Plugged Into Health @ Hinman Straub – July 2, 2018
Medicaid Pharmacy Updates
CMS Issues Guidance to States on Medicaid Coverage of Drugs Approved by FDA under Accelerated Approval Pathway
On Wednesday, CMS issued guidance to State Medicaid agencies related to accelerated approved drugs. The guidance provides there is no distinction for Medicaid coverage between drugs approved through the accelerated pathway and drugs approved under ordinary FDA review. Thus, drugs granted accelerated approval must be covered by MMC plans and State Medicaid programs. The pertinent guidance states: “drugs that are granted “accelerated approval” are drugs approved by FDA under section 505(c) of the FFDCA, and are able to satisfy the definition of covered outpatient drug, and if used for a medically-accepted indication, then the drug must be covered by state Medicaid programs if the manufacturer has an applicable signed Medicaid national drug rebate agreement for participation in the MDRP.”
VBP Updates
VBP Pilot Webinar
Last week, DOH held a webinar to discuss best practices and lessons learned in the VBP Pilot Program. The webinar included two presentations from VBP Pilot providers. John Dionisio presented on SOMOs Community Care’s experience (SOMOs Your Health IPA, formerly known as Advocate Community Partners), and Michael Endries presented on behalf of St. Joseph’s Hospital Health Center. SOMOS holds six of the twelve NYS VBP Pilot contracts (all TCGP arrangements) and was the only contractor to enter into “risk-based” VBP arrangements in Year 1 of the pilot. The SOMOS network includes more than 2,500 community-based PCPs and specialist providers that serve more than 650,000 Medicaid beneficiaries. St. Joseph’s participates in two TCGP pilots and has 90,000 attributed lives. The VBP Pilots began January 1, 2017 and conclude December 31, 2018.
Highlights from the presentation include:
SOMOS
- Target Budget: Two SOMOS contracts used cost-based methodology from the prior year, as opposed to the three-year trend recommended in the Roadmap for target budget setting. The purpose of this was to avoid including program costs that are no longer relevant, Mr. Dionisio explained. While not discussed during the presentation, it is worth noting that MMC rate makers still use a three-year blend for developing base premiums. Four of the SOMOS contracts used MLR based methodologies that account for historical costs with plans, revenues, and expenses, which then are trended forward.
- Shared Savings/Losses: SOMOS kept the number of quality targets “low”. Achieving 90% quality resulted in higher percentage towards shared savings and reduced losses. DOH only required SOMOS to report on one Category 2 measure. They selected Patient Self-Management and Action Plan for Asthma. Category 1 measures were used to set shared savings. Mr. Dionisio said SOMOS is working to centralize differences in quality reporting among the six different MCOs they contract with in the Pilot.
- Program Recommendations: Dionisio’s included a series of takeaways and recommendations:
- Be realistic with timing: Expect delays in DOH contract approvals, release of data, stimulus and incentive payment and related funds flow.
- Importance of data: According to Mr. Dionisio, many providers will continue to be hesitant to go into higher risk-based contracts without access to quality and financial data, and VBP dashboards provided by DOH. He noted that some MCOs limit information shared to providers.
- Increase standardization: Stricter parameters on certain aspects of reporting and contracting, such as with respect to quality measures and data, would be helpful. Flexibility can be helpful but it can lead to too much discretion and interpretation during the early years of VBP.
- Greater premium transparency: Provide more than just claims data to allow providers to negotiate more evenly with MCOs. Suggestions include providing insight into risk scores at the IPA level and not just the MCO level.
St. Joseph’s Hospital Health Center
- Target Budget: Endries’ presentation included a slide on “acceptable target budgets” with two columns, showing his health system’s preference and the preference of the health plan for each aspect of the budget setting. Areas of divergence include:
- Plan preference to use % of medical expense ratio (“MER”) to set the budget vs. St. Joseph’s preference to use the same methodology employed under APM models or in commercial insurance;
- Joseph’s preference to include only historical expenditures of the attributed population in the budget vs. the plan’s need to include administrative costs to “ensure margins are preserved”;
- Joseph’s preference to apply negotiated trend to the target budget from Year 1 to Year 2, vs. the plan preference to rebase to the target MER; and,
- Joseph’s preference to exclude service categories that “providers are unable to impact” or “have significant ‘headwinds’”. The prime example given of this was prescription drugs.
