1. What’s New:
Rules & Informational Letters
Presented: December 2017

2. Presentation By: Gayla Harken: gharken@iowaproviders.org
Lisa Schwanke:
Brita Nelson:
Amy Desenberg-Wines:
Presentation By:

3. The News
(duh)

4. The News AmeriHealth Caritas is out
Amerigroup isn’t taking new people until further notice
People who had requested to go to Amerigroup by November 16, 2017 are now being picked up by IME Fee for Services (FFS) until Amerigroup can increase capacity.
Be aware that some members who tried to select Amerigroup but were transferred to FFS may have erroneously received UHC cards. Check the
ELVS line to confirm MCO assignment
UnitedHealthCare now covers a vast majority of Iowa’s Medicaid population
The News

5. The News ID Daily services have moved to tiers
Daily SCL (H2016 HI) RBSCL for Children (H2016 U3) Daily Adult Day Care (S5102) Extended Day Adult Day Care (S5105); is being combined with S5102 Daily Day Habilitation (T2020) 
Tax Reform will have an impact on Medicaid budgets
CHIP funding
The News

6. Informational Letters
We’re picking the highlights. For a full list of informational letters, go here:
e/providers/rulesandpol icies/bulletins
Informational Letters

7. Informational Letters - Billing IME
IL 1850-MC-FFS
FFS_ServiceCodeChangestoHCBSHabilitationHom eBasedHabilitationService.pdf
Remember - Billing codes have changed for Habilitation too! The letter above explains that the changes will be made to the habilitation HBH services codes starting December 1.

8. Informational Letters - Tiered Rates
IL 1846-MC-FFS
MC-FFS_TieredRatesforHCBS_ID_Waiver.pdf
This spells out tiered rate structure for ID Daily Services

9. Informational Letters - Settings Assessments
IL 1842-MC-FFS
FFS%20HCBSResidentialSettingMemberAssessment.pdf
This IL discusses the process that Community Based Case Managers and IHH care coordinators are to use to assess the individual residential settings for compliance with the Iowa HCBS Settings standards.

10. Informational Letters - 1855
IL 1855-MC-FFS-D
MC-FFS- D_Provider_Enrollment_with_Managed_Care_O rganizations.pdf
Indicates full floor rate payment for providers pursuing MCO contracts through December 31, 2017

11. Informational Letters - Suspension of MCO Choice
IL 1862-MC-FFS-D
MC-FFS- D_SuspensionofMCO%20Choice%20%282%29_ JS%20%281%29.pdf
This letter contains info on checking ELVS for member eligibility.
If there is a conflict between ELVS and ISIS, go with ELVS. It is typically more current. If you believe ELVS information is incorrect, contact member services.

12. Informational Letters - Non-emergency Medical Transportation
IL 1861 NEMT Transition Update
MC_Non- emergencyMedicalTransportationIAHealthLinkTran sitionUpdate.pdf
This IL gives information about how to schedule NEMT after the withdrawal of AmeriHealth.
Rules and policy application for NEMT have NOT.

13. Informational Letters – Waste and Fraud Prevention
IL 1867-MC-FFS-D Annual Submission Requirements Regarding Prevention and Detection of Medicaid Fraud and Abuse
If your agency collects $5 Million or more in Medicaid funding, you HAVE TO do this.
FFS- D_AnnualSubmissionRequirementsRegardingPrev entionandDetectionofMedicaidFraudandAbuse.pd f

14. Proposed Rules
Section Subtitle

15. Rule Updates
Sign Up for Updates: If you have not signed up to receive DHS updates regarding new rule publications, you can do that here. Once you are registered, you can manage your subscription requests from there.

16. RCF Cost Report Changes
ARC 3259c This rule eliminates RCF cost reporting for privately operated RCFs next year

17. HCBS Eligibility Retention
ARC 3234c This rules allows HCBS members to retain eligibility after being hospitalized (inpatient) from 31 to 120 days. This change took place Changed chapter

18. ID Waiver Tiers
These rules allow for the implementation of the SIS tiers. They were filed emergency, but are now available for comment until December 26, 2017.
December 27 Bulletin will include dates for public hearing on these rules. Thank you for your advocacy!

19. Federal Rule notes
CHIP (Children’s Health Insurance Program) funding is not yet extended.
This is the program that provides access to medical treatment for kids who are not covered by insurance. In Iowa, it is called Hawk-i.
We understand Iowa’s current funding will reach through March and will be exhausted sometime in the quarter ending June 2018.
It is expected that some Federal action will be taken on this in January 2018.

20. Federal Rule notes
Tax Plan - There are many outstanding questions regarding the long-term impact of this plan. Given the addition to the deficit, it is understood that passage of this plan will result in attempts at reduction to entitlements and safety- net programs such as Medicaid, Medicare and Social Security.

