1 H1N1 Webinar November 12, 2009 Darryl W. Ng Director of Government Affairs Community Health Care Association of New York State Tele. (212) Mobile (917)

2 H1N1 Webinar This Webinar will paint two pictures. The first picture will be on H1N1 Vaccine Reimbursement Scenarios. The second picture will be on HIN1 Influenza Like Illness (ILI) Reimbursement Scenarios.

3 H1N1 Webinar At this point, we can only provide broad stokes and acknowledge that most of the painting will have to be filled in by the unique detailed strokes of the individual health centers and then further customized by the fine print in their contacted plans.

4 1.) Medicaid Managed Care & Family Health Plus FHP Scenario A) Existing patient, i.e., CHC has a contract with the patient’s plan and is listed as the primary provider. CHC can bill plan for the following or a combination there of: $13.23 (H1N1 admin cost) + $13.23 (Pneumococcal admin cost) + $13.23 (Seasonal Flu admin cost) + (Actual Acquisition Cost of Pneumococcal Vaccine) + (Actual Acquisition Cost of Season Flu Vaccine). Scenario B) Patient has not identified the CHCs as his/her primary care provider but CHC has a contract with the plan. CHCANYS is working with the insurance plans to develop a “new code” so that CHC can override the out of network provision and bill for H1N1 admin cost. CHC will not be able to bill for the Pneumococcal and Season Flu related charges, i.e., vaccine acquisition and administration cost, as this new code will be restricted to H1N1. If “new code” is not viable, Plans have pledge to come up with a new way to do it. We told the Plans that going through their normal “appeals process” is not a feasible/realistic option. Scenario C) CHC does not have a contract with the patient’s insurance plan. CHCANYS is currently getting a list of Plans that have agreed to reimburse out of network for H1N1 Admin Cost, i.e., $ The majority of Medicaid Managed Plans are said to be already doing this. We have asked for a list of the plans that are doing this with corresponding contact names so that we can distribute list to CHCs. Note: Under VFC, providers can receive enhanced fee of $17.85 for patients up to the age of 19 for Pneumococcal Admin Cost and Seasonal Flu Admin Cost. This is moderately higher than the corresponding admin cost for patients over 19 cited above, i.e., $ H1N1 Vaccine Scenarios

5 H1N1 Vaccine Scenarios 2.) Commercial Managed Care Plans Theoretically, the same as scenario A, B and C listed above but substitute “$13.23” for “reimbursement amounts will be in accordance with provider agreements for the participating providers and will be negotiated with out of network provider.” We are hearing that the range is from $13.23 to $21.00.

6 H1N1 Vaccine Scenarios 3.) Medicaid Fee for Service If an existing or new patient is a fee for service Medicaid enrollee, the CHC should bill Medicaid as follows: $13.23 (H1N1 admin cost) + $13.23 (Pneumococcal admin cost) + $13.23 (Seasonal Flu admin cost) + (Actual Acquisition Cost of Pneumococcal Vaccine) + (Actual Acquisition Cost of Season Flu Vaccine).

7 H1N1 Vaccine Scenarios 4.) Uninsured Patients Outside of some grants for this purpose, there is no vehicle to get reimbursement for H1N1 vaccination for uninsured patients. HRSA has recently raised the possibility of creating an uninsured reimbursement pool for this purpose but discussions are just beginning.

8 H1N1 Vaccine Scenarios Other Pending Considerations Pertaining to H1N1 Vaccine Reimbursement Is it feasible for CHCs do the administration of the vaccine and the processing of the corresponding bill for $13.23? Why has the State chosen $13.23 as its Medicaid rate H1N1 vaccination administration rate when the State’s Medicare rate for vaccination administration is $19.57? We have not charted on the Medicare issues yet. HRSA has clarified that folks that get only the vaccination need to get counted in the new UDS system but they should not be registered under the CHCs’ normal patient count. There is a special new section in the UDS to count folks that only get the vaccination. Additional New York Medicaid Vaccine Reimbursement clarification: 1.) If a patient presents with a medical condition and receives the H1N1 vaccine at this visit, then the Medicaid payment should be the threshold rate of reimbursement on the E&M visit only (Evaluation and Management code). A secondary procedure code for administration of the vaccine should be added to the encounter form to track H1N1 vaccinations. It is recommended that it is documented when a patient is offered the H1N1 vaccine and refuses using V-codes. 2.) If a patient presents for the H1N1 vaccine only, the administration fee will be billed as an ordered ambulatory $ The Medicaid reimbursement for administration of the H1N1 vaccine will be $ As referenced above, CHCs need to track vaccinations to include on the new UDS system but not included in the patient count as a user. 3.) Medicaid Managed Care Plans adhere to the above 1 and 2 however reimbursement depends on the contracted reimbursement amounts.

