REVISIONS NOTE This information has been updated as of 6102016 Providers should review this information thoroughly as some of it has revised FeeforService Initiative The Georgia Department of Behavioral Health and Developmental Disabilities DBHDD is phasing in changes to the way it p ID: 728435
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Slide1
Tier 2 plus Providers
Fee-for-Service InitiativeSlide2
REVISIONS
NOTE:
This information has been updated as of 6/10/2016. Providers should review this information thoroughly as some of it has revised.Slide3
Fee-for-Service Initiative
The Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD) is phasing in changes to the way it pays providers for delivering state-funded behavioral health services.
These changes begin July 1, 2016, and include a migration to a fee-for-service payment structure for specific DBHDD provider categories.
Tier Two Plus providers deliver Medicaid billable services, as well as the core benefit package under a state-funded contract with DBHDD. The following information only applies to Tier Two Plus providers.
Slide4
July 1, 2016 Transition
Limited roll-out of Fee-for-Service effective July 1, 2016 to include:
Adult MH Core Benefit Package
Adult AD Core Benefit Package
Substance Abuse Intensive Outpatient Program
Psychosocial Rehabilitation - Individual and Group
Peer Support – Individual, Group, and Whole Health and WellnessSlide5
Adult MH and AD Core Benefits Package
BH Assessment and Service Plan Development
Psychological Testing
Diagnostic Assessment
Crisis Intervention
Psychiatric Treatment (E&M)
Nursing Services
Medication Administration
Psychosocial Rehabilitation - Individual
Addictive Diseases Support ServicesCase ManagementOutpatient Services – Individual and GroupOutpatient Services – FamilyCommunity Transition PlanningPeer Support – Individual Peer Support – Whole Health and Wellness
Core services transitioning to fee-for
service on July 1,
2016
BH Assessment and Service Plan Development
Psychological Testing
Diagnostic Assessment
Crisis Intervention
Psychiatric Treatment (E&M)
Nursing Services
Medication Administration
Psychosocial Rehabilitation - Individual
Addictive Diseases Support Services
Case Management
Outpatient Services – Individual and Group
Outpatient Services – Family
Community Transition Planning
Peer Support – Individual
Peer Support – Whole Health and WellnessSlide6
Fee-for-service Transition
Phased transition of other Specialty Services beginning in calendar year 2017
Phased transition of remaining Grant-in-Aid based services to Fully Costed Reimbursement contracts beginning in calendar year 2017
Implementation of approval-based Supplemental Support Funds requests begins in July 1, 2017Slide7
Tier Two Plus Provider Funding
Maximum Reimbursement Limits
Providers will only be reimbursed for claimed services up to the amount of their current contract for affected services (i.e. their maximum reimbursement limit).
Maximum reimbursement limits are being assigned to Tier Two Plus providers as a statewide budgetary control mechanism. This limit provides a reasonable assurance that the state allocation for community behavioral health services is not exceeded on an annual basis.
Initial limits for FY17 will be based upon FY16 contracted values for the core benefit package and other selected services transitioning to FFS on July 1, 2016.
Maximum reimbursement limits will be reviewed for potential adjustment to allow for possible redirects of funding at mid-year and year-end.
Reviews will be based upon actual utilization data collected.Slide8
Tier Two Plus Provider Funding
Minimum Reimbursement Limits
Tier Two Plus providers will be eligible for one year of transitional revenue protection in the form of guaranteed minimum levels of reimbursement.
Minimum reimbursement limits for FY17 will be set at 70% of a provider’s FY16 funding levels for the core benefit package and other services being transitioned to FFS on July 1, 2016. Actual earned revenues will be reviewed and compared to initial Minimum Reimbursement Limits at mid-year and year-end.
Any shortfall between actual earned revenues and Minimum Reimbursement Limits will be addressed through an increase in supplemental support funding at year-end or upon approved intermediate request by contractor.Slide9
Tier Two Plus Provider Funding
Supplemental Support Funding
Adjustments will be made based upon required additional funding resulting from minimum reimbursement limits, if applicable
Future FFS Transitions
Remaining services not transitioning to FFS on July 1, 2016 will transition to FFS or to fully-
costed
reimbursement beginning in calendar year 2017Slide10
Provider MRL Accumulators
Claims payment will be applied to provider’s Maximum Reimbursement Limit
(MRL) accumulators
based on diagnosis codes on claim (MH or AD
).
The
diagnosis code(s) on a claim should represent the principle condition, problem or other reason the service being billed was intended to address.
Claims paid under the fund sources SFAD (State Funds – Adult) and GACF (State Funds – Crisis) are included. Services falling under SFCA (State Funds – C&A), WTSO/WTSR (Women’s Treatment Outpatient & Residential), and TCMH/TCDC (Treatment Court – not required to report) are not included
.
The accumulators will add all claims paid until the MRL is reached.Once the MRL is reached, claims will become “pre-pay” and utilization is then tracked as state encounters.Slide11
Providers with both MRL AccumulatorsMH and
AD:
The following section provides information specific to the implementation of Maximum Reimbursement Limit Accumulators for providers who will have an accumulator set up for both Mental Health and Addictive Disease services.
Provider MRL Accumulators Slide12
Providers with both MRL AccumulatorsMH and AD
How claims are applied:
A mental health or addictive disease diagnosis code is required in Diagnosis Code 1 position on each claim.
Claims with two diagnosis codes will be split and 50% applied to each
MRL when applicable (providers with both MH and AD funding accumulators). If one accumulator has been reached then only 50% of the claim will be paid.
