Part II. Presented by Division of Behavioral Health and Recovery, in partnership with Health Care Authority, Health Benefit Exchange, and Office of the Insurance Commissioner.. May 27, 2014. Welcome. ID: 713964
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Chemical Dependency Services in the New Medicaid and Insurance WorldPart II
Presented by Division of Behavioral Health and Recovery, in partnership with Health Care Authority, Health Benefit Exchange, and Office of the Insurance Commissioner.
May 27, 2014Slide2
This webinar is the 2nd in a two part series.
The first webinar presented a general overview of Washington State’s public and private coverage options - past and present. The slide presentation can be found in the “For Contractors and Providers” section of the DBHR website. The recorded version will be available by June 1, 2014.
This webinar is intended to provide answers to the questions presented during the first webinar.Slide3
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Be sure to enter the telephone code, if you haven’t already.For problems during the webinar, please contact Scott McCarty via email
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(646) 307-1721 Access Code: 855-682-878Audio Pin: (unique code on your panel)
Be sure to customize the contact info at bottom and the phones/access code info.Slide4
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Questions pane– Allows attendees to submit questions and review answers (if enabled by the organizer). Broadcast messages from the organizer will also appear here.Slide5
Webinar Outline Review Last Webinar
General InformationGrace PeriodsIncarcerationBillingTARGET ReportingDBHR PolicySlide6
Introductions Emily Brice, Office of the Insurance Commissioner
Michael Arnis, Health Benefits ExchangeGail Kreiger, Health Care AuthoritySlide7
Key Lessons from Last Webinar
Two kinds of commercial insurance:Qualified Health Plans offered through Healthplanfinder (Exchange), subsidies available Off-Exchange plans in outside market
QHPs and most other individual & small group plans must cover Essential Health Benefits, including mental health & substance use
Limited open enrollment period, but special enrollment eventsSlide8
Enrolling Outside Open Enrollment
Question from first webinar: What about someone who loses their job (due to substance use) and then has no income going forward.
Next open enrollment = November 15 – February 15
Until then, special enrollment if qualifying event
Life events (e.g., marriage, baby, income change)Losing other coverage (e.g., divorce, job loss)S
ubmit documentation to Healthplanfinder or planMore info:www.wahbexchange.org/info-you/individuals-and-families/special-enrollment-faqs/www.insurance.wa.gov
/your-insurance/health-insurance/individuals-families/special-enrollment-periods/ Remember: Washington Apple Health (WAH) enrollment continuousSlide9
CD Services Required in Essential Health Benefit
Question from first webinar: What are the minimum required chemical dependency services required to be covered in EHB? Ex: outpatient, intensive outpatient treatment, inpatient treatment, intensive inpatient treatment, detox, etc.
284-43-8678 list specifics of EHBs for CD-related services:
misuse screening and counseling (preventive
service that must be provided without cost-sharing). Chemical dependency detoxification (which may not be uniformly limited to a 30-day limit, but may be subject to utilization review). Inpatient, residential, and outpatient substance use disorder services, including partial hospital
programs or inpatient services, at parity as required under state and federal parity laws. Prescription medication needed for substance use disorders, including those prescribed during an inpatient or residential course of treatment. Acupuncture
treatment visits, without visit limits when provided for chemical dependency. Treatment for CD services in “approved treatment programs” under Ch. 70.96A, per RCW 48.21.180, 48.44.240, 48.46.350 and CD definitions in RCW 48.44.245 and 48.46.355.Slide10
EHB Implementation May Differ
EHB sets standard, but details may differ. Eg., Formulary must be “substantially equal” re: category and classes covered, number of drugs per class
Sources of details:
Clinical medical necessity guidelinesUtilization management guidelinesSlide11
Example from 2014 Qualified Health Plan Policy
Covered ServicesTreatment and services for substance use disorders for patients with a DSM category diagnosis, including:
Care at a hospital, CD rehab facility, residential treatment program, partial hospitalization, intensive outpatient, group or individual outpatient, or home health setting
Prescription drugs prescribed during inpatient admission covered
be medically necessary and cover least restrictive setting Inpatient admissions related to substance use disorders require preauthorization (unless involuntary commitment)Emergency admissions require notificationSlide12
Example from 2014 QHP PolicyNot Covered
Alcoholics Anonymous or other similar CD programs or support groups;Biofeedback, pain management and/or stress reduction classes;Care necessary to obtain shelter, to deter antisocial behavior, to deter runaway or truant behavior;
Dependency benefits not specifically listed;
or other assessments to determine the medical necessity of court-ordered treatments;Court-ordered treatments or treatments related to deferral of prosecution, deferral of sentencing or suspended sentencing or treatments ordered as a condition of retaining driving rights, when no medical necessity exists; or
Custodial Care, including housing that is not integral to a Medically Necessary level of care, such as care necessary to obtain shelter, to deter antisocial behavior, to deter runaway or truant behavior or to achieve family respite…Slide13
Prior Authorization and QHPs Question
from first webinar: Providers are getting pre-auths but still not getting paid, why? Plan can use medical management techniques
But parameters in WAC 284-43-410:
Must make standards available to providers
Cannot retrospectively deny coverage/payment on standards not communicated to provider
Timeliness standards:1 business day for emergency
24 hours for concurrent if also urgent 48 hours for urgent care5 calendar days for non-urgent pre-service30 calendar days for post-service reviewsSlide14
General InformationQuestion from first webinar:
When can a person apply for Apple Health?Based on Life EventsLoss of employment
Loss of health insurance
Change of income
Question from first webinar:
Are habilitative services covered for individuals on classic Apple Health?