9 H1N1 ILI Reimbursement Scenarios 1.) Medicaid Managed Care & FHP Scenario A) Existing patient, i.e., CHC has a contract with the plan and is listed as the primary provider. CHC should bill insurance plan for ILI visits as it typically does for any other visit. Reimbursement amounts will be in accordance with provider agreements for the participating providers. CHC should bill the State for the Medicaid wrap. Scenario B) Patient has not identified the CHC as his/her primary care provider but CHC has a contract with the plan. CHCANYS is working with the insurance plans to develop a “new code” so that CHC can override the out of network provision and bill for ILI visits. This new code will be restricted to only H1N1 vaccination administrative cost ($13.23) and ILI visits. If “new code” is not viable, Plans have pledge to come up with a new way to do it. We will hear from them shortly. CHC should also be able to bill the State for the Medicaid wrap here, but this has not been verified by the State yet. Should the “new code” agreement not work out, CHC have the following untenable options: 1. Providing ILI visits/care with no reimbursement 2. Referring patient back to their primary provider 3. Referring patient back to their insurance plan 4. Referring patient to emergency room. Scenario C) CHC does not have a contract with the patient’s insurance plan. CHCANYS is currently developing a MOU template so that CHCs can bill for H1N1 admin cost and ILI visits. CHC should also be able to bill the State for the Medicaid wrap here, but this has not been verified by the State yet. Should the “MOU” agreement not work out, CHC have the following untenable options: 1. Providing ILI visits/care with no reimbursement 2. Referring patient back to their primary provider 3. Referring patient back to their insurance plan 4. Referring patient to emergency room.

10 H1N1 ILI Reimbursement Scenarios 2.) Commercial Manage Care Plans Theoretically, the same as scenario A, B and C listed above but with the likelihood that some private plans will opt out of the “new code” and MOU agreement referenced above. Similar to the Medicaid manage care plan scenarios listed above, should the “new code” and “MOU” agreement not work out, CHC have the following untenable options: 1. Providing ILI visits/care with no reimbursement 2. Referring patient back to their primary provider 3. Referring patient back to their insurance plan 4. Referring patient to emergency room.

11 H1N1 ILI Reimbursement Scenarios 3.) Medicaid Fee for Service If an existing or new patient is a fee for service Medicaid enrollee, the CHCs should bill Medicaid in accordance with its existing PPS rate.

12 H1N1 ILI Reimbursement Scenarios 4.) Uninsured Patients Health centers are required to provide services to the uninsured on a sliding scale basis. Similar to other types of uninsured visits, CHCs are encouraged to seek compensation for uninsured ILI visits via the New York State’s Indigent Care Pool, which reimburse cost at approximately 36 cents to the dollar. HRSA has recently raised the possibility of creating a separate H1N1 reimbursement pool for additional financial relief but discussions are just beginning.

13 H1N1 ILI Reimbursement Scenarios Other Pending Considerations Pertaining to H1N1 ILI reimbursement: Is it feasible for CHCs to do ILI visits without the State’s assurance that CHCs would be able to apply the Medicaid wrap (Scenario B and C)? HRSA has clarified that folks that get only the vaccination need to get counted in the new UDS system but they should not be registered under the CHCs’ normal patient count. There is a special new section in the UDS to count folks that only get the vaccination. All patients that receive ILI visits should be counted in the CHCs’ normal patient count under UDS.

14 Final Slide: So that we end this “state of emergency” crisis presentation on an positive and optimistic note, i.e., the glass is half Tamiflu full… In Chinese Calligraphy, the written word for “crisis” is drawn by merging the written word for “danger” and “opportunity.” The “H1N1 crisis” fits that definition. The H1N1 crisis poses many dangers for many obviously reasons, but it also provides lot of opportunities because it: Provides a platform to communicate the importance health care, particularly primary care. Highlights FQHCs leadership roles in primary care, emergency preparedness, etc. Enable FQHCs to have a much deserved seats at public health tables. Encourages out of the box thinking and new solutions. Provides a unique situation where different parties are now motivated to have the same life saving and cost saving goals. Supports FQHC’s mission of providing care to the community when and where it needs it the most.