1. Opportunities Presented by
CMS Guidance Re: Federal Funding for Services “Received Through” an IHS/Tribal Facility
Bruce Goldberg, MD
&
Laura Platero
April 19, 2017

2. Prior to February 26, 2016 Guidance
States could claim 100% federal funding for services provided at an IHS/Tribal facility and furnished to Medicaid eligible AI/AN’s
States reimbursed for services provided to Medicaid eligible AI/AN’s outside of an IHS/Tribal facility at a state’s regular FMAP rate (~70/30 – 50/50 depending on state)
Still have to provide Medicaid covered benefits

3. New Guidance – Feb. 26 Letter
CMS has reinterpreted the scope of services considered to be “received through” an IHS/Tribal facility for purposes of eligibility for 100% FMAP
Now includes any services that the IHS/Tribal facility is authorized to provide according to IHS rules and that are also covered under the approved Medicaid state plan – also includes any services established in the future as a state plan benefit
This includes long-term services and supports (LTSS) and Emergency and Non-Emergency Medical Transportation (EMT and NEMT).
This produces overall savings to the state.
Still have to provide Medicaid covered benefits

4. New Guidance – Feb. 26 Letter
Allows 100% federal funding for services “received through” an IHS/Tribal facility and furnished to Medicaid eligible AI/AN's
100% federal funding now available for care provided to AI/ANs in private sector
Opportunity for a state to claim 100% federal funds in circumstances where they had been paying 30-50% of the bill, thereby creating the possibility of substantial state fund savings.
Still have to provide Medicaid covered benefits

5. To be Eligible for 100% FMAP Services:
An IHS/Tribal facility must request the service
There must be a care coordination agreement between the IHS/Tribal facility and the provider
There is a relationship between the patient and the IHS/Tribal provider
Still have to provide Medicaid covered benefits

6. Care Coordination Means
The IHS/Tribal provider requests the service and sends the information to the provider receiving the referral
The provider receiving the referral sends information back to the IHS/Tribal provider
The IHS/Tribal provider continues to assume responsibility for the patient
The IHS/Tribal provider puts the referral information in the patients medical record
Still have to provide Medicaid covered benefits

7. OPPORTUNITY
For a state to consult with Tribes and work together with them to improve the health of Tribal members by assuring that savings available through this program are reinvested in Tribal communities.
For example, create a Tribal Health Improvement Fund:
To improve access to care
Provide mental health services
Other health related issue
Still have to provide Medicaid covered benefits

8. For Private Sector Providers
No change in how they bill for and are paid for Medicaid clients.
Potential funding to work with IHS/Tribal programs, and possibly urban programs, on projects of mutual interest
Still have to provide Medicaid covered benefits

9. Some of What Is Needed
Agreement with state to share funds made available through this program!!
Care coordination agreements with providers
Mechanisms to track/coordinate care and administer the referrals
Mechanisms to: track funding, invoice and receive funds
Audit and compliance for Tribal organizations
Compliance documentation for State claiming:
Service delivered to eligible AI/AN who is patient of an IHS/Tribal provider per written referral request
Service is within scope of care coordination agreement
Rate of payment is authorized under State Plan
There is no duplicate billing
Still have to provide Medicaid covered benefits

10. Oregon Experience To Date
9 Tribes and urban program working collaboratively with the state to implement this program
First claims have been submitted
State working with CMS to gain clarity on implementation
Still have to provide Medicaid covered benefits

11. Governor Brown’s Commitment
“I am committed to investing the savings from this change to Medicaid policy into Tribal programs and services that improve the health of American Indian and Alaska Native communities.”
Governor Kate Brown (September 7, 2016)
Still have to provide Medicaid covered benefits

12. Progress
Starting with hospital claims – as these are relatively low volume but high cost
Expand to other providers
Care Coordination agreements in place with 9 hospitals
Procedure in place with Medicaid agency for claiming
First claims submitted
Currently a manual process – need to automate
Working with CMS to clarify their policies
Initially CMS staff have taken a very literal and burdensome approach to claiming
Still have to provide Medicaid covered benefits

