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Medicaid Coverage for the Diabetes Prevention Program: The Process to Make and Implement the Policy Change
Sarah Brokaw, MPH
Montana Diabetes Program
Montana Incentives to Prevent Chronic Disease
Grantee Conference Call
March 4, 2015
MIPCD March Program Activity Webinar
Sustainability Part I: Medicaid Options
Meeting Agenda
March 2, 2015; 3:00-4:30 p.m. (EST)
Please note this call has been extended to 90 minutes
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Welcome
1115 Waiver, and State Plan Amendment Overview- Econometrica TA team
State Sharing: Medicaid Options (topics include 1115 Waivers, State Plan Amendments and Community Health Worker Reimbursements)
NH, CT, MT, MN
Question and Answers
Open Forum
Next Call
April 6, 2015; 3:00-4:00 p.m. (EST)
Adjournment
Sustainability Part I: Medicaid Option
Purpose/Focus: Sustainability Part I: Medicaid Options
Objectives:
At the end of this event, participants will:
Understand the 1115 Waiver Process including State Amendments
Have tools to explore Medicaid options for program sustainability beyond grant support
Event Manager: Kai Baker Stringfield
Part 1: Opening and Framing
Operator welcome and logistics (housekeeping items) - Trevor Johnson
Kai frames the event, additional logistics - Kai Baker Stringfield
Part 2: Overview: 1115 Waiver and State Amendments
Introduction to 1115 Waivers and State Amendments - Nancy Weller, Econometrica TA team
Q&A, Facilitated by Nancy - Nancy Weller, Econometrica TA team
Part 3: Medicaid Options- State Sharing
Connecticut, State Plan Amendment - Carolann Kapur, Medical ASO Liaison, Connecticut Department of Social Services
Q&A - Carolann Kapur, Medical ASO Liaison, Connecticut Department of Social Services
Montana, State Plan Amendment - Sarah, Brokaw, Program Manager, MT MIPCD
Q&A - Sarah, Brokaw, Program Manager, MT MIPCD
Minnesota, Community Health Worker Reimbursements - Ellie Garrett, health services policy analyst for the MN Department of Human Services (DHS) and the DHS project manager for the WCPD project. 
Q&A - Ellie Garrett, health services policy analyst for the MN Department of Human Services (DHS) and the DHS project manager for the WCPD project.
New Hampshire, 1115 Waiver Process - Kelley Capuchino, Medicaid Policy Analyst, NHDHHS Bureau of Behavioral Health
Q&A - Kelley Capuchino, Medicaid Policy Analyst, NHDHHS Bureau of Behavioral Health
Part 4: Closing
 Closing and post-webinar survey - Kai Baker Stringfield

2. Background
Meeting with Montana Medicaid and Diabetes Program staff in 2010 (Administrators, Bureau Chiefs, program staff)
Made case for Medicaid coverage for the DPP
Showed evidence for health outcomes improvement using our own data and from the DPP literature (Tuomilehto et al. 2001, Knowler et al. 2002, Knowler et al. 2009)
Demonstrated cost neutrality/cost savings based upon our own funding levels and from the cost-effectiveness literature (Herman et al. 2005, Herman 2011)
CMS Medicaid Incentive to Prevent Chronic Disease Grant
MT Medicaid and Diabetes Program applied together in May 2011
Received the grant in September 2011
Formalized partnership and our timeline and workplan to obtain Medicaid coverage from September 2011 to April 2012
Continued to work together closely on implementing this coverage
Added ongoing support such as national recommendations from CDC

3. Montana Medicaid Policy Change
Administrative Rules of Montana rule change
Rule amended: Services Provided by General Medicaid Services
Rule added: Preventive Services by Medicaid Primary Care Services
Source:
State Plan Amendment to Preventive Services Section
Draft began in 11/2011 and approved 4/13/2012
Effective 2/2/2012
Source:
Reimbursement set according to fee schedule rates
$21.88 weekly (Total for completion of all 16 weekly sessions = $350)
$25.00 monthly (Total for completion of all 6 monthly sessions = $150)
Total reimbursement of $500 per Medicaid member for 22-session DPP
Source:
Completing the logistics to get Medicaid coverage and reimbursement
For program sustainability beyond grant support
Via rule change and State Plan Amendment
Rule change language written and approved.
State Plan Amendment language written, reviewed by MT Medicaid, Regional Medicaid, and CMS staff. Received questions from CMS to respond to.
Public hearing on March 28, 2012.
Set reimbursement fee schedule with Medicaid and Xerox, the third party payor.

4. Examples of Provider Notices
Used the information to promote referrals by providers, proper billing by billing staff, and awareness among lifestyle coaches.
*Note that these provider notices are currently being updated with information from the next slide

5. DPP – Claims Submission
Public Health
Hospital
Use the contracted NPI
Bill as 837P or CMS-1500
Must bill separate lines for each date of service
S9455: will pay $25.00 after co-pay
S9460: will pay $21.88 after co-pay
Use the contracted NPI
Bill as 837I or UB-04
Must bill separate lines for each date of service
S9455: will pay $25.00 after co-pay
S9460: will pay $21.88 after co-pay

6. System Errors Being Corrected
Medicare Crossover Claims
Xerox will update the claims system to include Revenue code 500 which will allow claims for members receiving Medicare and Medicaid to pay correctly and a Medicare denial will not be required.
Critical Access Hospital (CAH)
Xerox will update the claims system to allow CAHs to be paid at the same rate as all other facilities for S9455 and S9460.
NPI
Medicaid is working with Public Health and Xerox to update any inactive NPIs that were contracted to allow claims to pay correctly.

7. *Providers have 365 days from date of service to submit claims
The Good News
Providers are currently being paid for their DPP services for DPP claims that are:
submitted with an active NPI contracted with Public Health
for Medicaid members only (not Medicare crossover)
for all facilities excluding CAHs
*Providers have 365 days from date of service to submit claims