- Measure Selection: Endries underscored the importance of working with a network of providers to determine which measures can help achieve results. He said he did not blame plans for preferring claims based measures, which are more easily automated and less susceptible to manipulation than outcome measures that require the provider to report information into the EMR.
- Potential Headwinds: Endries described managing pharmacy as the greatest potential headwind that can impact a provider’s performance. He said if it is possible, providers should try to get pharmacy excluded from the arrangement.
- Long-term future of VBP: Endries said he did not envy payers because PCPs are going to be reluctant to give up their existing incentive programs for VBP.
Social Determinants of Health and VBP Webinar
On Wednesday, July 11, 2018 from 10:00 to 11:30 a.m., the Department of Health, Office of Health Insurance Programs, Bureau of Social Determinants of Health, will be hosting a webinar for Community Based Organizations (“CBOs”) that are considering or are in the process of entering into a VBP contract. Topic areas covered in the webinar will include:
- How CBOs can get involved in VBP
- How a CBO can create a value proposition
- Types of CBO/VBP contracting arrangements
- VBP myths and facts for CBOs
- Key items to include in CBO/VBP contracts
- Live Q&A
To register for the webinar, click here.
VBP QIP Contracting Extension
The contract submission deadline for the VBP QIP P4R for those with persistent issues has been extended to July 31, 2018. Each VBP QIP Facility and MCO submitting contracts must complete a Contract Status Extension document (here & here) to explain why they were not able to meet the original June 29th deadline.
The Contract Status Extension Form must be submitted to the [email protected] mailbox by Friday, July 6, 2018.
Any facility unable to meet the program milestone of having 80% of the organization’s Medicaid Managed Care dollars in a level 1 or higher VBP arrangement will be subject to a penalty equivalent to 20% of the DY4 VBP QIP award as documented in the VBP QIP program guidance. Penalties will be imposed in a future rate adjustment.
Action Items:
- For Managed Care Organizations (“MCOs”): MCOs not submitting all of the VBP contracts for they were in negotiations with a facility should complete the “Plan Contracting Extension Form”.
- For Facilities: Facilities that have not finalized all contracts to reach the 80% milestone should complete the “Facility Contract Extension Form”.
Medicaid Policy Clarification and Criteria Standards for Treatment of Gender Dysphoria
The Department of Health recently issued a notice clarifying Medicaid coverage requirements for the treatment gender dysphoria.
First, the notice notes that effective September 1, 2018, mainstream Medicaid managed care plans, HIV Special Needs Plans and Health and Recovery Plans (“MMCPs”) will be required to obtain Department of Health approval for all service authorization and utilization review criteria for Hormone Therapy and Surgery for the Treatment of Gender Dysphoria.
Secondly, the notice requires that MMCPs immediately confirm their current policies and procedures for the coverage of gender dysphoria services are consistent with requirements issued by the Department of Health, including, but not limited to, the following:
- Gender identity as related to gender dysphoria: The diagnostic criteria for gender dysphoria are applicable to people of all genders and are not limited to people with binary gender identities. Gender dysphoria treatment for enrollees of all gender identities is covered under 18 NYCRR § 505.2(l).
- Reduction mammoplasty: Pursuant to 18 NYCRR § 505.2(l)(4)(i), Plans are required to cover reduction mammoplasty. Administrative prior authorization requirements may be applied; however, Plans may not conduct a utilization review and must accept the enrollee’s treating provider’s determination of medical necessity. Plans must also accept the enrollee’s treating provider’s determination of the enrollee’s breast tissue condition, and shall not include the evaluation of photographic documentation in the administrative prior authorization process.
- Breast augmentation: Pursuant to 18 NYCRR § 505.2(l)(4)(ii), Plans are required to cover breast augmentation. Same requirements as Reduction mammoplasty.
