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  • MEDICAID created by Title 19 of the Social Security Act (SSA) in 1965 to provide medical assistance for certain individuals and families with low income and resources . MEDCAID is the largest program providing medical and health-related services to Alabama's poorest people MEDICARE created by Title 18 of the Social Security Act in 1965 to provide for seniors 65+ MEDICARE provides hospital insurance also known as Part A coverage, and supplementary medical insurance (SMI), also known as Part B coverage MEDICARE beneficiaries (65+) and who have low income and limited resources may receive help paying for their out-of-pocket medical expenses from Medicaid “ Dual eligibles ” are entitled to Medicare and are eligible for some type of Medicaid benefit
  • Thank you for the opportunity to provide basic information regarding Medicare’s new prescription drug plans called Medicare Part D. I hope this information will be helpful to you in understanding Medicare Part D. MMA (Medicare Modernization Act) will provide Medicare beneficiaries with prescription drug coverage regardless of income, resources, medical condition, or prescription drug costs. The effective start date is January 1, 2006. The goal is to lower prescription drug costs and help protect against higher costs in the future. Medicare is a federal health insurance program for: people 65 years of age or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure with dialysis or a transplant, sometimes called ESRD). (There are appox.172,000 individuals in Alabama who have Medicare and Medicaid. However, there are approx. 88,000 who have Medicare and full Medicaid.) Prior to December 31,2005, full dual eligibles received prescription drug coverage through Medicaid.
  • Medicare Part A is coverage for hospital visits. Medicare Part B is coverage for doctor visits. Medicare Advantage plans (Part C) is a type of HMO, PPO, or FFS. Names of Medicare Advantage plans (Part C) include: Medicare Advantage, VIVA, Senior 1 st , HealthSprings, United Health Care, Medicare Health Plan. Part C was formerly known as Medicare Plus Choice. Humana and BCBS will begin offering drug plans beginning 1-1-06. Medicare Advantage plan is a plan in which you see physicians, hospitals, and providers that belong to a network. You can see physicians, hospitals, and providers outside of the network for an additional cost. Medicare Part D is an insurance provided by private companies that have been approved by Medicare. This drug coverage may help lower prescription drug costs and help protect against higher costs in the future. Drug plans will have a list of covered drugs called a formulary. This list must meet certain requirements but may change from time to time. If the list changes because of cost or , drug changes your plan must let you know 60 days in advance. Your decision about Medicare prescription drug coverage depends on the kind of health care coverage you have now. Like other insurance, if you join, you will pay a monthly premium, which varies by plan, and a yearly deductible. You will also pay a part of the cost of your prescriptions, including a co-payment or coinsurance. Costs will vary depending on which drug plan you choose. Some plans may offer more coverage and additional drugs for a higher monthly premium.
  • Everyone with Medicare is eligible for Medicare Part D drug coverage, regardless of income and resources, health status, or current prescription expenses. Some plans will operate nationwide, others in a certain region of the country. Medicare drug plans will vary in what prescription drugs they cover, and how much you have to pay, and which pharmacies you can use. Medicare Part D is not free. Like other insurances, there will be a monthly premium. Rules: Enrollment is voluntary for most. But individuals with Medicare and full Medicaid have been auto-enrolled if you didn’t sign up by the end of Dec. so you won’t miss a day of coverage. In order to join Part D, you must have Medicare (Part A and/or B). You must join a Medicare drug plan to get coverage. You must enroll in a plan that serves your area. If you don’t enroll in a drug plan by May 15, 2006, you may have to pay a penalty if you decide to join a drug plan later. Even if you don’t use a lost of prescription drugs now, you should consider joining. As we age, most people need drugs to stay healthy. For most people, joining now means protecting you from unexpected drug bills in the future. Costs will vary depending on which drug plan you choose. The enrollment period is from November 15, 2005 through May 15, 2006. If you joined by December 31, your coverage began January 1 st . If you join after that , your coverage is effective the first day of the month after the month you join. If you don’t sign up when you are first eligible or by May 15 th , you may pay a penalty. If you don’t sign up by May 15 th , your next opportunity to enroll is from November 15 through December 31 st . By the way, Medicare Prescription Discount cards will no longer be available beginning May 15, 2006. There is still time left to investigate which plan is best for you, so please don’t rush into signing up for a plan without doing your homework first.
  • Medicare contracted with 42 private insurance plans in Alabama. If you have limited income and resources, and you qualify for extra help, you may not have to pay a premium or deductible. Extra Help is available through the Soc Security Administration. Income and asset restrictions apply. How can I receive extra help? Extra help is based on the amount of income and resources. What counts as Income? Social Security, wages, dividends, rental property, worker’s compensation and education grants. What counts as assets? Bank accounts and the value of investments, life insurance policies, and extra real estate. This does NOT include your home, vehicle, burial plots or personal possessions, or $1,500 in savings intended for burial expenses. Single people on Medicare with income below $14,700 and resources up to $11,500 may qualify for extra help. Married people on Medicare with income below $19,800 and resources up to $23,000 may qualify for extra help. There is no charge to apply. “If in doubt, fill it out”. Almost 1 in 3 people with Medicare will qualify for extra help and Medicare will pay for almost all of their prescription drug costs. If you qualify for extra help, you will get help paying for your drug plan’s monthly premium, and/or for some of the cost you would normally pay for your prescriptions. Again, the amount of extra help you get will be based on your income and resources. You may apply for extra help through the Social Security Administration.