Pt, OT, ST and DME services may fall under the new habilitative benefitQuestion from first webinar: Is Apple Health managed care in each county?Yes some form of managed care is available in each county. Some counties have mandatory managed care coverage.Slide15
General Information, continued
Question from first webinar: Can a patient have their own employee insurance plan and be on Apple Health?An individual
can have coverage thru their employer and can also qualify for Apple Health
Question from first webinar:
be eligible for low income in December 2013 and become ineligible in January 2014?
Income could changeQuestion from first webinar: Is there a central portal for providers to check eligibility?ProviderOneThird party InsuranceSlide16
QHPs and Grace Period
Question from first webinar: Is there a grace period? Will the provider be responsible for cost if enrollee does not meet their grace period?
Non-subsidized enrollee 1-month grace period
enrollee 3-month grace period:
QHP will be expected to pay claims during the first month, but may suspend claims in the second and third months
QHP cannot deny claims during the second and third months Settling outstanding premiums, then claims paidQHP carriers must notify providersSlide18
QHPs and Grace PeriodSubsidized enrollee 3-month grace period: flowSlide19
Incarceration and the ExchangeQuestions
from first webinar: What is the definition of “incarceration”? Does an individual who is incarcerated for 3 days jail time need to disenroll? Can an incarcerated individual apply for benefits?
means serving a term in prison or
Incarceration is not being in jail or prison pending disposition of charges (not convicted of a crime
).Incarceration is not being on probation, parole, home confinement, or a residential facility under supervision.Incarcerated people don’t have to pay the fee for being uninsured
Incarcerated pending disposition of charges can use the MarketplaceSlide21
Incarceration and MedicaidMedicaid won’t pay for medical
care while a person is in prison or jail. Can enroll in Medicaid while incarcerated. Apply online
www.wahealthplanfinder.org For a complete list of options go to:
BillingQuestions from first webinar:
How does a provider get paid from ProviderOne after insurance has paid?Submit the claim with the Explanation of Benefits (EOB) from the insurance company.
Questions from first webinar
How will a provider know if deductible has been met?
Ask the insurance company. Medicaid
will include the deductible in their paymentQuestions from first webinar: Should a provider be collecting the deductible?If the client is covered by Medicaid you can’t collect a deductible from the client.Slide24
TARGET ReportingQuestion from first Webinar: What are Health
Exchanges considered for TARGET purposes?Health Exchange plans are considered private pay in TARGET
Question from first Webinar: Is TARGET tracking Presumptive SSI clients?
In discussion on how to best track
Question from first Webinar: If a parent is an N05, are their dependents also N05s?
, the children are enrolled in an existing children ‘s program.Slide25
Question from first Webinar: When will rates go up?In the preliminary discussion phase
Question from first Webinar:
Is there a “wait list” requirement for Washington Apple Health clients?
Must schedule an appointment for assessment.Question from first Webinar:
Are UAs covered chemical dependency treatment?Opiate SubstitutionPregnant WomenQuestion from first Webinar: Is there discussion about funding Recovery Coaches?
In the preliminary discussion phaseSlide27
Question from first Webinar: Is abuse diagnosis a billable service?Pregnant Women
from first Webinar:
Will treatment services provided to individuals presenting with the new DSM-5 substance abuse diagnosis of mild be reimbursable
?Yes, for Pregnant women and youthNo other determination yet for adultsQuestion from first Webinar: Can other DBHR funds be used to provide treatment to those who can’t afford deductibles or copays?
DBHR will not be paying for insurance from other funds.Slide28
DBHR PolicyQuestion from first Webinar
: Is it a requirement that treatment services be provided to those who refuse to sign up for Apple Health or Exchanges?There is no requirementQuestion from first Webinar
: Will DBHR fiscal be sending a report to counties indicating how much state funds should be considered match for Title XIX set-aside?
Working on spreadsheet on how to plan for match on Presumptive SSI.Slide29
Question from first Webinar: Who to contact with questions about QHPs or other insurance?Apple Health (Medicaid): Customer Service Center(1-800-562-3022), Long waits are sometimes required, but self-service options are available
Healthplanfinder: Enrollment or subsidies
1-855-WAFINDER (1-855-923-4633), M-F 7:30 a.m. to 8 email@example.comOIC: Insurance coverage, costs, and practices1-800-562-6900, M-F
8 a.m. to 5 p.m.File complaint online: www.insurance.wa.gov/complaints%2Dand%2Dfraud/file%2Da%2Dcomplaint/insurance%2Dcompany/Slide30
Thank You for participatingIf you have any other questions that were not answered here please contact Sandra Mena-Tyree at