10/16/2018

Medicaid

Recent Oncology Related Issues and News

PENDING MEDICAID ISSUES - UPDATED 10/16/2018

Michigan Managed Medicaid Plan Medical Benefit Drug Restrictions

MSHO continues to address the disparity in drug approvals between traditional Medicaid and the managed Medicaid plans. The managed plans are required to approve therapies that are a medical benefit with traditional Medicaid.  Thank you to those that sent in examples.  Those examples are in the hands of Medicaid and we are awaiting the next steps.  Stay tuned....

Update 9/4/18:  While many exclusions were reported on Total Health Care, it seems there has been some progress on getting some items approved.  Aloxi is still listed on the Website as EXCLUDED from coverage, however, a member office called for authorization to give it with Carbo/Taxotere regimen and they APPROVED it right away as a Medical Exception, no fuss at all.  They said they give exceptions when the treatment is listed as Highly Emetogenic and this one was on the list!  

Therefore, MSHO members should attempt to get approval for ANY/ALL drugs that are approved by traditional Medicaid and continue to report to MSHO if they have any instance when any Managed Medicaid plan does not allow the same coverage.

Update 8/6/18 - It has been reported to MSHO that Meridian Medicaid has approved Neulasta for patients that would meet medical necessity for Medicare on the first request - Progress.  MSHO is continuing to work with traditional Medicaid to address other disparities with Managed Medicaid Plans.

Update 7/10/18 - MSHO continues to work with traditional Medicaid to address issues with Managed Medicaid plans not offering the same benefits as traditional Medicaid.  There has been some success with approvals on a case by case basis for Meridian Medicaid.  Efforts continue.

Update 6/4/18 - MSHO has submitted the first case to traditional Medicaid who has agreed to follow up with the managed plan, Total Healh Care, within 30 days.  Stay tuned.

Update 5/15/18 - MSHO conferenced with traditional Medicaid and established a plan to address the disparities and step edits in place with many of the Managed Medicaid plans.  This process will begin later this week addressing a couple of companies at a time.  We will continue to update as issues are resolved.

5/1/18 - MSHO and Medicaid have set a call to discuss the best approach to address the outstanding issues.  This call will occur next week.

Proposed Medicaid Policy Effective January 1, 2019 
Claims for Medicaid Beneficiaries Eligible for Medicare

To View Policy, CLICK HERE

NOTE from Vernell Hester, COC, CHONC, Billing Specialist, Beaumont Health Hematology Oncology:  

Good News - If this goes through and starts in January, it will be a great help for all of those patients who neglect to enroll in Medicare because they think they are fully covered by Medicaid and don’t want that extra expense of Part B premiums!  As of now, we have to bill the patient for 100% of the charges, since Medicaid will not pay anything without Medicare being active and paying first, and hope the patient is able to get retro coverage.  Then we have to jump through hoops to get the patient to enroll themselves or get Medicaid Buy-In.  Sometimes patients have even stopped treatment when they learned they were not covered!

Most Recent Bulletins That May Affect Medical Oncology

October 1, 2018 - MSA 18-34 - Ordering of Genetic Laboratory Services by Physician Assistants (PAs) and Advanced Practice Registered Nurses (APRNs)

 CLICK HERE  to review all MSA Bulletins

Most Recent Announcements That May Affect Medical Oncology

October 4, 2018: Attention ALL Providers: The Centers for Medicare & Medicaid Services (CMS) is required to remove Social Security Numbers (SSNs) from all Medicare cards by April 2019. A new, unique Medicare Beneficiary Identifier (MBI) Number is replacing the SSN-based Health Insurance Claim Number (HICN) on each new Medicare card.  Beginning October 1, 2018, CMS will begin mailing new Medicare Cards to people with Medicare in the state of Michigan.

Beginning October 1, 2018 providers may begin to see the Medicare Beneficiary Identifier (MBI) in CHAMPS member eligibility screens. The MBI will also display in the 270/271 eligibility response if the beneficiary has an MBI on file in CHAMPS.

Providers should refer to the CMS Fact Sheet to ensure they are prepared to receive the MBI: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TransitiontoNewMedicareNumbersandCards-909365.pdf

Learn more about the CMS New Medicare Card Project: https://www.cms.gov/medicare/new-medicare-card/nmc-home.html

October 4, 2018: Attention All Outpatient Hospital Providers: MDHHS is aware of a system issue that caused claim lines with drugs purchased through the 340B program to be incorrectly underpaid. This may have also affected a small volume of claims that have claim lines with submitted charges that are less than the payment rate. The issue was resolved with the July 2018 quarterly updates that went into the system on September 21, 2018. All affected claims have been identified and adjusted for correct payment. If claims were missed during the resurrection process, providers should adjust them with the claim note “340B underpayment defect”. Any claims billed ongoing will be reimbursed accurately.

To visit the Biller "B" Aware website CLICK HERE