  • The Initial Enrollment Period is November 15, 2005 through May 15, 2006. If you have Medicare and Medicaid – you are in a plan now whether you enrolled or not. If you did not enroll by Dec 31, 05, Medicare randomly assigned you to a plan and you should have received notification in the mail. You may switch to another plan anytime. If you fall in one of the other 4 groups (No drug coverage, Employer/union coverage, Medicare Advantage Plan, or Medigap), you have until May 15 th to enroll. There will be a 1% penalty for each month added to your monthly fee if: 1. If you have been notified that your current drug coverage is not at least as good as Medicare’s plan and you haven’t enrolled – or – If you enroll after May 15 th , Example: monthly fee costs $37 per month, your penalty will be 37 cents multiplied by the number of months delayed – plus your monthly fee. So if your one month late enrolling, you would pay $37.37 per month as long as you have Medicare Part D. If you have creditable coverage, you do not need to apply. However, please keep your letter of creditable coverage in case you need to apply later so that you won’t have to pay a late-enrollment penalty in addition to your monthly premium. Your current Medicare card will not change. When you join a plan, you will receive a Drug Plan Card that you will use to obtain your prescriptions. Until you receive your new drug card, you will receive a yellow letter telling you the drug plan you are in, that you will use until you receive your new Drug Plan Card. You can find out which plan you have been assigned to using any of the four resources listed below. The information you will need to find out your plan is located on your current Medicare card which is red, white and blue. A yellow letter you received from Medicare identifying the plan. Visit Call 1-800-Medicare (1-800-633-4227) Go to your pharmacy.
  • Your doctor may be able to switch you to a medicine that is covered by the plan Dual eligibles can change monthly. Others can change plans during open enrollment every year November 15 through December 31 of every year.
  • For Reference: (SHIP phone number for Alabama is the Age-line Number.)
  • I
  • We will also roll out a new interactive web portal. Within the portal, you can submit claims, verify eligibility, check remittance advises, request and view Prior Authorizations and check claim status. I have some screen shots of the web portal I will be showing you now.
  • Dental

    1. 1. Alabama Medicaid Update Tina G Pippin Dental Program Director Alabama Dental Association Annual Session June 16, 2006
    2. 2. Medicaid Overview
    3. 3. Medicaid “Rules” <ul><li>Medicaid was established in 1965 by federal law to provide medical assistance to low income and resource individuals. </li></ul><ul><li>States may choose to have a Medicaid program, but must comply with all federal Medicaid requirements once a program has been implemented. </li></ul><ul><li>Funded through a federal and state partnership (generally 70/30 in Alabama) </li></ul>
    4. 4. “ Rules” continued <ul><li>Federal law sets minimum eligibility and benefit levels. </li></ul><ul><li>With few exceptions, Alabama’s program is at the federal minimum level for eligibility. </li></ul><ul><li>Alabama has one of the most conservative benefit packages in the country. </li></ul><ul><li>Medicaid cannot make any more program cuts and still be in compliance with federal regulations. </li></ul>
    5. 5. Don’t be confused… <ul><li>Medicaid is a federal and state program and provides medical assistance to low income and resource individuals. </li></ul><ul><li>Medicare is a federal program to provide medical insurance generally to individuals aged 65 and older. </li></ul>
    6. 6. Who Determines Eligibility <ul><li>Three Alabama agencies certify individuals for Medicaid. </li></ul><ul><li>Agencies certify certain groups of individuals for Medicaid based on their circumstances. </li></ul><ul><li>These agencies are: </li></ul><ul><ul><ul><li>The Social Security Administration </li></ul></ul></ul><ul><ul><ul><li>The Department of Human Resources </li></ul></ul></ul><ul><ul><ul><li>The Alabama Medicaid Agency </li></ul></ul></ul>
    7. 7. The Face of Medicaid
    8. 8. Demographics FY 2005 <ul><li>Medicaid covers: </li></ul><ul><li>20.7% of Alabama’s total population (includes all eligibility categories) </li></ul><ul><li>46% of all deliveries in Alabama </li></ul><ul><li>37.9% of Alabama’s children (under 19) </li></ul><ul><li>19.7% of Alabama’s elderly (65 and above) </li></ul><ul><li>74% of nursing home days in Alabama </li></ul>
    9. 9. Total Medicaid Eligibles As a Percentage of Alabama’s Population Note: Includes individuals eligible for Plan First FY
    10. 10. Medicaid Children Under age 19 as a Percent of Alabama’s Child Population FY
    11. 11. Children in Working Families As of September 2005 Source: Obtained for MLIF and SOBRA populations based on information from Medicaid applications as filed.
    12. 12. What are the sources of health insurance coverage in Alabama? 3.7% 31.4% 53.7% 11.2% AL Rate UNK Individual Coverage 25.3% Public Program 62.6% Employer Sponsored Coverage 14.6% Uninsured US Rate (CPS 2001) Coverage
    13. 13. AL Uninsurance Rates by Age All rates reflect point in time data.