21. Other Important Stuff

22. HCBS Self Assessment
They were Due December 1. Many HCBS providers are required to submit a self-assessment and not doing so can jeopardize your Medicaid eligibility.

23. Other Important Stuff
Q&A: The Q&A document regarding AHC's exit has some updates.
DHS Rule Changes: All proposed rule changes are linked here.
NEMT Info:

24. Good Cause
DHS "Good Cause" Page:
If the good cause process does not result in the current MCO changing, then they wil go to the other MCO, even if it is AG.

25. Transportation
From United regarding transportation: We still have the agreement with MTM, so if the providers are contracted with them, rides can be secured through our transportation vendor. That hasn’t changed. If they are not contracted with MTM, they can certainly bill United for authorized services, but they will be reimbursed at the state rate (with the out of network reduction of 80%) until they are either contracted through MTM or sign the transportation agreement with us directly. If a provider is actively pursuing a contract with United, we will honor the state rates at 100% for 30 days. If they are not actively working with us to get a contract, then the rate will pay at the out of network rate. Transportation Matrix from June 2016:

26. Billing IME For anyone who will be billing IME:
We know that some providers previously billed Magellan, and may not be familiar with the IME billing process. For those of you familiar with the fee-for-service process though IME, it is/will be the same as in March 2016.
DHS has recommend that providers read the provider manuals regarding billing. they are pretty user friendly and spell out which forms to use and how to submit billing. Then if they still have billing questions they can contact Provider Services.
Waiver has the ability bill ONLY using a month span. Habitation can do daily.

27. Billing IME Continued….
The HCBS and Hab provider manuals have not been updated for the new procedure codes for HBH or the ID Daily SCL Tiers so providers should reference the Informational Letters we sent out.

28. Billing IME Continued….
IL 1864 MC-FFS -
1864 Speaks to B3 Service billing

29. Billing IME Continued…. (Mental Health Cent)
United is not paying telehealth care coordination (T1016) because they do not recognize this as a CMS code.
INSTEAD: Agencies can bill Q3014 instead from the IME Fee Schedule, but the rate is $21.28 instead of $30
IME is working on correcting the modifiers and definitions between the enhanced and CMHC fee schedules.

30. Employment
Employment Matrix - SO. GOOD!
Employment FAQ Developed last year:

31. Employment: WIOA Fines
If you hold a sub-minimum wage certificate, it is YOUR RESPONSIBILITY to be sure the requirements around WIOA Section 511 are met. Iowa providers have begun to be fined for lack of compliance. Here are some resources to help you with understanding responsibilities for employing adults and youth in subminimum wage.

32. SIS Score Docs
Keep in mind, the tiered rate is NOT determined by total SIS score.
(See IL 1846-MC-FSS)
These documents may be helpful

33. Questions We Keep Hearing
Clear as mud

34. Q: When we bill in December for November, is it with the new codes or the old ones?
A: THE OLD ONES. You will bill all MCOs, including AmeriHealth Caritas as you would have previously.

35. Q: What do I do if we don’t have our tiered rates?
A: Your organization should have received a letter from IME indicating if your organization is going directly to published tiers or will be phased in from above or below those tiers. If you did not get this letter, contact Provider Services. If you do not have tier assignments for members, contact Inde Seerdorf

36. Q: What do I do if I don’t have the SIS assessments for people we serve?
A: Providers have been told they will receive copies of the scores per sub-section. This information has been received by some, but not all at this time. If you haven’t received copies, ask the member’s case manager for that information. If you do not get it from them, you can have the member contact member services and request a copy that will be provided to them.

37. Q: How do I know who a member’s case manager is?
A: Case managers are supposed to be reaching out to members on their caseload. UHC and IME have indicated that they will be getting this information to members. UHC has also stated that many AHC case managers have been hired by them and therefore, their case manager will be the same. If a person does not know their CM, they can contact member services at UHC or IME respectively.
We have been told they will also be reaching out to providers.

38. Q: Has NEMT changed due to the tiers?
A: No. We are aware that in some instances, rides have been difficult to schedule. IME is aware of this and attempting to correct this situation.

39. Q: 40 hours for Daily SCL - Where does that come from and how is it calculated?
WHAT SERVICES ARE INCLUDED IN DAY SERVICES?Day services include, but are not limited to, enhanced job search, supported employment, prevocational services, adult day care, day habilitation, and employment outside of Medicaid reimbursable services. Any funding source paying for the services listed above would be included as a day service. Any day service authorized in a CCO budget will also be considered a day service listed above to determine the SCL rate “with” and “without” day services.
Tier FAQ:
School counts

40. Q: Does school count toward the 40 hours?
A: Yes

41. Q: What are the transportation requirements for SCL daily providers?
From HCBS SIS Tier FAQ: Tiered rate reimbursement for daily SCL includes the cost of all transportation unless paid through the Non-Emergency Medical Transportation (NEMT) state plan benefit or the local school system for members accessing RBSCL services. Transportation can no longer be billed separately for members receiving daily SCL. Supported employment providers can still bill for transportation as it relates to employment. Day Hab providers will still need to provide transportation once a member has arrived at their program.

