Montana Health and Economic Livelihood Partnership (HELP) Plan December 30,

Agenda  Eligibility Populations  Medical and Behavioral Benefits & Chart  Copayment Requirements  Standard Medicaid Changes  Administrative Rules of Montana (ARMs)  Contact Information 2

HELP Plan Eligibility Populations The following populations are eligible for Third Party Administrator (TPA) Services:  Adults between the ages of years of age, with an income at or below 138% of the Federal Poverty Level (FPL) – i.e. $16,424 for an individual;  May not be enrolled or eligible for Medicare;  May not be incarcerated;  Must be a United States Citizen or documented, qualified alien; and  Must be a Montana resident. 3 3

Non-TPA Expansion Populations Benefits are administered through the Medicaid State Plan for:  Individuals under 50% FPL,  Individuals determined to be medically frail; and  Individuals exempt by federal law. Benefits may be through the Medicaid State Plan for:  Individuals who live in a geographical area with insufficient health care providers; and  Individuals in need of continuity of care that would not be available or cost-effective through the TPA. 4 4

HELP Plan Health Benefits  Required by the Affordable Care Act (ACA)  Ambulatory Patient Services  Emergency Services  Hospitalization Services  Maternity and Newborn Services  Mental Health and Substance Use Disorder Services  Prescription Drug Services  Rehabilitative and Habilitative Services and Devices  Laboratory and X-Ray Services  Preventive Services  Pediatric Services  Additional Healthcare Benefits (administered by DPHHS)  Vision Services  Dental Services  Hearing Aids Services  Audiology Services  Transportation Services  Indian Health Services/Tribal Health Services  Federally Qualified Health Clinic Services  Rural Health Clinic Services  Diabetes Prevention Program 5 5

HELP Plan Medical and Behavioral Health Benefits Administered by Blue Cross Blue Shield of Montana (BCBSMT):  Hospital Services  Physician and Mid-Level Services  Emergency Services  Durable Medical Equipment/Medical Supplies/Prosthetics  Behavioral Health and Substance Use Disorder Services  Home Heath (180 visits) and Hospice Services  Rehabilitative and Habilitative Services  Diagnostic Laboratory and X-Ray Services  Preventive Services  Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT)  Convalescent Home Services (up to 60 days)  Surgical Services  Medical Vision Services 6 6

7 BenefitHELP TPA Standard Medicaid State Plan Cost Share 1. Ambulatory Patient Services a) Primary Care X Yes b) Specialists X Yes c) Other Practitioner (Nurse, APRN, Physician Assistant) X Yes d) Hospice X No e) Adult Dental Services (Treatment Limit $1,125/Annual; Dentures, Preventive/Diagnostic, and Anesthesia do not count toward annual limit.) XYes f) Urgent Care X Yes g) Home Health Care (Limit 180 visits/Annual) X Yes h) FQHC/RHC Services XYes i) Family Planning Services and Supplies X No j) Routine Eye Exams (1 Exam/Annual) X Yes k) Hearing Aid XYes l) Dialysis X Yes m) Allergy Treatment X Yes n) Telehealth Services (type of service delivery) X No o) Indian Health Service (IHS) and Tribal Health Services XNo p) Outpatient Surgery Facility X Yes q) Audiology XYes r) Outpatient Hospital X Yes s) Adult Eye Glasses (Medicaid Contract - Limit One Pair/12 Months) XNo t) Accident Related Dental Surgery and Services X Yes u) Other Individualized Education Services (related to a medical condition other than diabetes) X Yes v) Non-Emergency Transportation Services XNo 7

8 Benefit Claims Processed by TPA Claims Processed by DPHHS Cost Share 2. Emergency Services a) ER Department ServicesX No b) Non-ER Department ServicesX Yes c) Air & Ground Ambulance XNo 3. Hospitalization a) Observation/AnesthesiaX Yes b) Inpatient Services (Includes: Transplant, Physicians, and Surgical)X Yes c) Cosmetic Surgery (Condition with Severe Detrimental Effect)X Yes d) Transplant and Donor Services (Excludes: donor searches and experimental treatments) X Yes e) Blood TransfusionsX Yes f) Reconstructive breast surgery following a medically necessary mastectomy- including any surgery to the non-affected breast to establish a symmetrical appearance, and prostheses. X Yes 4. Maternal and Newborn Care (Pre and Post) a) Prenatal and Postnatal CareX No b) Delivery and All Inpatient Services for MaternityX No c) Long Acting Reversible Contraceptives Inserted at Time of Delivery (LARC) X No 5. Mental Health and Substance Use Disorder Including Behavioral Health Treatment a) Mental/Behavioral Health Outpatient Services (not provided in an IMD) X Yes b) Mental/Behavioral Health Inpatient Services (not provided in an IMD)X Yes c) Substance Abuse Disorder Outpatient Services (not provided in an IMD)X Yes d) Substance Abuse Disorder Inpatient Services (not provided in an IMD) X Yes 6. Prescription Drugs (Identical Coverage as Existing Medicaid) a) Home Infusion XYes b) Tobacco Cessation XNo c) OTCs XYes d) Vaccines XNo e) Contraceptives XNo 8