    14. 14. Eligible and Payment Distribution By Age FY 2005
    15. 15. Medicaid Eligibles by Aid Category FY 2005
    16. 16. Eligibles Percent Distribution by Race FY 2005
    17. 17. Cost Per Eligible FY 2005 By Category By Gender By Age
    18. 18. Economic Impact Hospital Care Primary Care Maternity Care Pharmacy MEDICAID
    19. 19. High Medicaid Counties FY 2005 These 12 counties have the highest concentration of Medicaid eligibles across the general population (30% or greater). Bullock 35% Lowndes 33% Butler 33% Macon 31% Conecuh 31% Marengo 30% Dallas 41% Perry 43% Greene 40% Sumter 39% Hale 32% Wilcox 46%
    20. 20. These 11 counties have the highest concentration of Medicaid eligibles across the children’s population (50% or greater). Bullock 66% Lowndes 55% Butler 56% Macon 50% Conecuh 56% Perry 63 % Dallas 65% Sumter 65% Greene 66% Wilcox 71% Hale 50% High Medicaid Counties FY 2005
    21. 21. <ul><li>In FY 2004, Medicaid paid approximately $3.7 billion to providers for various health care services rendered; $2.7 billion represents federal funds brought into the State. </li></ul><ul><li>In FY 2005, Medicaid paid approximately $3.9 billion to providers for various health care services rendered; $2.8 billion represents federal funds brought into the State. </li></ul>Economic Impact
    22. 22. Medicaid expenditures supported more than 84,323 jobs in various industries within the state. 1 1 Economic Impact of the Alabama Medicaid Agency on the Economy of the State of Alabama and its Counties, Amy K. Yarbrough, MSHA, MBA, Administrative Fellow, University of Alabama at Birmingham Economic Impact (continued)
    23. 23. <ul><li>Medicaid payments </li></ul><ul><li>5 counties receive in excess of $100 million </li></ul><ul><li>Jefferson $520 million </li></ul><ul><li>Mobile $252 million </li></ul><ul><li>Tuscaloosa $144 million </li></ul><ul><li>Madison $127 million </li></ul><ul><li>Montgomery $315 million </li></ul><ul><li>8 counties receive payments in excess of $60 million. </li></ul><ul><li>16 counties receive payments in excess of $40 million. </li></ul><ul><li>31 counties receive payments in excess of $20 million. </li></ul>Financial Impact by County FY 2005
    24. 24. <ul><li>Without Medicaid revenue, critical components of Alabama’s healthcare infrastructure could not continue to exist. </li></ul><ul><ul><li>52% of the patient days at The Children’s Hospital of Alabama are paid for by Medicaid. </li></ul></ul><ul><ul><li>77% of the patient days at USA Children’s and Women’s Hospital are paid for by Medicaid. </li></ul></ul><ul><li>Source: Information obtained from Medicare Cost Reports as filed. </li></ul>Financial Impact by Hospital
    25. 25. Program Funding
    26. 26. Federal Funds 70.83% Benefit Payments 98.0% Administrative Costs 2.0% State Funds 29.17 % Where It Comes From, Where It Goes FY 2005
    27. 27. Distribution of Payments Excluding Hospital Disproportionate Share Payments FY 2005
    28. 28. Dental Care Expenditures FY 1998-2005 Millions FY
    29. 29. Medical Care Expenditures FY 1994-2005 Billions Excludes DSH payments, enhancements, and pharmacy rebates FY
    30. 30. <ul><li>Medicare Modernization Act, 2003 </li></ul><ul><li>Health Insurance Portability and Accountability Act </li></ul><ul><ul><li>(Currently implementing NPI) </li></ul></ul><ul><li>Pryor Amendment, 1990 (Mandated open drug formulary) </li></ul><ul><li>OBRA 1989 (Mandated the EPSDT program) </li></ul><ul><li>CCA 1988 (Mandated coverage of QMB) </li></ul>History of Unfunded Mandates
    31. 31. General Fund Contributions Medicaid as a Percent of the GF FY
    32. 32. Medical Services Update
    33. 33. Town Hall Presentation to Provider Support Personnel
    34. 34. Goal <ul><li>Improve health care outcomes for Medicaid recipients through creation of a medical home while containing the escalating cost of quality health care. </li></ul>
    35. 35. Basic Program Concepts <ul><li>Providers enroll as a Primary Medical Provider (PMP) </li></ul><ul><li>Patients are assigned to a PMP </li></ul><ul><li>Services must be provided directly or through referral ( NO REFERRAL needed for Dental Services) </li></ul><ul><li>PMPs are paid a monthly case management fee based on signed contract </li></ul>
    36. 36. Who Can Be A PMP? <ul><li>Pediatricians </li></ul><ul><li>Internists </li></ul><ul><li>Family Practitioners </li></ul><ul><li>General Practitioners </li></ul><ul><li>OB/GYNs </li></ul><ul><li>FQHC </li></ul><ul><li>RHC </li></ul><ul><li>Specialists (ex: special needs child) </li></ul>
    37. 37. Who Is IN Patient 1st? <ul><li>SOBRA Children </li></ul><ul><li>MLIF Eligibles </li></ul><ul><li>Infants Of SSI Mothers </li></ul><ul><li>Aged </li></ul><ul><li>Blind </li></ul><ul><li>Disabled </li></ul>
    38. 38. Who is NOT In? <ul><li>Foster Children </li></ul><ul><li>SOBRA Adults </li></ul><ul><li>Dual Eligibles </li></ul><ul><li>Institutionalized (nursing homes, group homes, MR facilities, DYS) Lock-Ins </li></ul><ul><li>Enrollees of Private HMO </li></ul><ul><li>Medically Exempt </li></ul>
    39. 39. Real World Numbers <ul><li>1,018 PMPs Enrolled </li></ul><ul><ul><li>944 Physicians </li></ul></ul><ul><ul><li>74 Clinic Based </li></ul></ul><ul><li>448,708 Total Enrollees </li></ul><ul><ul><li>84,247 Over 21 </li></ul></ul><ul><ul><li>364,461 Under 21 </li></ul></ul><ul><ul><li>* As of 4/20/06 </li></ul></ul>
    40. 40. Program Redesign . . . <ul><li>This time around … </li></ul><ul><li>A cost effective model </li></ul><ul><ul><li>More program accountability </li></ul></ul><ul><ul><li>Have ability to demonstrate success </li></ul></ul><ul><li>More focus on affecting behavior </li></ul><ul><ul><li>Effective patient management tools through program enhancements </li></ul></ul><ul><ul><li>Patient information </li></ul></ul>
    41. 41. Moving Into the 21st Century Tools to Help the PMP Manage the Patient In-Home Monitoring InfoSolutions ePrescribing
    42. 42. In-Home Monitoring aka Disease Management <ul><li>Partnership with USA Hospital and the Alabama Department of Public Health (ADPH) </li></ul><ul><li>Telemetry concept </li></ul><ul><li>Targets chronic diseases through claims utilization </li></ul><ul><li>Diabetics initial phase </li></ul><ul><li>Can monitor blood sugars, weight and blood pressure </li></ul><ul><li>Coordination with Primary Physician </li></ul><ul><li>Supported with case management </li></ul><ul><li>Web based with real-time reporting available </li></ul>