42. Q: Can we charge members for transportation if we provide SCL Daily services?
Yes. AND it depends on the situation, the assessments and the service plan. From the FAQ:
37. CAN A PROVIDER CHARGE A MEMBER FOR TRANSPORTATION COSTS ASSOCIATED WITH THE PROVISION OF DAILY SCL?
Only HCBS Waiver transportation that is identified in the member's service plan is required to be paid by the provider. Transportation provided outside of what is identified in the member's service plan is not required for payment by Medicaid. Arrangements for transportation between the member and provider may occur.

43. Q: Authorizations - Are they extended for 30 days or through December?
Through December 31. From the FAQ:
PLEASE CONFIRM THAT HCBS AUTHORIZATIONS ARE GOOD FOR 30 DAYS, WE ASSUME THIS MEANS UNTIL DECEMBER 31, 2017.
The member's new MCO will honor continuity of care for the month of December The member's new MCO will be responsible for authorizations or extensions of the authorization past that date. Each MCO will use their own policies and processes to authorize service plans in the future. FFS will follow the same process.

44. Authorizations continued…
Fee-for-Service plans and authorizations currently due are being authorized through March 31, If something had been authorized for beyond that, the later date will remain. We expect this process of IME extending through that date to continue until a time when people transition to Amerigroup.

45. Q: When will people who wanted to go to Amerigroup be transitioned?
A: This question was asked at the Health Oversight Committee meeting. There is currently no expected transition date.

46. Q: MCO Credentialing - Do all of our licensed therapists really have to credential with the MCOs individual?
No.
From Lori at UHC:
For CMHC’s. We had a meeting and all providers, regardless of if they are in a CMHC, who are prescribing, referring or ordering(this would be anyone above a Master’s level clinician) will have to enroll in IME. Any provider within the CMHC who is Master’s level or lower, we are temporarily turning off that edit so that claims will pay, until we come to an agreed upon solution. Regarding those claims that have denied from 9/26/2017 to 11/27/2017, we will be reconsidering only those that are the Master’s level or lower, that were denied.

47. Q: What is happening with B3 services under FFS/IME?
DHS received permission from CMS to proceed and offer B3 services through FFS. There is no prior authorization needed. Fee Schedule:

48. Q: What ARE the prior authorization requirements now?
Prior Authorization Grid: If you need to refresh your memory on which MCOs require what for prior authorizations, click here.
From IME:

49. Prior Authorization Continued
INFORMATIONAL LETTER NO.1665 describes the process for FFS Employment authorizations –

50. Q: Do IHHs have to use ISIS to enter people on Habilitation that are going to FFS?
A: Yes. IHH have been asked to do this ASAP. If you have question on how to do completed, contact LeAnn Moskowitz or Le Howland. DHS is working on a webinar assist IHH staff on this. Several updates to ISIS have delayed recording of this resource.

51. Q: IHH Roster
IHH should confirm the roster of their member in IMPA and notify Joyce Vance if members are not assigned and should be OR if there will need to be special claim handling for December. UHC CEO said during Health Committee Oversight Meeting that they are internally targeting end of January 31. When asked when providers will be notified, said that communications are being reviewed by the State and they expect to have them reviewed by the end of the year.

52. Q: What hours are associated with the ID tiers?
SCL:
No hour association - NOT like HCBS Habilitation
Time without staff is based on individually-assessed need and IDT decision.
Day Hab:
Nothing has changed related to the hours associated with the full day of service

53. Q: Does remote monitoring “count” toward total hours in the new tiers?
A: Yes. This needs to be directed by the person-centered planning process.

54. Q: If our service plans or authorizations don’t have the updated codes, what do we do?
United IHH info: We would not request the IHH’s to update their plans to include the new modifiers. We should be able to “crosswalk” those plans internally. As long as the levels of care are unchanged, there is nothing more required at this time. UnitedHealthcare doesn’t require NOD’s, nor do we require an authorization for HAB services. This should be a good thing and one less activity for providers to perform. The processes that the IHH’s have previously been following for United should continue, the only difference may be associated with the providers who are billing for the coordination of care. The level of care is in the case plan, regardless of who the MCO is.
IME:
Amerigroup: Bill the correct codes for services after December 1.

55. Upcoming Trainings
SIS Assessment by AAIDD – Tentatively February 8, 2018
TA Regional –
April 9 – Storm Lake
April 10 - Independence
April 11 – Iowa City
April 12 - Johnston

56. Questions and Our Contact Info