9 Benefit Claims Processed by TPA Claims Processed by DPHHS Cost Share 7. Rehabilitative and Habilitative Services and Devices a) Rehabilitative Services: Coverage will be provided for rehabilitative care services when the individual needs help to keep, get back or improve skills and functioning for daily living that have been lost or impaired because the individual was sick, hurt or disabled. These services will include, but are not limited to: (1) physical therapy (2) occupational therapy; (3) speech-language pathology; and (4) behavioral health treatment. Applied behavior analysis for adults is excluded. These services may be provided in a variety of Inpatient and/or Outpatient settings as prescribed by a Physician. X Yes b) Habilitative Services: Coverage will be provided for habilitative care services when the individual requires help to keep, learn or improve skills and functioning for daily living or to prevent deterioration, if making reasonable progress, determined by DPHHS. These services include, but are not limited to: (1) physical therapy (2) occupational therapy; (3) speech-language pathology; and (4) behavioral health treatment. Applied behavior analysis for adults is excluded. These services may be provided in a variety of Inpatient and/or Outpatient settings as prescribed by a Physician. X Yes c) Prostheses (to replace a body part missing due to accident, illness, or injury). (Excludes: computer-assisted communication devices, or replacement of lost or stolen prosthesis) X Yes d) DME (Includes: blood glucose testing and supplies; spacers for metered dose inhalers; enteral solutions; syringes and needles. Excludes: exercise equipment, lifts, hot tubs, computerized equipment, athletic equipment, replacement of lost or stolen items, repair or rental equipment, or convenience items.) X Yes e) Skilled Nursing Services (Limit 60 Day/Annual; Excludes: Custodial Care) X Yes f) Cochlear Implants X Yes g) Transitional Services (Includes: Swing Beds and Short Term Rehabilitation) X Yes 9

10 Benefit Claims Processed by TPA Claims Processed by DPHHS Cost Share 8. Laboratory Services a) Diagnostic Test (X-Ray and Lab) X Yes b) Imaging (CT/PET Scans and MRI) X Yes 9. Preventive and Wellness Services and Chronic Disease Management a) Preventive Care, Screening, Immunizations X No b) Breast Pumps - Limit One Per Birth X No c) Preventive Health Services (Meets Federal Guidelines) X No d) Diabetes Prevention Program XYes e) Diabetes Self-Management Education X Yes 10. Pediatric Services Including Oral and Vision Services (EPSDT)Covered for medically necessary services for age No 11. Additional Medicaid State Plan Services a) Long Term Care Services (Nursing Facility, Community First Choice, Personal Care) XNo b) Mental Health Services (Therapeutic Foster Care & Group Home, PACT, Day Treatment) X Yes (some services) c) Podiatry XYes d) Targeted Case Management (High Risk Pregnant Women, Several Disabling Mental Illness, Developmental Disabilities, Substance Use Disorder) XNo e) Passport, Health Improvement Program, Team Care, Nurse Advice Line, Patient Centered Medical Home XNo 10

Copayment Requirements  For State Plan Medicaid Members:  Effective January 1, 2016  Inpatient Hospital Services = $75 (change from $100)  Outpatient Drugs = minimum of $1 up to maximum of $4, not to exceed $24 per month (change from $5 and $25)  Outpatient Services = minimum of $1 to maximum of $4 (change from $5)  Cost sharing may not be charged for services provided for the following purposes (ARM ):  (a) emergencies; (b) family planning; (c) hospice; (d) personal assistance services; (e) home dialysis attendant services; (f) home and community based waiver services; (g) nonemergency medical transportation services; (h) eyeglasses purchased by the Medicaid program under a volume purchasing arrangement; (i) early and periodic screening, diagnostic and treatment (EPSDT) services; (j) independent laboratory and x-ray services; (k) services for Medicare crossover claims where Medicaid is the secondary payor under ARM (18). If a service is not covered by Medicare but is covered by Medicaid, cost sharing will be applied; and (l) services for third party liability (TPL) claims where Medicaid is the secondary payor under ARM If a service is not covered by TPL but is covered by Medicaid, cost sharing will be applied * A provider notice will be sent to Medicaid providers on or before 1/1/

12 Premiums and copayments combined may not exceed 5 percent of family household income. Certain services, including the following, are exempt from copayment under federal or state law: Emergency services Preventive health care services including primary, secondary or tertiary preventive health care services Family planning services Pregnancy related services Generic drugs Immunizations Medically necessary health screenings ordered by a health care provider TPA HELP Plan Copayments and Premiums 12

Standard Medicaid Benefit Changes Current  Dental: No annual treatment limit  Eye Exams: 1/24 months  Eyeglasses: 1/24 months  Home Health Care: 75 visits  Hospice: Does not cover curative services for adults  Therapies: 40 hour/annual  Cardiac Therapy: 2-1 hour sessions/day and 36 sessions total limit  Folic Acid: Not covered OTC  Detox Services: Up to 7 days  Chemical Dependency (Inpatient and Outpatient): Children only  Mental Health Outpatient: 24 sessions/annual Changes Effective 1/1/2016  Dental: $1,125 annual treatment limit (Excludes: Dentures, Preventive/Diagnostic and Anesthesia)  Eye Exams: 1/12 months  Eyeglasses: 1/12 months  Home Health Care: 180 visits  Hospice: Will cover curative services for adults  Therapies: No annual limit  Cardiac Therapy: No daily or session limit  Folic Acid: Covered OTC  Detox Services: No daily limit  Chemical Dependency (Inpatient and Outpatient): Add Adults  Mental Health Outpatient: No session limit 13

HELP Plan Administrative Rules of Montana (ARMs)  Purpose  Definitions  Eligibility for Coverage  Benefits Plans  MAGI as the Measure of Income  Premiums  Copayments 14

Contact Information Rebecca Corbett HELP Plan Program Officer  HELPPlan.mt.gov  Benefits Information  Draft HELP Program Evidence of Coverage  HELP Plan Rules  Senate Bill 405  Community Based Programs  How to apply for the HELP Plan 15