    43. 43. InfoSolutions <ul><li>Purpose is to inform providers of prescription activity based on Medicaid paid claims data. </li></ul><ul><ul><li>Desktop or PDA tool for physicians </li></ul></ul><ul><ul><li>Download patient prescription information </li></ul></ul>
    44. 44. e-Prescribing Component of InfoSolutions <ul><li>Download prescription history </li></ul><ul><li>Automatically alerted to potential drug-to-drug interactions </li></ul><ul><li>Prescribe/refill multiple medications </li></ul><ul><li>Print prescriptions up to 30 feet away using Bluetooth technology </li></ul><ul><li>Establish “favorites” list of frequently prescribed medications </li></ul><ul><li>View both Blue Cross/Medicaid formulary </li></ul>
    45. 45. Plan f i rst <ul><li>Different from “regular” family planning </li></ul><ul><li>Have to use enrolled providers </li></ul><ul><li>Providers dispense birth control pills and the “patch” </li></ul><ul><li>Nuva Ring is not covered </li></ul><ul><li>Women will have to recertify each year </li></ul>
    46. 46. Successful … very <ul><li>95,448 women enrolled (3/06) </li></ul><ul><li>Teen enrollment grew by 21% during 1st five years </li></ul><ul><li>9,014 births averted in DY 4 (10/03-9/04) </li></ul><ul><li>Approximately 25% of women utilize private providers (in addition or instead of public) </li></ul><ul><li>Enrollees were 42% more likely to use contraceptives and 33% more likely to use effectively </li></ul>
    47. 47. Pharmacy Update
    48. 48. Prescription Utilization FY 2005
    49. 49. Pharmacy Expenditures Percent Change from Previous Year Net of Rebates
    50. 50. <ul><li>The Preferred Drug List (PDL), monthly brand limit, and system edits continue to be important management tools. </li></ul><ul><li>These programs are estimated to save 20% of the pharmacy program expenditures in FY 2007. </li></ul>Program Update Projected FY 2007 expenditures with program initiatives - $443.6; without initiatives - $554.5; before rebates. Medicaid Fiscal Division
    51. 51. Monthly Brand Limit <ul><li>July 1, 2004 a monthly brand limit was implemented, allowing 4 brand prescriptions per month with unlimited generic and OTC prescriptions. </li></ul><ul><li>Children and nursing home patients are excluded. </li></ul><ul><li>Anti-psychotic and anti-retroviral drugs are allowed up to total of 10 brand prescriptions. </li></ul><ul><li>Allowances are made for additional brands per month for certain classes if a physician needs to “switch” a patient from one brand to another in the event of adverse or allergic reactions. </li></ul>
    52. 52. PDL Update <ul><li>November 1, 2003 a Preferred Drug List (PDL) was implemented, requiring that drug classes be reviewed by our Pharmacy and Therapeutics (P&T) Committee for clinical recommendations for inclusion into the PDL. </li></ul><ul><li>Medicaid is currently re-reviewing implemented classes into our PDL to ensure up-to-date clinical information is taken into consideration for PDL clinical decisions. </li></ul>
    53. 53. Medicare Part D Update
    54. 54. a
    55. 55. Medicare Prescription Drug Coverage What Do You Need To Know?
    56. 56. Medicare Basics <ul><li>Part A </li></ul><ul><ul><li>Hospital Insurance </li></ul></ul><ul><li>Part B </li></ul><ul><ul><li>Medical Insurance (doctor visits) </li></ul></ul><ul><li>Part C </li></ul><ul><ul><li>Medicare Advantage </li></ul></ul><ul><li>Part D </li></ul><ul><ul><li>NEW Medicare Prescription Drug Benefit </li></ul></ul>
    57. 57. Eligibility and Enrollment <ul><li>Entitled to Part A and/or enrolled in Part B </li></ul><ul><li>Must reside in the plan’s service area </li></ul><ul><li>Program voluntary (for most) </li></ul><ul><li>Must enroll with the drug plan </li></ul><ul><li>Monthly fees apply (for most) </li></ul>
    58. 58. Prescription Drug Benefit <ul><li>Available to everyone with Medicare </li></ul><ul><li>Provides coverage for brand-name and generic drugs </li></ul><ul><li>Medicare contracts with private companies </li></ul><ul><li>Benefit started January 1, 2006 </li></ul><ul><li>Extra help with drug cost available for many people with limited income and resources </li></ul>
    59. 59. Initial Enrollment Period <ul><li>November 15, 2005 through May 15, 2006 </li></ul><ul><li>Penalty of 1% per month added to monthly fee if </li></ul><ul><ul><li>Enrollment is delayed and </li></ul></ul><ul><ul><li>Beneficiary is without “creditable coverage” </li></ul></ul>
    60. 60. Coverage Varies by Plan <ul><li>Select the Plan that meets your needs </li></ul><ul><li>Plans may not cover all drugs </li></ul><ul><li>Plans must give a 60-day notice if they decide not to cover a drug </li></ul><ul><li>Plans must have Appeals process </li></ul>
    61. 61. What to do if your Prescription Plan will not pay for your medicine? <ul><li>Check with your doctor to see if he/she can switch you to a medicine that the plan will cover </li></ul><ul><li>Change Plans </li></ul><ul><li>If your medicine can not be changed ask your doctor to request an appeal on your behalf </li></ul>
    62. 62. Requesting a Coverage Determination or Appeal <ul><li>Beneficiary can request </li></ul><ul><li>Appointed representative </li></ul><ul><li>Prescribing physician can request </li></ul><ul><li>Others can assist with form completion, letter writing, etc. </li></ul>
    63. 63. Need Help With Medicare Part D? <ul><li>Call 1-800-MEDICARE (1-800-633-4227) </li></ul><ul><li>Visit </li></ul><ul><li>For extra help: </li></ul><ul><li> - Social Security Administration </li></ul><ul><li> - 1-800-772-1213 </li></ul><ul><li> - </li></ul><ul><li> - 1-800-AGELINE (1-800-243-5463) </li></ul><ul><li>Questions regarding Medicaid (1-800-362-1504) Visit </li></ul>
    64. 64. Resources <ul><li>Enrollment and Appeals Guidance </li></ul><ul><li>“ How to File a Complaint, Coverage Determination, or Appeal” </li></ul>
    65. 65. Dental Program
    66. 66. Premise Good oral health prevents pain, suffering, missed days of school or work and unnecessary costs due to dental treatment.
