Office
of
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Topic |
Service Limits |
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Overview |
The KyHealth Choices waiver proposes new limits on the number or frequency of a variety of services for all Medicaid beneficiaries, including children. It is not clear that service limits are needed. All services provided under Medicaid already must meet the standard of medical necessity set out under 907 KAR 3:130. As well, the state’s recently improved information and management systems enable it to identify and respond to unusual patterns of services. Many of the services that DMS proposes to limit under the waiver already are subject to prior authorization. For example, ancillary services such as physical therapy (PT), occupational therapy (OT) and speech therapy (ST) require individual plans of care. Currently, children on Medicaid and
the KCHIP-funded Medicaid expansion program are entitled to Medicaid services
and to any service allowed by federal Medicaid law, even if it is not part of
the The proposed redesign of KCHIP to
a stand-alone program would result in some children moving from Medicaid to
KCHIP. Phase II of the plan proposes
bidding out the entire Even the most responsive system will be challenged to handle the volume of requests to exceed limits. Providers may tire of making them and may get discouraged from participating in Medicaid. For each request delayed or foregone, recipients may end up with the bill. Strong standards are needed to assure timely response, accurate information about where each recipients stands in relation to limits and due process when denials occur. |
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Key Provisions of Waiver |
The plan creates four benefit packages, all of which contain service limitations. Many of the service limits are new. All limits are “soft” and may be overridden if the provider demonstrates medical necessity through a prior authorization process. All benefit packages, including the benefit package for children, limit prescription drugs to 4 per month with a maximum of three brand name drugs. Persons with a number of medical conditions are excluded from the limits, including people with heart disease and diabetes. The process by which exemptions will be granted is not set out in the waiver. Under the waiver, In the interim, the Kentucky Medicaid Administrative Agent (KMAA) will manage the EPSDT Program, which will be renamed the “Children’s Health and Prevention Program.” The waiver emphasizes that KMAA will ensure that all “T” (treatment) services are medically necessary. It is critical that the appropriate EPSDT standards be used in making decisions on treatment.
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Expressed Goal or Pledge |
To stretch resources to more appropriately meet the needs of current Medicaid members while encouraging them to be personally responsible for their own health care. |
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Questions |
Will the Phase II redesign of KCHIP
include all members in the · Under age 1 with income > 185% FPL but < 200% · From age 1 but under age 6 with income >133% FPL but < 200% FPL · Children from age 6 to under age 19 with income > 100% but < 200% FPL Or, will they include only those children in the above groups who are > 150% of poverty? In Phase II, will the entire Impact Plus is not addressed in the waiver. Will the full array of Impact Plus services continue to be available for those children with severe mental illness and behavioral problems at risk of institutionalization? The Global and How will “counting” work? Will it be on a calendar year basis? Or, will each recipient have an individual “clock” that starts when they become eligible? If there is a single clock, will limits for individuals be prorated based on month of entry or the month operation under the waiver starts? What will happen to current recipients if the waiver starts after January? Will any services already used count against their limits? |
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Concerns |
Services for Children Currently, children in Medicaid
and the KCHIP-funded Medicaid expansion program are entitled to the full
range of Medicaid and EPSDT services, including EPSDT special services. The waiver would limit services for all children
in the new Dental: Currently, Hearing: Vision: Currently, two pairs of glasses per year are allowed for child under 21. Under the waiver, the limit would be $400 per year for glasses. PT, OT and ST: Currently, ancillary services are
allowed as approved by a physician.
The Chiropractic: Currently, 12 visits are permitted
before prior authorization is required.
12 additional visits are permitted without prior authorization if the
last visit was more than 6 months ago. The
Home Health Services: Currently, these services must be prior
authorized but are not artificially limited; the number of visits is
determined by the plan of care. The Limits on services are often
considered absolute by providers and members.
Imposing limits will mean that some children go without. Either that, or their providers will have to
make special requests on their behalf.
