December 27, 2012

This is a special edition of the KAAP newsletter.  It concentrates on changes in healthcare in Kansas as the ACA and State-developed programs are instituted.

 

Articles by Dennis Cooley, MD, FAAP

 

KanCare Implementation

On December 7 of this year, the Brownback Administration probably let out a sigh of relief. That was the date CMS approved the 1115 waiver which allows the state to move ahead with full implementation of the new Kansas Medicaid plan- KanCare according to a press release from KDHE:

 

"The Centers for Medicare and Medicaid Services (CMS) has informed Kansas it believes the State has demonstrated it is programmatically prepared for a Jan. 1, 2013, start date for KanCare, the proposed system of integrated care for Medicaid and Children's Health Insurance Program (CHIP) beneficiaries."

 

The Brownback Administration proposed changes in our Medicaid program with the hopes of limiting the expanding costs of the program. According to the KHI news service "Dr. Robert Moser, secretary of the Kansas Department of Health and Environment, said the administration's earlier projections of $1 billion in savings over five years as a result of KanCare were still on track with about $400 million of that accruing to the state and the rest to the federal government. "

 

It should be emphasized these are savings in the projected increased costs of the program not in the actual costs of the current program.

 

How will these savings be attained? According to the KDHE press release:

 

"The State is partnering with three health plans to achieve measurable goals, and to focus on wellness and care coordination. Savings are not achieved by reducing eligibility or provider reimbursement. KanCare continues current program benefits and also adds services such as heart and lung transplants, and bariatric surgery.  Value-added services, such as adult preventive dental services, offered by the three health plans will be delivered at no cost to the state."

 

In addition, the Managed Care Organizations (MCOs) will be in pay for performance programs with the state withholding a portion of the capitation based on this. The state is not involved in any provider pay for performance programs and these programs should not affect provider payments.

 

The three MCOs are United Health Care, Sunflower (Centene), and Amerigroup.

 

For most pediatricians whether or not the full implementation was approved didn't have much effect as children were already being moved into the three new MCOs. Children have been in a managed care Medicaid program for many years and the only change is that we would be dealing with three Managed Care Organizations instead of two. Still while the concept of managed care may be familiar to us the fact we now have to deal with three separate companies instead of two does make administrative work for the providers more complex. For example, we have been told the formulary will be the same for all three MCOs, but Prior Authorization will be different.

 

Recipients will be put in a health plan, but have 90 days to change after the January 1 start date. Presumptive eligibility will be unchanged as will all services currently covered.

 

As the new system unrolls, I expect problems will arise. The Chapter can help forward complaints to KDHE through the Kansas Maternal Child Health Council (KMCHC) and Pediatric Council.
Increase Medicaid Payments

One of the provisions of the ACA (Obamacare) was that starting January 2013 Medicaid payments on certain primary care services would be paid at the Medicare level. On November 1 of this year, CMS released the final rule concerning this increase.

 

There has been and continues to be much confusion concerning this part of the ACA. This article is an attempt to clear up some of this, but a large reason for the confusion may be that there are still many unanswered questions about this ruling. I will also review efforts by the chapter to assure that the implementation of this goes as smoothly as possible.

 

First some background.

The Supreme Court of the United States (SCOTUS) upheld the constitutionality of the ACA this past summer with one exception - the Medicaid expansion to 138% of the FPL. This ruling upheld all other parts of the ACA including the increased payments for Medicaid to Medicare levels. This is not an option for the states. If there is any doubt about this, I attended a meeting in Washington DC in November at which Cindy Mann the Deputy Director of CMS was a speaker. She stated unequivocally that no state could drop out of this part of the ACA. Interestingly, in a recent conversation with Dr. Pam Shaw, our AAP District VI chair, she related how many state Medicaid directors in our district still did not understand that this portion of the ACA was not part of the Medicaid expansion that was struck down and thought that it was optional.

 

So what does this all mean?