    67. 67. Why Is Good Oral Health Important? <ul><li>Dental related illness causes poor children to “miss” 12 times more school days than children from higher income families </li></ul><ul><li>Poor oral health has been associated with other medical problems including heart disease and premature births </li></ul>
    68. 68. Is There An Oral Health Problem In Alabama? <ul><li>Two out of five Alabama schoolchildren are estimated to have untreated tooth decay </li></ul><ul><li>Almost 70% of low-income children in Alabama did not visit a dentist last year </li></ul>
    69. 69. Is There An Oral Health Problem In Alabama? <ul><li>Alabama has 30% fewer dentists per capita than the nation and our dentists are not distributed evenly (38 dentists in Alabama versus 54 per 100,000 population nationally) </li></ul><ul><li>One-third of all Alabamians over age 65 have no teeth, the 9th highest percentage in the country </li></ul>
    70. 70. Dental Program Vision Statement <ul><li>To ensure every child in Alabama enjoys optimal health by providing equal and timely access to quality, comprehensive oral health care, where prevention is emphasized promoting the total well-being of the child. </li></ul>
    71. 71. Alabama Medicaid Dental Program <ul><li>Approximately 450,000 Medicaid eligible children with limited access to dental services </li></ul><ul><li>8 counties with no Medicaid dentists or one Medicaid dentist </li></ul><ul><li>Limited participation in other counties with most not accepting new Medicaid patients </li></ul>
    72. 72. Currently….. <ul><li>Increased dental rates to 100% of BCBS 2001 rates </li></ul><ul><li>More procedure codes covered </li></ul><ul><li>Increased provider assistance </li></ul><ul><li>Made case management services available </li></ul><ul><li>Increased enrolled dentists to over 700 </li></ul>
    73. 73. Where to begin? <ul><li>Where do I find ______? </li></ul>
    74. 74. Alabama Medicaid Provider Manual <ul><li>Updates Quarterly </li></ul><ul><li>Provides All Information on Policy and Billing </li></ul><ul><li>Now Available on CD Rom </li></ul><ul><li>You are responsible for policies listed in the manual. </li></ul>
    75. 75. Chapters you need…. <ul><li>Chapter 1 Introduction Chapter 2 Enrollment Chapter 3 Eligibility Chapter 4 Prior Authorization Chapter 5 Filing Claims Chapter 6 Receiving Reimbursement Chapter 7 Rights and Responsibilities Chapter 13 Dental </li></ul>
    76. 76. Appendix <ul><li>Appendix B Electronic Media Claims (EMC) Guidelines </li></ul><ul><li>Appendix E Medicaid Forms </li></ul><ul><li>Appendix G Non-Emergency Transportation (NET) </li></ul><ul><li>Appendix I Outpatient Hospital and ASC Procedures </li></ul><ul><li>Appendix J Explanation of Benefit Codes </li></ul><ul><li>Appendix K Third Party Carrier Codes </li></ul><ul><li>Appendix L AVRS Quick Reference Guide </li></ul><ul><li>Appendix N Medicaid Contact Information </li></ul>
    77. 77. Come On Board!!! <ul><li>How do I become a provider? </li></ul><ul><ul><li>For an enrollment application Contact </li></ul></ul><ul><ul><ul><li>EDS provider enrollment unit 1-888-223-3630 </li></ul></ul></ul><ul><ul><ul><li>Medicaid’s dental program 1-334-242-5997 </li></ul></ul></ul><ul><ul><li>EDS issues a 9 digit provider number (effective the first day of the month the application is received) </li></ul></ul><ul><ul><li>You must receive a provider number for each physical location where you perform services </li></ul></ul>
    78. 78. Provider’s Rights <ul><li>Keep records for 3 years plus current </li></ul><ul><li>Provide same services to Medicaid patients as all other patients </li></ul><ul><li>Can bill recipients when services are non-covered or patient exceeded limits </li></ul><ul><li>Can limit number of patients seen, days seen or ages </li></ul>
    79. 79. Chapter Three--Eligibility Who is eligible? <ul><li>Three important questions to ask… </li></ul><ul><ul><li>Are they eligible? </li></ul></ul><ul><ul><li>Are they under the age of 21? </li></ul></ul><ul><ul><li>Do they have full Medicaid benefits? </li></ul></ul>
    80. 80. Verifying Eligibility <ul><li>Three Primary Ways 1. Provider Electronic Solutions Free Software provided by EDS. Quick response time – one at time or in batches 2. Automated Voice Response Toll free Number 1-800-727-7848 Available 23 hrs/day, 7 days per week 3. Secure Website: </li></ul><ul><li> </li></ul>
    81. 82. Provider Assistance Center <ul><li>Toll free number 1-800-688-7989 </li></ul><ul><li>Speak with a representative </li></ul><ul><li>Verify up to 6 recipients at a time </li></ul><ul><li>NOTE: If you want claims history information, you must ask for a provider representative. </li></ul>
    82. 83. Dental Benefit Information <ul><li>Provides last two PAID dates of service for the following codes: </li></ul><ul><ul><li>Panoramic X-rays – D0330 </li></ul></ul><ul><ul><li>Full Series X-rays – D0210 </li></ul></ul><ul><ul><li>Oral Exams – D0120 or D0150 </li></ul></ul><ul><ul><li>Prophylaxis/Fluoride – D1110, D1120, D1201, D1203, D1204, D1205 </li></ul></ul><ul><ul><li>Space Maintainers – D1510, D1515, D1520, D1525, D1550 </li></ul></ul>
    83. 84. Third Party Liability (TPL) <ul><li>Verify at each visit </li></ul><ul><li>Apply all payments received toward services rendered </li></ul><ul><li>If incorrect - update recipient file by calling: </li></ul><ul><li>A-G 334-242-5280 H-P 334-242-5254 Q-Z 334-242-5279 </li></ul>
    84. 85. Prior Authorization <ul><li>Who… </li></ul><ul><li>What… </li></ul><ul><li>When … </li></ul><ul><li>Where? </li></ul>
    85. 86. How to Obtain a Prior Authorization <ul><li>Use the Prior Authorization Dental Request Form (form 343) in provider manual Chapter 4 (can copy) </li></ul><ul><li>Mail to: EDS PO Box 244032 Montgomery, AL 36124-4032 </li></ul><ul><li>Note: X-rays must be mailed in a separate sealed envelope </li></ul><ul><li>and be of diagnostic quality </li></ul>