13. Submitting Claims, Billing and Tracking: Tribal and Non-Tribal Providers
Non-IHS/Tribal provider bills for the services for the Medicaid member referred by the IHS/Tribal facility and sends a copy of the billing to the IHS/Tribal provider.
IHS/Tribal provider completes the “Care Coordination Episode Tracking Template” and submits to OHA.
OHA acknowledges receipt of Care Coordination Episode Tracking Template from IHS/Tribal provider.
OHA processes claim manually, completes claim adjustment to a 100% FMAP claim (This will be automated-no completion date yet)
Pending discussion and agreements between State and Tribes regarding specifics regarding methodology, return the savings to IHS/Tribal providers
Everything will be billed as it normally would have been
OHA will pull the claims billed by the non-tribal provider, and if coordinated through your health clinic, will adjust to 100% FMAP
Currently, OHA is pulling this data manually, but an automated MMIS process is currently in process
On a monthly basis, OHA will send your clinic a spreadsheet showing the savings created through these care coordination activities

14. Covered facility is your clinic’s name
If you do not know the tax ID number of the CC Provider; that’s okay, either insert their NPI or leave it blank
You can also work with us to identify their tax ID
The Tax ID will allow us to capture many different services that may occur throughout their organization for the AI/AN member based on your referral
Indicate Y that you do have a CC agreement with the CC Provider and it is still active; if no, you really shouldn’t be submitting
And finally, type of CC agreement: This will mostly be “provider”. We are waiting on clarification from CMS on whether or not tribes can establish CC agreements with CCOs to claim 100% FMAP

16. A Word about Documentation
The documentation must be sufficient to establish that:
The item or service was furnished to an AI/AN patient of an IHS/Tribal facility practitioner pursuant to a request for services from the practitioner;
The requested service was within the scope of a written care coordination agreement under which the IHS/Tribal facility practitioner maintains responsibility for the patient’s care;
The rate of payment is authorized under the state plan and is consistent with federal requirements; and
There is no duplicate billing by both the facility and the provider for the same service to the same beneficiary.
Be sure to document that your facility requested services for the AI/AN member
Date of visit that caused referral
Date of referral
Condition that caused referral

17. Is 100% FMAP Available for Services to AI/AN Medicaid Managed Care Members?
Yes, if:
The service is furnished to an AI/AN Medicaid beneficiary enrolled in the managed care plan;
The service meets the same requirements to be considered “received through” an IHS/Tribal facility as would apply in the fee-for-service system;
The managed care plan maintains auditable documentation that those requirements are met;
The non-IHS/Tribal provider is a network provider of the enrollee’s managed care plan; and
The non-IHS/Tribal provider is paid by the managed care plan consistent with the network provider’s contractual agreement with the managed care plan.
On the template on the previous slide, submit ALL care coordination episodes (CCO and FFS). Our system will determine the member’s enrollment status; CCO 100% savings model is currently being developed, but continue to submit the episodes

18. Submitting Claims, Billing and Tracking: OHA
Interim process:
OHA inserts patient/provider/date information in the MMIS.
OHA pulls reports on a defined timeline.
OHA completes prior period adjustments on claims that change claiming to 100% FMAP.
MMIS automatically reviews and uses claims data.
MMIS automatically claims 100% federal match.
OHA calculates savings.
OHA distributes savings to IHS/Tribal providers in a manner to be determined.
So to recap, here is how the data will flow after you refer the member to the outside provider:
You submit the care coordination episodes to us using the template
We will plug the episode into the MMIS (not as a claim) in the Recipient Special Program Tracking panel
This will establish the relationship between your clinic, the referral provider, the member, and the dates of care coordination that you specified in the template
The non-tribal provider will bill the claim as usual, and it will hit the MMIS as usual (typically within 120 days of the DOS per rule)
On a monthly basis, OHA will query the MMIS (possibly more frequently when the system is automated) to find the non-tribal provider’s claims with the AI/AN member
These claims will be adjusted to 100% federal funding thereby saving the state and tribes money
OHA will follow-up with Tribes individually, on a monthly basis, with a spreadsheet showing the savings generated by your care coordination activities

20. 100% FMAP Going Forward
OHA is currently in the process of identifying IT systems changes and will move to implement processes that will simplify and streamline the 100% FMAP process as quickly as possible.
Tribes are discussing how to disburse the savings.
Ongoing work with CMS.
Note: We’d like to acknowledge Janna Starr at OHA who gave us permission to use some of her slides.

21. Questions?
For more information: Bruce Goldberg