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Spring Provider Workshops 2017
West Virginia Department of Health and Human Resources
Bureau for Medical Services (BMS)
Sarah Young, Deputy Commissioner Dee Ann Price, Quality Unit Director
April 3 - Martinsburg, WV April 4 - Wheeling, WV April 5 - Morgantown, WV April 6 - Vienna, WV April 10 - Roanoke, WV April 11 - Charleston, WV April 12 - Huntington, WV April 13 - Beckley, WV
West Virginia Medicaid Enrollment Update
As of March 1, 2017, West Virginia Medicaid covers 542,049 individuals - approximately 29% of West Virginia’s population:
Fee-for-service (FFS), i.e., traditional/regular Medicaid:
115,760 members currently enrolled
Includes foster care children, Medicaid Waiver recipients, nursing facility residents, elderly/disabled categories, and those who also receive Medicare
Mountain Health Trust (MHT), the State’s Medicaid Managed Care Program:
426,289 members currently enrolled
Includes most children, pregnant women, adult expansion, parents and caretaker relatives
Effective January 1, 2017, West Virginia Medicaid expanded its MHT Managed Care Program and transitioned approximately 46,000 Supplemental Security Income (SSI) members from FFS to MHT.
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Managed Care Update: SSI Transition
Continuity of Care:
SSI members receiving services at the time of Managed Care
Organization (MCO) enrollment were allowed 90 days to
complete a current ongoing course of treatment with a non-
network provider.
This allowed additional time for the provider to contract with
the member’s MCO.
If the provider does not want to contract with the member’s
MCO, the MCO will work with the member and current non-
network provider to identify a new provider and ensure that
an appropriate transition plan is developed, including the
exchange of patient records.
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Managed Care Update: OON Transfers
Reminder to hospital providers regarding non-emergent member transfers to an out-of-network (OON) facility:
Confirm whether a member is enrolled in an MCO or FFS.
For MCO members, obtain prior authorization from the MCO.
For FFS members, obtain prior authorization from KEPRO.
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Managed Care Update: Carved Out Services
What benefits are NOT included in the Managed Care Plans? Transplants Nursing Facility Services Medicaid Waiver Services
Aged and Disabled Waiver (ADW) Intellectual and Developmental Disabilities Waiver (IDDW) Traumatic Brain Injury Waiver (TBIW)
Non-Emergency Medical Transportation (NEMT)* Hepatitis C medications Hemophilia medications Personal Care Services For these services, providers will continue to send claims to Molina for all members (FFS and MCO). *NEMT services are provided and paid for by Medical Transportation Management (MTM).
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Managed Care Update: Contacts
MCO Contact Information:
Aetna Better Health of West Virginia (formerly CoventryCares) Michelle Coon, Director of Operations/Site Manager, phone: 304-348-2017, email: [email protected]
The Health Plan Christy Donohue, Director, Medicaid, phone: 304-720-4923, email: [email protected]
UniCare Health Plan of West Virginia Tadd Haynes, Chief Operating Officer, email: [email protected] Anthony Duncan, Director, Network Relations, phone: 304-347-2481, email: [email protected] Terri Roush, Manager, Network Relations, email: [email protected] Carrie Blankenship, Network Education Representative, phone: 304-533-4086, email: [email protected]
West Virginia Family Health Donna Sands, Director of Operations/Controller, phone: 304-424-7661, email: [email protected]
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Adoption of CDC Opioid Guidelines
West Virginia Medicaid is incorporating the Centers for Disease Control and Prevention (CDC) Opioid Prescribing Guidelines for the management of chronic pain by: Reviewing coverage of non-pharmacological therapies. Implementing a program that calculates and tracks morphine-equivalent dose
and requires a prior authorization (PA) for chronic doses over 50 MME/day. Providing counseling regarding naloxone therapy in case of overdose. Improving access to behavioral health services. Placing a “hard stop” on the concurrent coverage of opiates and
benzodiazepines. Working to improve access to substance use disorders (SUD) screening and
treatment services. Developing uniform prior authorization form for opioids. Constructing template for treatment plan based on guidance. Implemented by FFS on January 17, 2017.