    86. 88. Prior Authorization <ul><li>Some of the services requiring Prior Authorization: </li></ul><ul><ul><li>Complete Bony Extractions </li></ul></ul><ul><ul><li>Periodontics </li></ul></ul><ul><ul><li>Space Maintainers after the first two </li></ul></ul><ul><li>Look in Chapter 13 for complete list. </li></ul>
    87. 89. Inpatient and Outpatient Hospitalization <ul><li>Required for children ages 5 through 20 when medical criteria is met </li></ul><ul><li>Not required for children under age 5 </li></ul><ul><li>Reimbursed for recipients older than 21 when dental problems have exacerbated underlying medical condition </li></ul>
    88. 90. Hospital Care <ul><li>Dentists must have all procedures loaded to prior authorization file to get paid </li></ul><ul><li>Use correct place of service </li></ul><ul><li>Hospitals use D9420 for payment for facility fee </li></ul><ul><li>Must receive prior authorization number from dentists for children 5 or greater </li></ul>
    89. 91. Emergency Prior Authorization <ul><li>Call the Dental Program at 334-242-5997 </li></ul><ul><ul><li>Talk with staff or leave a voice message with the following information: </li></ul></ul><ul><ul><ul><li>Recipient’s name and Medicaid number </li></ul></ul></ul><ul><ul><ul><li>Provider number of dentist </li></ul></ul></ul><ul><ul><ul><li>Phone number of dentist </li></ul></ul></ul><ul><ul><ul><li>Fill out Prior Authorization Request Form 343 and mail that day </li></ul></ul></ul>
    90. 92. Chapter 13 Dental Program <ul><li>Examinations </li></ul><ul><ul><li>D0120 Periodic: Once every six months (not to the date/within the same month) </li></ul></ul><ul><ul><li>D0140 Limited oral: Problem focused, once per recipient per provider per year and cannot be billed in conjunction with periodic or comprehensive. Need to document what done. </li></ul></ul><ul><ul><li>D0150 Comprehensive: Once per recipient per provider, must document! </li></ul></ul>
    91. 93. Prophylaxis and Fluoride Billing <ul><li>When billing for prophylaxis and fluoride treatment performed on the same date of service for a recipient, use the appropriate combined code : </li></ul><ul><ul><li>D1201 Topical fluoride with prophylaxis - Child (up to and including age 12) </li></ul></ul><ul><ul><li>D1205 Topical fluoride with prophylaxis – Adult (over 12 years of age) </li></ul></ul>
    92. 94. Radiology <ul><li>Full mouth and panoramics are covered every three years at age 5 (exceptions by report) </li></ul><ul><li>Posterior bitewing and single anterior can be taken every six months </li></ul><ul><li>BW-4 Films limited to age 13 and older </li></ul><ul><li>Must be of diagnostic quality </li></ul>
    93. 95. Space maintainers <ul><li>Non-covered for premature loss of primary incisors and placed greater than 180 days after the premature loss of a primary tooth </li></ul><ul><li>Non-covered for permanent tooth </li></ul><ul><li>Limited to one per recipient’s lifetime for a given space to be maintained </li></ul><ul><li>Bill the space where tooth was extracted </li></ul><ul><li>If extraction of tooth is not is Medicaid paid claim history, you must send in for override </li></ul>
    94. 96. Endodontics <ul><li>Pulp caps without a protective dressing are non-covered </li></ul><ul><li>D3120 - Indirect pulp caps covered for deep carious lesions on permanent teeth only </li></ul><ul><li>D3220 - Therapeutic pulpotomy covered for primary teeth only; not billable with other endo codes </li></ul><ul><li>Criteria for pulpal therapy and root canals </li></ul>
    95. 97. Incomplete Procedures <ul><li>Applies to multiple appointment procedures i.e. root canals and crown </li></ul><ul><li>Effective July 1, 2003, payment is made to the provider that started the procedure </li></ul><ul><li>Must have documentation in record of multiple attempts to complete procedures (letters, phone calls) </li></ul><ul><li>Subsequent provider should know that procedure </li></ul><ul><li>is considered non-covered </li></ul>
    96. 98. Crowns and Core Buildups <ul><li>Covered following root canal therapy ONLY </li></ul><ul><li>Crowns limited to permanent teeth </li></ul><ul><li>Recipients must be 15 years of age </li></ul><ul><li>Cast post and core must be radiographically visible, one-half length of canal </li></ul><ul><li>Must have post-op x-ray after crown inserted </li></ul>
    97. 99. What if the root canal is not in paid claims history? <ul><li>Send in for an administrative review with a clean claim and x-ray showing completed root canal therapy and crown inserted (DO NOT send in for a prior authorization.) </li></ul><ul><li>Only send claim with procedures needed for review </li></ul><ul><li>Send to the Medicaid Dental Program </li></ul>
    98. 100. Periodontics <ul><li>Only codes covered include D4341 scaling and root planing, D4355 full mouth debridement and D4910 periodontal maintenance </li></ul><ul><li>All require prior authorization with periodontal charting and/or radiographs </li></ul><ul><li>Criteria listed in Chapter 13-22 and 13-23 </li></ul>
    99. 101. Oral Surgery <ul><li>Primary teeth limited to D7140 unless by report for valid indications </li></ul><ul><li>Prior authorization required for D7240 and D7241 (by report) </li></ul><ul><li>Surgical extractions require documentation listed in Chapter 13-24 </li></ul><ul><li>Extractions due to crowding to facilitate orthodontics are non-covered </li></ul>
    100. 102. Palliative (Emergency) Treatment D9110 <ul><li>This must not be billed with definitive treatment or emergency procedures. </li></ul><ul><li>These procedure codes </li></ul><ul><li> include: </li></ul><ul><li>-D0210 -D0350 -D0470 -D9220 -D9610 -D1110 through D7971 </li></ul>
    101. 103. Non-Covered Services <ul><li>These include, but are not limited to dental implants, prosthetic treatment (bridgework, partials or dentures), all porcelain crowns, esthetic veneers and adult dental care. </li></ul><ul><li>Refer to Provider Manual Chapter 13 for details. </li></ul>
    102. 104. <ul><li>Reimbursment </li></ul>Show me the money!