The increased rates will include E/M codes 99201-99499 and vaccine administration codes 90460, 90461, 90471-74. The rates will be based on the Medicare rate in effect in CYs 2013 and 2014, or if higher the rate using the CY 2009 Medicare conversion factor and 2013 and 2014 RVUs. Pediatricians including pediatric specialists will be eligible for these rate increases along with nurse practitioners.

 

What about other pediatric services? This increase is part of a federal law and is being paid for by the federal government. It would require Congress to amend the law to increase the codes covered (which is highly unlikely).

 

What about the state increasing payments for other services? Again in view of the projected shortfall in the state's revenue this coming year this is almost impossible.

 

Payments may be done either as add-ons or quarterly lump sums. The entire increase will be paid for by the federal government for 2 years (more on this later). States have until the end of March 2013 to submit their plans. The increased payments will cover both fee for service and managed care programs. Payments must go to providers and cannot be used by the MCOs for administrative or other services.

 

Patients enrolled in the CHIP program when it is not an expansion of Medicaid do not have to be included in these increased payments. In Kansas, the CHIP program was not part of a Medicaid expansion, but established as a separate program so does not have to be included. However, there is some indication that in Kansas at least providers will receive the increased payments for CHIP patients, also. This will be discussed later when I review the efforts by the Chapter.

 

The Final Rule states that physicians participating in the VFC program can only bill for CPT code 90460 when administering a multi-component vaccine. This disallows for using the 90461 code in addition to the 90460 code for these multi-antigen vaccines. This certainly is not consistent with AAP recommendations.

 

I have included a web site from the AAP Department of Federal Affairs that includes detailed information on this topic including FAQs. You can also get to the information by simply going to the AAP website and clicking on Advocacy, then Federal Advocacy then Access to Care: Medicaid Payment

http://www.aap.org/en-us/advocacy-and-policy/federal-advocacy/access-to-care/Pages/Access-to-Care-Medicaid-for-children.aspx

 

The AAPs Department of Federal Affairs has played a vital role in getting these increases and we owe Mark Del Monte and his staff our thanks for all the hard work they have done. They continue to advocate for pediatricians at the federal level.

 

Now for some of our efforts and what we have heard.

As part of the Committee on Federal Government Affairs, I was in Washington just before Thanksgiving to be briefed on developments at the federal level and to talk with our elected federal representatives. Joining me was Dr. Pam Shaw. This meeting allowed us to meet with staff members from two of our state's House members and staff from both of our state's Senators. Topics we discussed included Medicaid payments, graduate medical education and the pediatric workforce issues in our state, sequestration and cuts to children's programs, and the problems with drug shortages and compounding issues. My take on these conversations is that there is a small increase in the sense of willingness to compromise on the hill - but not much.

 

As I stated, the cost of the Medicaid increases will be covered by the federal government for 2 years; after that there is uncertainty. Already the funding is being questioned. In the efforts to address the budget some have suggested that this money be eliminated as a compromise to raising taxes on higher incomes. Others have suggested removing funding in order to offset the cost of the SGR. The KAAP was one of 50 chapters recently to sign on to a letter from the AAP, AMA, ACP, AAFP, and AOA to ask the House to not remove funding for this provision in the ACA. There is even a chance that funding may actually be extended after the first two years. In truth, probably the main impetus for this provision in the ACA was to get more providers to see adult patients with the mandatory expansion of Medicaid. When mandatory expansion was determined to be unconstitutional the administration was dealt a big blow. They want this expansion to occur and be successful so raising payments to Medicare levels may be considered important for this to happen.

 

I have been in contact with Kansas Action for Children concerning problems that could arise if CHIP patients are not included in the increased payments. We were planning on scheduling a meeting with KDHE, but have put it on hold after receiving an e-mail from KDHE stating that CHIP patients would be included. I have also reached out to a member of the KDHE Division of Health Care Finance to receive confirmation of this coverage. I have just received e-mail confirmation from her that CHIP patients will be covered at the same rates as Medicaid patients in the state. My office staff has also heard from one MCO that they will cover CHIP patients at the increased rates. As a result of these communications, I am very optimistic that CHIP patients will be covered, but the Chapter will continue to follow up on this issue. Also, I have been attending meetings with the KanCare Provider workgroup and will ask that this topic be included in the next meeting later in this month.