Once the MRL has been reached, claims will
be
processed in pre-pay
status and no payment will occur. The claim processes similar to state encounters
and is tracked for utilization purposes.The scenarios on the next slides depict claims paying against MRL’s for MH and AD. Slide13
Providers with both MRL AccumulatorsMH and AD
Scenario
Claim #
Claim Amount
MH
MRL Cap
Amt
Applied to MRL
MH Balance
ADMRL CapAmt Applied to MRLAD Balance1a$150$100,000$150$99,850
$50,000
-
$50,000
1b
$125
-
$99,850
$125
$49,875
Remaining balances carried forward to next slide.Slide14
Scenario Claim #
Claim Amount
MH
MRL Cap
Amt
Applied to MRL
MH Balance
AD
MRL
CapAmt Applied to MRLAD Balance2a$84$100,000$84$99,766$50,000-$49,875
2b
$54
-
$99,766
$54
$49,821
Remaining balances carried forward to next slide.
Providers with both MRL Accumulators
MH and ADSlide15
Providers with both MRL AccumulatorsMH and AD
Scenario Claim #
Claim Amount
MH
MRL Cap
Amt
Applied to MRL
MH Balance
AD
MRL CapAmt Applied to MRLAD Balance3a$90$100,000$45$99,721$50,000
$45
$49,776
3b
$156
$78
$99,643
$78
$49,698
Remaining balances carried forward to next slide.Slide16
Providers with both MRL AccumulatorsMH and AD
Scenario Claim #
Claim Amount
MH
MRL Cap
Amt
Applied to MRL
MH Balance
AD
MRL CapAmt Applied to MRLAD Balance4a$66$100,000$66$99,577$50,000
-
$49,698
4b
$112
-
$99,577
$112
$49,586
Remaining balances carried forward to next slide.Slide17
Providers with both MRL AccumulatorsMH and AD
Scenario Claim #
Claim Amount
MH
MRL Cap
Amt
Applied to MRL
MH Balance
AD
MRL CapAmt Applied to MRLAD Balance5a$70$100,000$0$0$50,000$35
$49,586
5b
$32
$16
$99,850
$0
$0
See next slide for total accumulation.Slide18
Applying Claims to Accumulators
Once an accumulator reaches $0, subsequent claims become pre-pay and no longer paid fee for service.
Scenario
Claim Amount
MH
MRL Cap
Amt
Applied to MRL
MH Balance
ADMRL CapAmt Applied to MRLAD Balance1a$150$100,000$150$99,850$50,000
-
$50,000
1b
$125
-
$99,850
$125
$49,875
2a
$84
$84
$99,766
-
$49,875
2b
$54
-
$99,766
$54
$49,821
3a
$90
$45
$99,721
$45
$49,776
3b
$156
$78
$99,643
$78
$49,698
4a
$66
$66
$99,577
-
$49,6984b$112-$99,577$112$49,586…..…..…..5a$70$0$0$35$49,586…..…..…..5b$32$32$99,542$0$0
Note: The rows below the dashed line assume that the MRL has been reached.Slide19
Providers with one MRL Accumulator
MH
or AD:
The following section provides information specific to the implementation of Maximum Reimbursement Limit Accumulators for providers who will have a single accumulator set up for either Mental Health or Addictive Disease services.
Provider MRL Accumulators Slide20
Providers with one MRL AccumulatorMH or AD
How claims are applied:
A mental health or addictive disease diagnosis code is required in Diagnosis Code 1 position on each claim.
Claims with two diagnosis codes will be
applied
to
the MRL accumulator regardless of the diagnosis on the claim.
For example, if a provider has AD funding only, one accumulator is set up. If a claim is to be paid the total amount of the claim is applied to the AD accumulator.
Once the MRL has been reached, claims will
be processed in pre-pay status and no payment will occur. The claim processes similar to state encounters and is tracked for utilization purposes.The scenarios on the next slides depict claims paying against a single MRL accumulator. Slide21
Providers with one MRL AccumulatorMH or AD
Scenario
Claim #
Claim Amount
MRL Cap
Amount
Applied to MRL
MRL Balance
1a
$150$100,000$150$99,8501b$125$125$99,725Remaining balance carried forward to next slide.Slide22
Remaining balance carried forward to next slide.
Providers with one MRL Accumulator
MH or AD
Scenario
Claim #
Claim Amount
MRL Cap
Amount
Applied to MRL
MRL Balance1a$84$100,000$84$99,6411b$54$54$99,587Slide23
Providers with one MRL AccumulatorMH or AD
Remaining balances carried forward to next slide.
Scenario
Claim #
Claim Amount
MRL Cap
Amount
Applied to MRL
MRL Balance
1a$90$100,000$90$99,4971b$156$156$99,341Slide24
Providers with one MRL AccumulatorMH or AD
Remaining balances carried forward to next slide.
Scenario
Claim #
Claim Amount
MRL Cap
Amount
Applied to MRL
MRL Balance
1a$66$100,000$66$99,2751b$112$112$99,163Slide25
Providers with one MRL AccumulatorMH or AD
See next slide for total accumulation.
Scenario
Claim #
Claim Amount
MRL Cap
Amount
Applied to MRL
MRL Balance
1a$70$100,000$0$01b$32$0$0Slide26
Applying Claims to Accumulators
Once the accumulator reaches $0, subsequent claims become pre-pay and no longer paid fee for service.
Scenario
Claim #
Claim Amount
MRL Cap
Amount
Applied to MRL
MRL Balance
1a$150$100,000$150$99,8501b$125$125$99,7252a$84$84
$99,641
2b
$54
$54
$99,587
3a
$90
$90
$99,497
3b
$156
$156
$99,341
4a
$66
$66
$99,275
4b
$112
$112
$99,163
….
….
….
5a
$70
$0
$0
5b
$32
$0
$0
Note: The rows below the dashed line assume that the MRL has been reached.Slide27
Questions?
Please
submit any questions to
FFS.questions@dbhdd.ga.gov