    103. 105. Paper Claims <ul><li>Only ADA-approved claim forms are acceptable Version 2002,2004 </li></ul><ul><li>OCR Scannable form recommended </li></ul><ul><li>CDT2005 codes must be used (D-codes) </li></ul><ul><li>There will be a release of CDT2007 in January </li></ul>
    104. 106. When it is required to send a paper claim? <ul><li>When filing: </li></ul><ul><ul><li>Accident Form XIX-TPD-1-76 </li></ul></ul><ul><ul><li>Third Party Denial </li></ul></ul><ul><ul><li>Administrative Review/ Override </li></ul></ul>
    105. 107. Why bill electronically? <ul><li>Less than two week turn-around on claims </li></ul><ul><li>Immediate claim correction </li></ul><ul><li>Enhanced online adjustment functions </li></ul><ul><li>Improved access to eligibility information </li></ul>Enhances effectiveness and efficiency
    106. 108. Enhancements <ul><li>Can now use LAN, ISP or DSL connection </li></ul><ul><li>View EOP within software </li></ul><ul><li>Claim status </li></ul><ul><li>Send adjustments/reversals electronically </li></ul>
    107. 109. Important Facts to remember… <ul><ul><li>Tooth numbers 1-9 must have a </li></ul></ul><ul><ul><li> “ 0” in front when billing (example 01) </li></ul></ul><ul><ul><li>Primary teeth - use letters </li></ul></ul><ul><ul><li>Supernumerary teeth – NEW VALUES! </li></ul></ul><ul><ul><li>Place of service codes include: </li></ul></ul><ul><ul><ul><li>11 office </li></ul></ul></ul><ul><ul><ul><li>22 outpatient, requires prior authorization </li></ul></ul></ul><ul><ul><ul><li>21 inpatient, requires prior authorization </li></ul></ul></ul><ul><ul><ul><li>31 nursing facility, requires prior authorization </li></ul></ul></ul>
    108. 110. Oral Cavity Codes <ul><li>00 – Full Mouth </li></ul><ul><li>01 – Upper Arch </li></ul><ul><li>02 – Lower Arch </li></ul><ul><li>10 – Upper Right Quadrant </li></ul><ul><li>20 – Upper Left Quadrant </li></ul><ul><li>30 – Lower Left Quadrant </li></ul><ul><li>40 – Lower Right Quadrant </li></ul>
    109. 111. Filing Limit <ul><li>Medicaid requires all claims for Dental providers be filed within one year of date of service. </li></ul><ul><li>Providers should process claims for payment as soon as service is completed. </li></ul><ul><li>120 days from other insurance EOP date </li></ul><ul><li>120 days from adjustment, if past the filing limit </li></ul>
    110. 112. Administrative Review <ul><li>Must be received within 60 days of the date the claim became outdated </li></ul><ul><li>Must have documentation showing attempts to get claim paid (see Chapter 7-6) </li></ul><ul><li>Mail to: Alabama Medicaid Agency Dental Program Administrative Review PO Box 5624 Montgomery, AL 36103-5624 </li></ul>
    111. 113. Changes to MMIS - 2007
    112. 114. Introducing interChange, The New Alabama Medicaid System
    113. 115. Medicaid Modernization <ul><li>Improvement/ Focus Areas: </li></ul><ul><ul><li>Create an NPI compliant system </li></ul></ul><ul><ul><li>Improve Technology for AMA </li></ul></ul><ul><ul><li>Improved Provider Access </li></ul></ul><ul><ul><li>Faster Claims Processing </li></ul></ul>
    114. 116. <ul><li>New Interactive Web Portal </li></ul><ul><ul><li>Interactive Claims Submission </li></ul></ul><ul><ul><li>Immediate claim correction capabilities </li></ul></ul><ul><ul><li>Improved EOP Retention </li></ul></ul><ul><li>Provider Electronic Solutions </li></ul><ul><ul><li>Upgrade Only </li></ul></ul><ul><li>NPI Numbers Utilized </li></ul>What Will Change With The New System? Alabama Medicaid Provider Community interChange
    115. 117. interChange Highlights <ul><li>System Features </li></ul><ul><li>Real-time claims processing </li></ul><ul><li>Interactive claims submission </li></ul><ul><li>Browser-based screens </li></ul><ul><li>Eligibility verification </li></ul><ul><li>Providers can correct and resubmit claims immediately </li></ul><ul><li>24x7 Provider access </li></ul><ul><li>Claim Status Inquiry </li></ul>
    116. 118. interChange Highlights Eligibility
    117. 119. interChange Highlights Claims Submission
    118. 120. interChange Highlights Claims Inquiry
    119. 121. interChange Highlights Explanation of Payment
    120. 122. interChange Highlights Viewing Submitted Claims
    121. 123. Upcoming Events <ul><li>Claims processing will continue in current system as performed today </li></ul><ul><li>Send your NPI information to EDS when requested (ALERT will be sent/read Provider Insider) </li></ul><ul><li>Training Classes for providers will be conducted in Spring 2007 </li></ul>
    122. 124. Smile Alabama! <ul><li>Primary goals: </li></ul><ul><ul><ul><li>Increase number of Medicaid dental providers </li></ul></ul></ul><ul><ul><ul><li>Increase number of children receiving dental care </li></ul></ul></ul><ul><li>Other goals: </li></ul><ul><ul><ul><li>Provider training and support </li></ul></ul></ul><ul><ul><ul><li>Patient education </li></ul></ul></ul><ul><ul><ul><li>Assistance with claims processing </li></ul></ul></ul><ul><ul><ul><li>Patient education tools/resources </li></ul></ul></ul>Medicaid’s Dental Outreach Initiative