 

The Kansas Chapter meets with KDHE staff as part of the grant for the Kansas Maternal Child Health Council. We met this month and received an update on the progress of KanCare and discussed the increased payments at this meeting where we were able to voice our concerns.

 

In our conversations with KDHE and the MCOs, it is apparent that there are still many questions that are unanswered and I believe this is because the MCOs and KDHE are still working on implementation. We still don't know how the increases will be paid - in quarterly lump sums or with each encounter. And what will happen after 2 years when and if the feds cut payments? The situation is constantly changing and the Chapter will work hard to keep you up to date as the information becomes available.

Health Insurance Exchanges

 

By January 2014, the federal law known as the Affordable Care Act (Obamacare) will require that Health Insurance Exchanges be operational. Health Insurance Exchanges are State based marketplaces for individuals and small businesses to buy health insurance. The exchange is not a health insurance company. The plans in the exchanges are regulated and standardized. Not everyone will be eligible for these plans and a person's eligibility will be determined by the exchange.

 

The states have three options to run the exchange:

  • a completely state run program,
  • a joint federal and state run program, or
  • a program completely run by the federal government.

Since the passage of the ACA in March 2010 states have had an opportunity to make decisions and receive federal grants to develop these exchanges. State leaders in Kansas, like many states where there was strong opposition to the legislation, chose a "wait and see" approach pending the Supreme Court ruling and later the elections in November. This approach has led to a difference of opinion between the States Department of Insurance and Insurance Commissioner Sandy Praeger on the one hand and the Governor and leaders in the state's legislature on the other. Indeed, the state sent back an implementation grant of $31million in August of 2011 much to the dismay of Commissioner Praeger.

 

With the Supreme Court ruling and the elections results assuring implementation of the ACA, the state must now decide what type of exchange program will be developed. It is too late for a completely state run exchange to be up and running by 2014. However, the state could still form a partnership with the federal government to run the program.

 

In November, Commissioner Praeger met with the Governor and discussed this option. She supported a state/federal partnership as this would allow some state control and input. The governor turned her down and it appeared the state would be having a federally run exchange program. Recently, in an effort to accommodate states that were waiting on the outcome of the November elections to decide on the type of program, the federal government extended the November deadline to February 15 of 2013. At a recent KHI meeting held in Topeka, Commissioner Praeger said she would try once more to persuade the Governor and state legislators to enter into a joint program with the feds on the Kansas Health Insurance Exchange.

Medicaid Expansion

One of the main components of the Affordable Care Act (ACA) was a mandatory expansion of the Medicaid program to include adults up to 138% of the FPL. The Supreme Court ruling last summer struck down this portion of the ACA and made this expansion optional for the states.

 

Kansas' current Medicaid program is one of the most restrictive in the nation. Only adults with children and below 32% of the FPL ($5,900 for a family of 4) are eligible.

 

If Kansas were to increase its eligibility to include adults up to 138% of the FPL it would almost double the current number of Medicaid enrollees. A recent study done by the Kansas Health Institute estimates that Kansas Medicaid rolls would expand by 240,000. Interestingly, of this number almost half (117,000) would be children. Although these children are already eligible for Medicaid, studies have shown that as more parents become insured so do children.

 

This expansion does come with a cost.  

  • 2014 to 2017, the federal government covers 100% of the costs,
  • 2017 to 2020 this drops to 95%, and
  • 2020 on it drops to 90%.  

 

This means Kansas will incur costs, also. The same study done by KHI projected that state costs would run $519 million from 2014 to 2020. During the same time period the federal dollars given to the state would be $3.4 billion. 

 

The Governor has not made a decision on expansion and expressed doubts about the financial feasibility of Medicaid expansion.

 

 

Kansas Chapter, American Academy of Pediatrics

www.kansasaap.org

info@kansasaap.org