A Recap of Important Information Shared by Pennsylvania Human Services Department

Posted on by kow5101

Key representatives from the Pennsylvania Department of Human Services (DHS) joined Pennsylvania’s community of Community Health Centers during last week’s 2023 PACHC Annual Conference and Clinical Summit. Here are some of the key takeaways from the session:

  •  MATERNAL HEALTH.
    • This is a key priority of DHS Secretary Arkoosh and the Shapiro Administration. Some of the ways the administration is supporting improvements in outcomes include: Maternal Medicaid coverage extends to 12 months postpartum; HealthChoices managed care organizations (MCOs) will reimburse for home visits for the first 18 months of a baby’s life; DHS is requiring MCOs to have value-based care maternity teams and is providing incentives for closing equity gaps in prenatal and postpartum care; and DHS is working with the Pennsylvania Doula Commission toward statewide certification and doula enrollment in Medical Assistance; DHS is working to find solutions for the commonwealth’s “maternal deserts.” DHS noted that they are unable to enroll doulas as a Medicaid provider until there are enough certified doulas to ensure statewide network adequacy.
  • MANAGED CARE ORGANIZATION (MCO) CREDENTIALING.
    • The 2024 HealthChoices MCO agreements will include a requirement that MCOs pay retroactive to the date of submission of a complete credentialing application.* DHS is also working with the MCOs on options to streamline credentialing processes while maintaining compliance with NCQA standards. *NOTE: Although the DHS Office of Medical Assistance Programs (OMAP) has shared this policy change with the DHS Office of Mental Health & Substance Abuse Services (OMHSAS), OMAP does not know at this time whether OMHSAS will align their policy for behavioral health MCOs with OMAP policy for physical HealthChoices MCOs.
  • DENTAL PRODUCTIVITY.
    • DHS has been working with the Budget Office to discuss funding needed to implement one of the two previously submitted PACHC recommendations. Those recommendations included the elimination of dental hygienist productivity in the calculation of PPS rates OR the elimination of separate productivity thresholds for hygienists and dentists in favor of a combined productivity standard. Both recommendations have a significant financial impact that are not currently included in the approved 2023-2024 state budget. PACHC will share more information when DHS announces a decision.
  • QUARTERLY MCO WRAPAROUND REPORTS.
    • It is in the best interest of all health centers to submit quarterly MCO wraparound reports whether or not there is a balance due. The reports help DHS confirm whether MCO are paying correctly, give health centers the opportunity for an advance on MCO reimbursement due to maintaining cash flow until MCO payment is made, and help DHS monitor MCO payment trends. Assessing MCO trends is important for both payments and denials, which you are encouraged to include on your wrap reports. Health centers that prefer not to receive the advance from DHS can simply check a box indicating so when submitting the report. It is possible to bill four T1015 codes per patient per day, but you can only bill and be paid one of each of the following types: medical, dental, BH, and vision per day. Denials should be reported, but only for informational purposes and not as part of the wrap calculation. The wrap reports have moved from Excel templates to an online portal. If you need access to the portal, please contact RA-PWOMAPFQHC-RHC@pa.gov. IMPORTANT: Only claims submitted to MCOs with a T1015 code should be included on MCO wraparound reports.
  • HEALTH CENTER AUDITS.
    • The two most frequent issues discovered on audit by DHS’ Bureau of Financial Integrity (BFI) are: 1) including MCO-denied encounters in the encounter count on wraparound reports; and 2) submitting claims not submitted to the payor to DHS for payment.
  • BEHAVIORAL HEALTH.
    • It is important to note that FQHC licensed professional counselors (LPCs) and licensed marriage and family therapists (LMFTs) may ONLY bill for behavioral health (BH) encounters and then only when BH is in scope for the health center.
  • GROUP BH THERAPY.
    • Since 2020, DHS has permitted billing at PPS for group therapy. See the bulletin for more information.
  • VALUE-BASED PAYMENT.
    • The MCO HealthChoices agreements require the MCOs to discuss conceptual VBP models with any interested FQHCs but do not require FQHCs to enter into these alternative payment methodology discussions. The 2024 HealthChoices agreement will require model implementation if an FQHC so chooses and the Centers for Medicare and Medicaid Services approves. For any VBP model, the PPS rate should remain on the payment floor unless a different agreement is reached between the MCO and the FQHC and approved by CMS.
  • 340B.
    • The Centers for Medicare and Medicaid Services (CMS) is working on a process to identify 340B claims under Medicare Part D. In response, DHS has decided to pause its work on this issue for Medicaid managed care until CMS releases its recommendations in the hope that the CMS strategy will align with state strategy.
  • STREET MEDICINE.
    • DHS has released a second MA Bulletin adding street medicine as a place of service for certain providers. FQHCs were inadvertently missed from the initial bulletin issued July 2023 but are and have been eligible to offer services outside of the health center to unhomed individuals.
  • COVID-19 VACCINE REIMBURSEMENT.
    • DHS is federally required to cover COVID-19 vaccination through Sept. 2024. A vaccine-only visit is reimbursable at $40 per MA Bulletin 01-23-08. DHS is to get back to PACHC on whether the cost of the vaccine is reimbursable above and apart from PPS since the cost of the vaccine ($130-150/dose) is not included in FQHC PPS rate calculations and health centers are struggling with this increased cost of care.
  • UPDATED PROMISE HANDBOOK.
    • DHS has a new goal of publishing the updated FQHC/RHC Provider Handbook (Appendix E) by the end of 2023.
  • LONG-ACTING REVERSIBLE CONTRACEPTION (LARCs).
    • It has taken longer than DHS anticipated to submit for and get approval from CMS to pay for LARCs outside of the PPS rate. DHS hopes for approval of the state plan amendment (SPA) by early 2024.
  • PHARMACISTS.
    • Beginning Jan. 1, 2024, DHS will permit the enrollment of pharmacists in Medical Assistance. PACHC is seeking confirmation that this means they will then be added to the list of providers eligible to generate an FQHC encounter.
  • DIETICIANS.
    • DHS also intends to add dieticians to the list of providers eligible to enroll in Medical Assistance. More information will be shared when it is available.