Implemented by MCOs April 1, 2017. CDC’s Opioid Prescribing Guidelines are available at
http://www.cdc.gov/drugoverdose/prescribing/providers.html
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Medicaid 1115 Waiver Proposal
The West Virginia Department of Health and Human Resources
submitted to the Centers for Medicare and Medicaid Services (CMS) a
section 1115 waiver application that describes an approach to
addressing the SUD epidemic for Medicaid enrollees in West Virginia.
The goal is to build a comprehensive continuum of care across the
state to more effectively prevent and treat SUD in West Virginia by:
Providing additional Medicaid services to promote SUD treatment;
Further integrating efforts currently underway through the Bureau
for Behavioral Health and Health Facilities;
Looking across all state agencies to ensure resources are being
leveraged wisely and efficiently; and
Accessing additional federal Medicaid funding to supplement
existing state funding.
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Medicaid 1115 Waiver Target Populations
2017 update: Both MCO and FFS members will be eligible for an enhanced set of SUD treatment services under the waiver.
Waiver will include strategies focused on SUD prevention and treatment among adolescents. At-risk families will be eligible for SUD treatment services
to allow for community-based treatment and supports to prevent the child from being placed out of home.
Foster care youth will be able to receive SUD treatment services through the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefit.
Medicaid will build on existing efforts to raise awareness and address the prevalence of babies born with exposure to substance use (31 out of every 1,000 births in West Virginia).
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Medicaid 1115 Proposal – SUD Services
Medicaid benefit expansions under the waiver: Statewide adoption of the screening, brief intervention, and referral to
treatment (SBIRT) method to ensure a consistent and effective diagnosis and enrollment process.
Expanded coverage of withdrawal management in regionally identified settings.
Short term, residential substance abuse treatment for Medicaid managed care enrollees.
Enhanced access to outpatient SUD treatment as appropriate when residential treatment is not required.
Coverage of methadone and methadone administration as part of the state’s opioid treatment program.
A comprehensive initiative for distributing naloxone and cross-training staff on administration of naloxone as part of the effort to reduce overdose deaths.
Coverage of a set of clinical and peer recovery support services and recovery housing supports designed to promote and sustain long-term recovery.
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BMS Policy and Program Updates
Take Me Home, West Virginia: Supports eligible Medicaid members to transition from
facility-based, long-term services and supports to their own homes and apartments in the community.
Has two transition navigator partner agencies: Metro Area Agency on Aging (AAA) Coordinating Council for Independent Living (CCIL)
Has approximately 11 full-time equivalent (FTE) transition navigators across West Virginia.
For more information about Take Me Home, West Virginia: Website: www.dhhr.wv.gov/bms/Programs/Takemehome Phone: 304-356-4926
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BMS Policy and Program Updates (Cont.)
Drug Screening:
BMS will continue to follow the CMS coding guidelines for reporting drug testing procedures. Current requirement is to submit drug testing services to BMS
using CMS codes 80305-80307, G0480-G0483, and G0659. New service limit is 24 per calendar year, for dates of service on
and after January 2017. Only one code per member/per date of service. BMS will continue to require a prior authorization for drug
screenings performed over the service limit. The HF modifier must be included on all drug screening codes
when related to substance abuse treatment (e.g., Suboxone).
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BMS Policy and Program Updates (Cont.)
BMS Quality Unit: CMS Adult Quality Measures (AMQ) Grant was partially extended until June
2017. Reporting to CMS the Adult and Child Quality Core Measures. Collaborating with Medicaid MCOs and External Quality Review Organization
(EQRO).
Adult Quality Measures Grant - Two Quality Improvement Projects (QIPs): Prenatal behavioral health risk assessment and postpartum care visit. Increasing follow-up after hospitalization for mental illness. The QIPs:
Include member communication regarding importance of follow-up appointment;
Provide information on transportation services; and Identify barriers for members to attend their follow-up appointment.
