Download
1 / 35
350 likes | 501 Views
Arizona Health Care Cost Containment System Administrator Meeting. Quality Update January 2014. Maternal and Child Health Updates. Significant revisions to the AHCCCS Medical Policy Chapter 400 Clarifications to what constitutes an EPSDT visit
E N D
Arizona Health Care Cost Containment SystemAdministrator Meeting Quality Update January 2014
Maternal and Child Health Updates • Significant revisions to the AHCCCS Medical Policy Chapter 400 • Clarifications to what constitutes an EPSDT visit • More clearly indicates what is included in the EPSDT visit fee • Identifies what can be billed separately from the EPSDT visit (if done during an EPSDT visit) • What circumstances • By whom and the qualifications, if any, that must be met by the provider or staff • Any specific tools or equipment that must be utilized in order to be reimbursed in addition to the EPSDT visit fee • American Academy of Pediatrics, Contractor staff, AHCCCS Office of the Inspector General staff provided input and review of the revisions • Modifies the approved developmental screening tools and ages for screening • Adds PCP varnish application during EPSDT visits • Adds dental home requirements • EPSDT forms have been updated • Requires obstetrical claims, regardless of method of payment (global or by service) to include all dates of service
Maternal and Child Health Updates • Newborn Screening Program • ADHS statute changes in 2013 to allow changes in the fee charged for newborn screening • Rulemaking has been underway to raise the price of the second newborn screening test from $40 to $65 • Contractors will be informed what the effective date of the increase is as soon as it is confirmed • The second screening is performed in the PCP’s office and is paid for by the health plan • Additional Rulemaking will begin around April for the purpose of discussing adding two new tests to the newborn screening panel and raising the second screening fee another $15 –AHCCCS will inform you of any future changes • CCHD – completed within 24 hours of birth in facility • SCID – included in the blood spot panel
Maternal and Child Health Updates • Baby Arizona Program • Program ended on December 31, 2013 • Affordable Care Act requires • Use of one enrollment and eligibility process • Those individuals that would qualify for coverage through Baby Arizona will qualify for either AHCCCS or an Exchange Plan • AHCCCS and ADHS have worked with ArMA and the Baby Arizona providers to determine which providers would still be willing to receive ADHS Hot Line referrals for sliding fee scale individuals that are not eligible for AHCCCS or an Exchange Plan
Maternal and Child Health Updates • SOBRA Family Planning Extension Program • Program ended on December 31, 2013 • AHCCCS SOBRA members that have delivered will now either qualify for AHCCCS or an Exchange Plan • As a result, sterilization reporting requirements have changed • Under age 21 only • Purpose: to confirm that the sterilization was medically necessary (otherwise not covered until 21 years of age)
Maternal and Child Health Updates • Primary Care Provider – Fluoride Varnish • Effective April 1, 2014 • Allows Primary Care Providers to apply fluoride varnish during EPSDT visits beginning at first tooth eruption up to age 2 years (no more frequent than every six months) • Includes PCP education or discussion with parent of the need for oral health care and referral to a dental home • Additional payment outside of the EPSDT visit fee • PCP should verify that they have received training on applying fluoride varnish • Office staff not eligible to apply fluoride varnish
Maternal and Child Health Updates • Dental Home • Not to be confused with requirements or description of a “medical home” • Dental Home • Allows members to select or be assigned to an oral health professional that they are established with, or if not established to an oral health professional within the Contractor’s network • Provides a “panel” of patients for outreach purposes so that the oral health professional can deliver services, send reminder notifications, etc. • Purpose/Goal: To increase utilization of EPSDT oral health services to the level/rate mandated by CMS (the 10% increase by 2015) • Contractors should begin implementation. Mandatory effective date will be discussed with Contractors in the near future
Quality Management Update • Behavioral Health credentialing requirements added to Chapter 900 • Initial requirements that will be strengthened over time • HCBS annual quality monitoring/site visit tool completed and will be fully implemented by Contractors by April 1, 2014
Quality Improvement • New Performance Improvement Project • Topic: Increasing the use of e-prescribing • Number or percent of prescriptions filled that were e-prescribed • Number or percent of providers that submit prescriptions utilizing e-prescribing • Methodology will be available soon
Performance Measure Transition Status • Vendor status • Contract has been signed with Optum to calculate AHCCCS Performance Measures beginning with the 2014 measurement year • The contract includes: • HEDIS measures • CMS Measures Sets (including Core Measure Sets) • Development of new measure sets included in federal measures sets • File returned to AHCCCS for additional stratification for quality improvement purposes • Development and implementation of Performance Measure requirements will begin in February 2014
CYE 2013 Performance Measures • AHCCCS may utilize the EQRO to run the CYE 13 performance measures • AHCCCS anticipates also reporting a limited number of measures for CYE 13 • Ensure the encounter data is accurate and complete – it does impact final performance measure rates
Table Slides - KEY • Highlighted in RED print – the rate declined in the CYE 2012 Performance Measure • Highlighted in ITALICS – the rate is below the AHCCCS Minimum Performance Standard (MPS) • Important to note that the size of the Contractor’s population is important when reviewing declining rates or those below MPS as these may impact the state wide aggregate performance
United Healthcare Community Plan (Acute)CYE 2012 Performance Measure Results
United Healthcare Community Plan (Acute) CYE 2012 Performance Measure Results
Application of Sanctions • AHCCCS will be applying Contractor sanctions to performance measures results • Factors AHCCCS considers in determining Contractor sanctions (not an exhaustive list): • Contractor did not meet the contractual minimum performance standards for the Performance Measure; and/or • Contractor’s performance rate is declining; and/or • Contractor’s performance may be negatively driving the aggregate rates; and/or • Past performance or corrective actions taken
Factors to Consider for Performance Improvement • Quality Improvement staffing levels (current number of GSA’s, population changes), skill set, experience • How many “hats” do the QI staff wear (all lines of business) • Organizational structure related to quality improvement • Local authority to implement interventions and/or activities to improve outcomes • How is data stored and how accessible is it: • If multiple lines of business is it combined or separate • Local ability to run stratifying reports, analyze data
AHCCCS Assistance • AHCCCS requested quality improvement resource information from Contractors (due 1/17/14) • QI resource information will be used with Contractor performance results and other available information for discussions with Contractors that have opportunities to improve • Technical assistance meetings with Contractor QI staff will continue in 2014 • Work group meetings will continue in 2014