- Hormone therapy prior to surgery: Pursuant to 18 NYCRR § 505.2(l), Hormone therapy is only needed if;
-
- appropriate to the enrollee’s gender goals,
- recommended by the enrollee’s treating provider,
- clinically appropriate for the type of surgery requested,
- not medically contraindicated, and
- the enrollee is otherwise able to take hormones.
- Referral letters: 18 NYCRR § 505.2(l)(3) requires that an enrollee, who is being referred for surgery for the treatment of gender dysphoria, have letters from two qualified NYS licensed health professionals. Plans must accept referral letters as an attestation that, when reviewed together, satisfy the above, without seeking additional documentation or justification.
- Gender markers on claiming systems: Plans are required to ensure that their claims processing systems are not inappropriately denying claims based on gender markers.
- Mental Health counseling requirement: 18 NYCRR § 505.2(l)(3)(i)(c) requires that an enrollee live for 12 months in a gender role congruent with the enrollee’s gender identity and has received mental health counseling, as deemed medically necessary, during that time. There is no requirement that the enrollee receive 12 months of mental health counseling during this period. Therefore, coverage cannot be denied solely because the enrollee has not received 12 full months of mental health counseling.
Children’s Health and Behavioral Health Services Medicaid Transformation Billing and Coding Manual
The Department of Health recently published the New York State Children’s Health and Behavioral Health (BH) Services Medicaid Transformation Billing and Coding Manual.
The billing manual, subject to required State and Federal approvals, reflects the billing structures for the Children’s System Transformation scheduled to begin on January 1, 2019. Additional billing criteria will be updated by the State. Future updates will only supplement current information, and will not change what is already in place. Providers should use this manual to begin preparation of claiming systems.
The Department has indicated that a supplemental billing manual, “NYS Children’s Health and Behavioral Health (BH) Services – Children’s Medicaid System Transformation Guidance for the Transitional Period” will be released shortly and will include guidance on transitional billing procedures, including transitional billing procedures for waiver providers that will transition to Health Home rates and for HCBS services that will transition to State Plan services after January 1, 2019.
Adult Care Facility Warm Weather Advisory
The Department of Health has issued a Dear Administrator Letter (DAL 18-17: Warm Weather Advisory) to adult care facility administrators as a reminder of the responsibility to provide residents with a comfortable and safe environment throughout the summer months and to take the necessary precautions to prevent heat related conditions. NYS Law requires the Department to set allowable temperatures for resident-occupied areas of the facility.
NYS Regulations require the operator to perform the following when the outside temperature exceeds 85 degrees Fahrenheit:
- Take measures to maintain a comfortable environment
- Monitor resident exposure and reactions to heat
- Arrange for health care, if needed
- Arrange for the temporary relocation of residents, if needed.
- One common room in such adult home, enriched housing program and residence for adults shall be required to be air-conditioned.
The Department recommends that the common rooms accommodate as many residents as possible. Facilities are expected to turn on the air conditioning in the common rooms and monitor the air temperature hourly in all common areas as well as in the non-air-conditioned rooms at various locations on each floor of the facility. If room air conditioners are typically used, the air conditioners must be turned on regardless of a resident’s ability to pay. Facilities that utilize central air conditioning do not no need to monitor hourly as long as the central air is turned on.
Additionally, facilities are required to post the following heat-related information in a conspicuous area that is accessible to both staff and residents.
- Steps to be Taken by Adult Care Facilities in Warm Weather
- Symptoms of Heat-Related Conditions and Management
- Medications with Added Sensitivity to Heat And Other Conditions
eMedNY Training Seminars and Webinars
The eMedNY Training Schedule for July – September is available and registrations for seminars and webinars are currently being accepted.
Some of the topics offered include:
- ePACES for Dental, DME, Institutional, Nursing Home, Professional (Real-Time), Physician, Private Duty Nursing, and Transportation
- eMedNY Website Review
- Medicaid Eligibility Verification System (MEVS)
- New Provider/ New Biller
eMedNY training seminars are being held at the following locations:
- Binghamton
- Canandaigua
- Hauppauge
- Jamestown
- Mexico
- Poughkeepsie
- Rensselaer
eMedNY also offers training webinars. Click here to view the training schedule and register.
Upcoming Calendar
|