Look for the “Quality Corner” in Medicaid Provider Newsletter updates.
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BMS Health Homes Program Update
West Virginia Health Homes: The first Health Homes Program, launched July 1, 2014, for Medicaid
members with bipolar disease who have or are at risk of having Hepatitis B or C, was expanded statewide in April 2017.
Second Health Homes Program launched April 1, 2017, to address the co-occurring conditions of diabetes and obesity.
To participate in either of these Health Homes Programs, please list your contact information on the workshop evaluation.
Additional Health Homes Program information is available on the BMS website: www.dhhr.wv.gov/bms/ and the KEPRO website: www.kepro.com.
Questions/concerns - contact KEPRO at 304-343-9663 or 1-800-461-0655.
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Transportation Update
Medicaid Non-Emergency Medical Transportation (NEMT) Broker is MTM (Medical Transportation Management): Recent NEMT statistics: Trips scheduled:
February 2017 = 59,182 Calendar Year 2016 = 715,581
Contact information: MTM 2 Hale Street Charleston, WV 25301 Phone: 1-844-549-8353 Fax: 1-844-239-5970
https://www.mtm-inc.net/west-virginia
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Provider Revalidation Update
Provider Revalidation is required every five years for Medicaid providers under 2011 Federal regulations for Provider Screening and Enrollment:
Effective September 25, 2016, Cycle 1 Provider Revalidation ended.
Cycle 2 Provider Revalidation will begin for West Virginia Medicaid providers in June 2018.
Revalidation date is based on most recent effective date.
Cycle 2 revalidation will include MCO providers, as applicable.
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Provider Enrollment Updates
January 1, 2017: BMS requested that the provider enrollment effective date be
based on the date Molina receives a complete, clean provider enrollment application, as long as the provider passes required screening. This should begin in April 2017.
January 4, 2017: CMS released revised “Medicaid Provider Enrollment
Compendium.” Sub-regulatory guidance, policy and clarification that State
Medicaid agencies must follow for provider enrollment. Located at: https://www.medicaid.gov/affordable-care-
act/downloads/program-integrity/mpec-142017.pdf.
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Provider Enrollment Updates (Cont.)
June 1, 2017:
West Virginia Medicaid must be in compliance with the Fingerprint Based Criminal Background Check (FCBC) requirement of February 2, 2011, federal regulations on provider enrollment and screening.
FCBC requirement applies to certain provider types enrolled on and after August 1, 2015, including, but not limited to: Home Health Durable medical equipment, prosthetics, orthotics and supply
providers (DMEPOS) Providers who have been excluded in the past 10 years Any other providers designated as “high risk” by BMS or CMS
Providers enrolled in Medicare or another state’s Medicaid or Children’s Health Insurance Program (CHIP) and who have already had a FCBC do not have to undergo another check.
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Provider Enrollment Updates (Cont.)
West Virginia Medicaid reviewed currently enrolled providers in “high risk” categories against information in Medicare’s provider enrollment, chain and ownership system (PECOS). Providers who did not have an FCBC on file in PECOS should have received
a letter. West Virginia Medicaid working with West Virginia Clearance for Access,
Registry and Employment Screening (WV CARES) Program to implement FCBC process. Providers who must meet the FCBC requirement will receive notification
from BMS informing them of the procedures they must follow and three pre-selected MorphoTrust locations for fingerprinting. Locations available on BMS website at: http://www.dhhr.wv.gov/bms/Provider/Documents/MorphoTrust%20Enrollment%20Center%20roster02282017.pdf
Providers are responsible for FCBC-related fees. Check must be mailed to Molina prior to fingerprinting.
Providers will have 30 days from date of notice to complete FCBC.
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Provider Enrollment Updates (Cont.)
January 1, 2018:
Molina will begin screening MCO providers. Managed Care Federal Rule (March 2016) stated Medicaid has
ultimate responsibility for screening, enrolling, and periodically revalidating all Medicaid MCO network providers.
21st Century Cures Act supersedes implementation date for MCO network provider screening.