Most important, we are concerned that
if One last item to help emphasize
the importance of EPSDT: We suggest
that Ancillary services Under all benefit plans, physical
therapy, occupational therapy and speech therapy are limited. Many Medicaid members, both adults and children, suffer from multiple physical and mental disabilities. For them, ancillary services are essential to maintain or reach an optimum quality of life. Most ancillary services require prior authorization already and, for services provided at home, very specific criteria must be met for coverage and time limits are placed on care. There are already sufficient checks and limitations on these services without imposing additional service limits. Prescription Drugs The proposed limit of 4 prescriptions per month (with maximum of 3 brand names) goes far beyond capturing “outliers.” Some 60,000 recipients already use five or more drugs at a time. Many would have to seek permission to continue their current drug regimen. (Others would be excluded from the limit based on their medical condition.) Some may end up going without. In this matter, people will be dependent on both the plan and the provider. When the waiver “clock” is started, thousands of requests will have to be made and processed in a very short time. Providers could become frustrated and abandon the quest. The KMAA process could get backed up. After start-up, it is not clear how providers even will know when to make requests. Will they get an emergency call from the pharmacist, whose customer is standing there with seven prescriptions, three of which cannot be filled? This scenario suggestion that the drug limits will result in individuals picking and choosing which medicines to use. If their choices are “wrong,” their health could suffer. As with drugs foregone due to co-payments, the result could be “adverse incidents” such as hospitalizations. As with all services, we do not believe prescription drug limits should be imposed on children. “Soft” limits and due process The waiver proposal states that all services limits are “soft.” Providers may ask permission to exceed them, but must establish that “extra” services are medically necessary. The KMAA will have to process thousands of requests, with a crunch during start-up of the waiver. (The main reason for the crunch: prescription limits are set monthly.) The chain of events leading to approval is fraught with peril: · Recipients or providers may not know when to ask permission · Providers may know when to ask, but may not do so, especially if they perceive the process as time consuming · Some recipients will be denied · Of these, some will appeal, but others won’t
Any weak link in the chain could mean that a medically necessary service is not provided. Any medically necessary service foregone could jeopardize health. It could be as simple as this: a provider gets endless busy signals when trying to fax a prior authorization request and gives up. The jeopardy can be reduced by imposing the highest performance standards on KMAA to ensure that the process is simplified, that all requests can get through and that response time is short. Meanwhile, the waiver proposal makes clear the fair hearing process under 907 KAR 1:563 will be available to appeal denials of prior authorization requests. That process can take up to 90 days. Below, we suggest that the quicker standards of response expected of Passport are needed. |
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Law |
EPSDT States are required to provide EPSDT services to both categorically and medically needy children on Medicaid up to age 21. 42 U.S.C. §1396a(a)(43). Comprehensive and regularly scheduled screening must be provided in four areas – medical, vision, hearing and dental. States are required to cover any medically necessary treatment to correct or ameliorate physical and mental illnesses, regardless of whether such services are covered for Medicaid adults. 42 U.S.C. §1396d(r). Required vision services include diagnosis and treatment for vision defects, including eyeglasses. Required dental services include relief of pain and infection, restoration of teeth and maintenance of dental health. Hearing services include diagnosis and treatment for hearing defects, including hearing aids. 42 U.S.C. 1396d(r). 907 KAR 1:034 Section 9 requires that prior authorization be obtained for any EPSDT diagnosis, treatment or special service that is not otherwise covered by Medicaid. The service must meet the medically necessary test set out in 907 KAR 3:130. All EPSDT services must be provided free of charge to individuals under 18.
KCHIP Under a state children’s health insurance program, services must include well baby and well child care, immunizations and emergency care. 42 C.F.R. 457.410. For those in a separate, non-Medicaid program, preventive and diagnostic dental services, including sealants, are included in well child care. 42 C.F.R. 457.520.
Ancillary Therapy (PT, OT, ST) These services are optional for the categorically needy. 42 U.S.C. 1396d(a)(11); 42 C.F.R. 440.110. Therapeutic services as ordered by a physician are covered under outpatient hospital services. 907 KAR 1:014. For ancillary services at home, prior authorization must be obtained and a plan of care which specifies the type, nature, frequency and duration of the service must be developed by the therapist and physician. 907 KAR 1:030. The plan must be reviewed every 60 days and must include a specific diagnosis and a reasonable expectation for gain. Individuals must meet very specific “technical criteria” to be found eligible. 907 KAR 1:023. The Cabinet must make an on-site review to evaluate the need for such services, and if authorized, set up a specific certification period. 907 KAR 1:023 Section 4. Prescription Drugs
“Soft Limits” Currently, the only “prior
authorization” process that is clearly spelled out is the one that covers prescription
drugs. 907 KAR 1:019 Section 4. Denial
of any Medicaid covered service currently may be appealed by requesting a
hearing pursuant to 907 KAR 1:563. The
regulation requires that the hearing be held within 30 days, a recommended decision
be issued within 30 days of the hearing, and a final decision be issued by
the Cabinet within 90 days of the hearing request. 907 KAR 1:563 Sections 6 and 9. Passport (the managed care waiver that
applies in |
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Recommendations |
1. There should no limits on services for children whether they are on Medicaid, the KCHIP-funded Medicaid expansion program or the non-Medicaid KCHIP program. 2.
All children now covered by EPSDT and EPSDT special services
should remain covered by EPSDT, regardless of whether the Cabinet bids out
the KCHIP plan or the entire 3. Where individual care plans are required for PT, OT and ST, no arbitrary numerical limits should be imposed. 4. Recently enacted changes in drug coverage (unlimited generics and a 3 brand name limit) should be given a chance to work before additional limits are imposed. 5.
6. Service limits should be tracked by the plan, with information available online for providers about the status of any patient at any time vis-à-vis limits. 7. Plan participants should be given ways to check their status vis-à-vis limits, including a toll-free call-in option. 8. It should not, however, be the member’s responsibility to keep track of service use or know all service limits. If a provider simply starts unauthorized services without seeking prior authorization, the member should not be liable. 9.
· The Department notify all Medicaid members of changes in their Medicaid coverage at least 30 days in advance.
· The Department provide a 10-day advance notice and a right to a hearing as provided under 907 KAR 1:600 to any individual who will exceed a limit immediately upon start-up of the waiver. · The process for prior authorization of drugs be used for the first level review of a request to exceed a service limit, including a response time of 24 hours and a provision allowing a provider to start urgently needed services for up to 72 hours pending a decision when necessary. · As in 970 KAR 1:019 Section 4, if the prior authorization request is denied, the member should be sent a denial notice with appeal rights. · While a fair hearing under 907 KAR 1:563 should continue to be available to any member who is denied a service because it exceeds the soft limits, that process takes too long for a service that is needed right away. A grievance procedure similar to that used in Passport could be used as an interim step to resolve service limit denials (within 48 hours for urgent matters, 30 days for non-urgent ones). |
Prepared
by:
Anne Marie Regan, Senior Staff Attorney
Office of
1139 East Broadway
502-584-0349