetic devices, eyeglasses – Family planning – Primary care case management – Rural and federally qualified health – Institutions for individuals with care (FXHS) services intellectual disabilities, formerly – Nurse midwife services intermediate care facilities for the – Nursing facility (NF) services for mentally retard (ICF/MR) services individuals 21 and over – Inpatient psychiatric care for – Home health for certain populations individuals under 21 – Personal care services – Expansion Medical – Essential Health Benefits Alcohol and drug treatment (“Benchmark Coverage” and “Benchmark Equivalent Coverage”) 5
Medicaid Background Eligibility Different types of Medicaid include different eligibility criteria and benefit coverage. Mandatory Coverage Populations. Optional Coverage Populations. Medicaid Expansion Coverage (Optional with states under Supreme Court’s decision in National Federation of Independent Business v. Sebelius –- NFIB, 132 S.Ct. 2566 (2012)). 6
Medicaid Background Medicaid covers 9.3 million non-elderly people with disabilities, including 1.5 million children. Medicaid provides health and long-term care coverage for people with severe physical and mental health conditions and disabilities (e.g., cerebral palsy, Down Syndrome, autism). Often, these individuals cannot obtain coverage in the private market or the coverage available to them falls short of their health care needs. Medicaid provides people with disabilities access to a fuller range of the services they need, helping to maximize their independence and, in the case of some disabled adults, supporting their participation in the workforce. Medicaid covers a large majority of all poor children with disabilities. Source: The Kaiser Commission on Medicaid and the Uninsured: Medicaid A Primer 2013 7
Medicaid Background (cont.) Medicaid Beneficiaries – 69.7 million (2014) (more than one in five Americans; Medicare enrollment was about 52.7 million at that time, though the numbers overlap because some individuals are dually eligible). Medicaid Spending - $449.4 billion (2013) (about 15 percent of total national health expenditures; Medicare spending was approximately $585.7 billion or 20 percent of total national health expenditures). Source: The Kaiser Commission on Medicaid and the Uninsured: Medicaid A Primer 2013 8
Single State Agency The Division of Medical Assistance and Health Services (DMAHS), under the Department of Human Services, is designated the single State agency for the administration of the New Jersey Medicaid Program. New Jersey State Plan may be found at: http://www.state.nj.us/humanservices/dmahs/info/state_plan.html 9
State Plan A submission by the State to the Federal Government to enable the State to claim federal funds for health benefits provided to eligible beneficiaries. Subject to review and approval by Secretary of Health and Human Services (HHS) acting through the Centers for Medicare and Medicaid Services (CMS). Must meet federal statutory and regulatory standards State may obtain 1115 Waivers such as New Jersey’s, which includes services for seniors, disabled and behavioral health services. 10
§ 10:49-1.4 Overview of provider manuals The Administration Manual is found at NJAC 10:49-1.1 et seq and is applicable to all providers: a) The Medicaid Fiscal Agent and the Division of Medical Assistance and Health Services maintain New Jersey Medicaid and NJ FamilyCare provider manuals. Each is designed for use by a specific type of provider that provides services to Medicaid and/or NJ FamilyCare beneficiaries. Each manual is written in accordance with Federal and State laws, rules, and regulations, with the intent to ensure that such laws, rules and regulations are uniformly applied. 11
§ 10:49-1.4 Overview of provider manuals b) Each provider manual consists of two chapters, broken down into subchapters. The first chapter is referred to as N.J.A.C. 10:49, Administration Manual, and outlines the general administrative policies of the New Jersey Medicaid program and other special programs including NJ FamilyCare. The second chapter of each manual specifies the rules and regulations relevant to the specific provider-type and the services provided. Following the second chapter of the manuals is the Fiscal Agent Billing Supplement. 12
Enrollment Pursuant to NJAC 10:49-3.1(b) following are permitted to participate as providers: 16. Mental health rehabilitation providers: i. Residential child care facilities (see N.J.A.C. 10:77 and 10:127); ii. Children's group homes (see N.J.A.C. 10:77 and 10:128); iii. Psychiatric community residences for youth (see N.J.A.C. 10:37B and 10:77); iv. Providers of behavioral assistance services for children/youth or young adults (see N.J.A.C. 10:77-4); 13
Enrollment (cont.) v. Mobile response agencies (see N.J.A.C. 10:77-6); vi. Providers of intensive in-community mental health rehabilitation services (see N.J.A.C. 10:77-5); vii. Programs for Assertive Community Treatment (PACT) Agencies/Teams (see N.J.A.C. 10:37J and 10:76); and viii. Community residences for mentally ill adults (see N.J.A.C. 10:37A and 10:77A). 14
New Supports Waiver Allows DDD to continue in an administration and consulting role to DMAHS in the administration of benefits to adults eligible for DDD services and Medicaid benefits. Supports Program Policies and Procedures Manual included at: http://www.state.nj.us/humanservices/ddd/programs/ff s_implementation.html 15
Payment for Services Fiscal Agent Molina. New Jersey Medicaid Management Information System (NJMMIS) http://www.njmmis.com/. Medicaid Managed Care Organizations. 16
Additional Recordkeeping May Be Necessary Medicaid requires appropriate certifications and sign offs regarding prior authorization, services rendered, staff qualifications, etc. Medicaid payment is subject to audit and verification that all documentation requirements have been met. 17
Submitting Claims Each Provider Services Manual has information relevant to the basis of payment for services and items of payment provided that is usually found in the second chapter of each manual. A Fiscal Agent Billing Supplement is included following each Provider Services Manual. Included in the Supplement are: – Prior authorization forms and instructions – Information for the proper completion and submission of claim forms – Procedure to follow when claims are rejected and returned to the provider by the Fiscal Agent during the adjudication process – Third-party liability verification – Procedure for submitting crossover claims and examples of timely submission of claims – Electronic media claims (EMC) submission – Remittance Advice Statements – Procedures for Electronic Funds Transfer (EFT) – Adjustments for overpayment of claims and adjustments by Medicare – Procedure to follow when a claim is paid in error (voids) – Procedure for inquiries about claims – Procedure for ordering forms – Information about provider services – Item-by-item instructions for completing the claim form and other forms. 18
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