Moved implementation date from July 1, 2018 to January 1, 2018.
MCO network providers must have a participation agreement in effect with State Medicaid agencies, even if they do not plan to participate in the Medicaid FFS program.
MCO network providers will be subject to revalidation every five years.
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Unenrolled Prescriber Edit: West Virginia Medicaid has opted for a phased-in approach for remaining
unenrolled prescribers.
Mirrors Medicare’s approach and dates.
Important: Unenrolled Prescriber Edit means that prescriptions (new or refill) written by providers who are not enrolled with West Virginia Medicaid on January 1, 2019, will be denied. This edit applies to all providers who prescribe, including those newly eligible to enroll as part of revalidation (i.e., hospital residents, physician assistants).
Provider Enrollment Edits
Claim Edit Name and
Disposition
Edit Description Date of
Edit Implementation
Unenrolled Prescriber - Deny Change edit disposition to “Deny” when
prescriber is not enrolled
January 1, 2019
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BMS Program Integrity (PI) Update
Electronic Health Record (EHR) Audits: Currently conducting EHR audits for Program Year 2014.
Audits will continue through the end of Program Year 2021.
Reminder: Provider documentation and system compliance must support information in attestation.
Provider Screening of Employees and Contractors: West Virginia Medicaid is required by CMS to direct providers to:
Screen employees and contractors for excluded persons to prevent Medicaid payments for items/services furnished or ordered by excluded individuals and entities.
Search the Office of Inspector General’s List of Excluded Individuals and Entities (LEIE) monthly to capture new exclusions or reinstatements that occurred since the last search.
LEIE’s online searchable database at: https://exclusions.oig.hhs.gov/.
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BMS Resources
West Virginia Bureau for Medical Services (West Virginia Medicaid) Mailing address: 350 Capitol Street, Room 251 Charleston, WV 25301 Telephone: 304-558-1700 Website: http://www.dhhr.wv.gov/bms/
Medicaid Fee-for-Service (FFS) Molina – Fiscal Agent: https://www.wvmmis.com/default.aspx KEPRO (formerly APS Healthcare) – Utilization Management Contractor: http://wvaso.kepro.com HMS – TPL Contractor: http://www.wvrecovery.com/
Medicaid Managed Care (Mountain Health Trust) MCOs – Aetna Better Health of WV, The Health Plan, UniCare and WV Family Health
Scion – Dental Benefits Manager: www.sciondental.com Maximus – Enrollment Broker: https://www.mountainhealthtrust.com/
FFS & Managed Care MTM – Non-Emergency Medical Transportation Broker: https://www.mtm-inc.net/west-virginia/
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Medical Card Update
West Virginia Department of Health and Human Resources
Office of Management Information Services
Tanya Cyrus, RN, MHA, CMCN Director, Medicaid Management Information Systems
West Virginia Medical Assistance Cards Beginning April 2015, DHHR transitioned from issuing monthly to
annual medical assistance cards.
West Virginia is one of 50 states who provide annual cards.
West Virginia has saved an estimated $2.5 million annually with this change.
Savings driven primarily in printing and mailing costs.
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West Virginia Medical Assistance Cards (Cont.)
Looking for your feedback on what’s working and what’s not working since transitioning to annual cards.
Seeking further feedback for additional cost savings and efficiencies by:
Leveraging existing resources like the Molina Automated Voice Response System (AVRS) and Provider Portal to check eligibility
Elimination of printing medical assistance cards
Smartphone app for medical cards
Please submit additional feedback through the workshop survey.
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Management Information Services Resources
West Virginia Office of Management Information Services (MIS)
Mailing address:
One Davis Square, Suite 200
Charleston, WV 25301
Website: http://www.wvdhhr.org/mis/
Email: [email protected]
West Virginia Office of Medicaid Management Information Systems (MMIS)
MMIS Director, Tanya Cyrus [email protected]
MMIS Operations Manager, Cynthia Shelton [email protected]
Mailing address:
One Davis Square, Suite 200
Charleston, WV 25301
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