    123. 125. Targeted Case Management <ul><li>Case management by social workers and nurses </li></ul><ul><ul><li>available through the EPSDT program </li></ul></ul><ul><ul><li>Assistance with patient education, follow-up on missed appointments, coordination of services, transportation. </li></ul></ul><ul><ul><li> </li></ul></ul>
    124. 126. Available Tools <ul><li>Alabama Medicaid Provider Manual </li></ul><ul><ul><ul><li>Available on CD-Rom </li></ul></ul></ul><ul><ul><ul><li>Policy/procedure information on all Medicaid Programs </li></ul></ul></ul><ul><li>Provider Insider Newsletter </li></ul><ul><ul><ul><li>Published bimonthly </li></ul></ul></ul><ul><ul><ul><li>Policy changes and clarification on existing policy </li></ul></ul></ul><ul><li>Alert Bulletins </li></ul><ul><ul><ul><li>“ Urgent” information published as needed </li></ul></ul></ul>
    125. 127. More Tools <ul><li>Mini Messages </li></ul><ul><ul><ul><li>Part of EOP statements </li></ul></ul></ul><ul><ul><ul><li>Gives status of system problems/claims issues </li></ul></ul></ul><ul><ul><ul><li>Notice of any recoupments/ re-processing of claims </li></ul></ul></ul><ul><li>Medicaid Web site: ( </li></ul><ul><ul><ul><li>Contains contact information </li></ul></ul></ul><ul><ul><ul><li>Forms </li></ul></ul></ul><ul><ul><ul><li>Provider Notices </li></ul></ul></ul><ul><ul><ul><li>Fee Schedules </li></ul></ul></ul>
    126. 128. Important Numbers To Remember <ul><li>Medicaid </li></ul><ul><ul><li>Dental Program (Policy Questions) 334-242-5997 Fax 334-353-5027 </li></ul></ul><ul><ul><li>Recipient Inquiry Unit (Toll-free) 1-800-362-1504 </li></ul></ul><ul><ul><li>Outreach/Education (Educational Materials) 334-353-5203 </li></ul></ul><ul><li>EDS </li></ul><ul><ul><li>Provider Assistance Center (Billing Issues) 1-800-688-7989 </li></ul></ul><ul><ul><li>Provider Enrollment (Enrollment Issues) 1-888-223-3630 </li></ul></ul><ul><ul><li>EMC (Electronic Claims Submission Issues) 1-800-456-1242 </li></ul></ul>
    127. 129. NET Non-Emergency Transportation <ul><li>Requires Prior Authorization </li></ul><ul><li>Provides transportation vouchers to patients (like a check) </li></ul><ul><li>Vouchers must be signed by dentist </li></ul><ul><li>Covers one escort for recipients under 21 </li></ul><ul><li>Must be done 5 days prior to appointment, unless urgent </li></ul><ul><li>Call 1-800-362-1504, press #3 </li></ul>
    128. 130. What’s happened since last year…
    129. 131. Health Watch Technologies (HWT) <ul><li>Medicaid is working with Health Watch Technologies (HWT) to further insure payment integrity. </li></ul><ul><li>HWT will provide a cross functional team to include professionals in medicine, law, public policy, hospital administration, nursing, mental health, and data analysis. </li></ul>
    130. 132. Review Algorithms <ul><li>Examples of review algorithms </li></ul><ul><li>CDT and HCPC coding guidelines to insure appropriate billing of comprehensive codes, mutually exclusive codes, and modifier use </li></ul><ul><li>Regulation and policy based rules to include coverage limitations and non-covered services </li></ul><ul><li>Unbundling review of lab and ER services, surgical procedures and procedures </li></ul>
    131. 133. Review Algorithms <ul><li>Examples continued: </li></ul><ul><li>Unreasonable volume to indicate excessive units of a service </li></ul><ul><li>Duplicate billings of the same claim or same service by multiple providers </li></ul><ul><li>Recipient utilization of narcotics, or other services that indicate potential drug seeking behavior </li></ul>
    132. 134. National Provider Identifier…NPI <ul><li>Covered providers can begin applying for NPIs May 23, 2005 </li></ul><ul><li>Compliance date applicable to most entities is May 23, 2007 </li></ul><ul><ul><li>By this date, covered entities must use only the NPI to identify providers in standard electronic transactions. </li></ul></ul><ul><ul><li> </li></ul></ul><ul><ul><li> </li></ul></ul>
    133. 135. NPI: The Concept <ul><li>Provides the ability to bill all health plans uniformly – no longer necessary to use different identifiers for different health plans, contracts, locations </li></ul><ul><li>Billing will be simplified </li></ul><ul><li>COB payments will come sooner </li></ul><ul><li>If 100% paper, does not apply </li></ul>
    134. 136. It’s All About Healthy Smiles for Healthy Children
    135. 137. AND you call who? Medicaid Dental Program Tina Pippin 334-242-5472 [email_address] EDS Cyndi Crockett Provider Relations Supervisor 334-215-4170 [email_address]
    136. 138. Questions….