Public Meeting for

Montana Health and Economic Livelihood Partnership (HELP) Program Benefits

November 12, 2015

1

Agenda• Welcome and Introductions• HELP Program Health Benefits• Copayment Information• Chart of HELP Program Benefits• HELP Program Populations• HELP Program Medical and Behavioral Benefits• Non-TPA Expansion Populations• Standard Medicaid Benefits• Administrative Rules of Montana Process• Public Comment Process

2

Posted Material

Information regarding benefits can be found at: http://dphhs.mt.gov/medicaidexpansion.

• Posted materials include:• Benefits Public Notice• Draft HELP Program Evidence of Coverage• HELP Program Rules• How to apply for the HELP Program

3

HELP Program Health Benefits• Required by the Affordable Care Act (ACA)

• Ambulatory Patient Services• Emergency Services• Hospitalization Services• Maternity and Newborn Services• Mental Health and Substance Use Disorder Services• Prescription Drug Services• Rehabilitative and Habilitative Services and Devices• Laboratory and X-Ray Services• Preventive Services• Pediatric Services

• Additional Healthcare Benefits (administered by DPHHS)• Vision Services• Dental Services• Hearing Aids Services• Audiology Services• Transportation Services• Indian Health Services• Federally Qualified Health Clinic Services• Rural Health Clinic Services• Diabetes Prevention Program

4

5

Premiums and copayments combined may not exceed 5 percent of family household income.

Certain services, including the following, are exempt from co-pays under federal or state law:

• Emergency services

• Preventive health care services including primary, secondary or tertiary preventive health care services

• Family planning services

• Pregnancy related services

• Generic drugs

• Immunizations

• Medically necessary health screenings ordered by a health care provider

6Benefit HELP TPAStandard Medicaid State Plan

Cost Share

1. Ambulatory Patient Services      a) Primary Care X   Yesb) Specialists X   Yesc) Other Practitioner (Nurse, APRN, Physician Assistant) X   Yesd) Hospice X   No  e) Adult Dental Services (Treatment Limit $1,125/Annual; Dentures, Preventive/Diagnostic, and Anesthesia do not count toward annual limit.)   X Yes

f) Urgent Care X   Yesg) Home Health Care (Limit 180 visits/Annual) X   Yesh) FQHC/RHC Services   X Yesi) Family Planning Services and Supplies  X   Noj) Routine Eye Exams (1 Exam/Annual) X   Yesk) Hearing Aid   X Yesl) Dialysis X   Yesm) Allergy Treatment     Yesn) Telehealth Services (type of service delivery) X   Noo) Indian Health Service (IHS) and Tribal Health Services   X Nop) Outpatient Surgery Facility X   Yesq) Audiology   X Yesr) Outpatient Hospital X   Yess) Adult Eye Glasses (Medicaid Contract - Limit One Pair/12 Months)   X Not) Accident Related Dental Surgery and Services X   Yesu) Other Individualized Education Services (related to a medical condition other than diabetes)  X   Yes

v) Non-Emergency Transportation Services    X No

7BenefitClaims

Processed by TPA

Claims Processed by

DPHHS Cost Share

2. Emergency Services      a) ER Department Services X   No b) Air & Ground Ambulance   X No 

3. Hospitalization      a) Observation/Anesthesia X   Yesb) Inpatient Services (Includes: Transplant, Physicians, and Surgical) X   Yesc) Cosmetic Surgery (Condition with Severe Detrimental Effect)  X   Yesd) Transplant and Donor Services (Excludes: donor searches and experimental treatments) X   Yes

e) Blood Transfusions X   Yesf) Reconstructive breast surgery following a medically necessary mastectomy- including any surgery to the non-affected breast to establish a symmetrical appearance, and prostheses.  X   Yes

4. Maternal and Newborn Care (Pre and Post)      a) Prenatal and Postnatal Care X   No  b) Delivery and All Inpatient Services for Maternity X   No  c) Long Acting Reversible Contraceptives Inserted at Time of Delivery (LARC) X   No 

5. Mental Health and Substance Use Disorder Including Behavioral Health Treatment      a) Mental/Behavioral Health Outpatient Services (not provided in an IMD) X   Yesb) Mental/Behavioral Health Inpatient Services (not provided in an IMD) X   Yesc) Substance Abuse Disorder Outpatient Services (not provided in an IMD) X   Yes

d) Substance Abuse Disorder Inpatient Services (not provided in an IMD) X   Yes6. Prescription Drugs (Identical Coverage as Existing Medicaid)      a) Home Infusion   X Yesb) Tobacco Cessation   X No  c) OTCs   X Yesd) Vaccines   X No  e) Contraceptives   X No  

8BenefitClaims

Processed by TPA

Claims Processed by

DPHHS Cost Share

7. Rehabilitative and Habilitative Services and Devices      a) Outpatient Rehabilitative - No limits, Including: Services provided for: physical therapy; speech therapy; cardiac therapy, and occupational therapy. X   Yes

b) Habilitative Services, Including: A specialized, intense and comprehensive program of therapies and treatment services, including but not limited to: physical, occupational and speech therapy, provided by a multidisciplinary team for treatment of an injury or physical deficit. A Rehabilitation Therapy program is provided by a rehabilitation facility in an inpatient care or outpatient setting; provided under the direction of a qualified physician and according to a formal written treatment plan with specific goals; designed to restore the patient's maximum function and independence; and medically necessary to improve or restore bodily function and the member must continue to show measurable progress. Applied Behavior Analysis (ABA) is not covered over age 18.

X   Yes

c) Prostheses (to replace a body part missing due to accident, illness, or injury). (Excludes: computer-assisted communication devices, or replacement of lost or stolen prosthesis) X   Yes

d) DME (Includes: blood glucose testing and supplies; spacers for metered dose inhalers; enteral solutions; syringes and needles. Excludes: exercise equipment, lifts, hot tubs, computerized equipment, athletic equipment, replacement of lost or stolen items, repair or rental equipment, or convenience items.) X   Yes

e) Skilled Nursing Services (Limit 60 Day/Annual; Excludes: Custodial Care)X   Yes

f) Cochlear Implants  X   Yesg) Transitional Services (Includes: Swing Beds and Short Term Rehabilitation) X   Yes

9BenefitClaims

Processed by TPA

Claims Processed by

DPHHS Cost Share

8. Laboratory Services      a) Diagnostic Test (X-Ray and Lab) X   No b) Imaging (CT/PET Scans and MRI) X   No 9. Preventive and Wellness Services and Chronic Disease Management      a) Preventive Care, Screening, Immunizations X   No  b) Breast Pumps - Limit One Per Birth X   No c) Preventive Health Services (Meets Federal Guidelines) X   No d) Diabetes Prevention Program    X Yese) Diabetes Self-Management Education X   Yes10. Pediatric Services Including Oral and Vision Services (EPSDT) Covered for 

medically necessary services for age 19-20

  No  

11. Additional Medicaid State Plan Services      a) Long Term Care Services (Nursing Facility, Community First Choice, Personal Care)

  X No

b) Mental Health Services (Therapeutic Foster Care & Group Home, PACT, Day Treatment)   X Yes (some 

services)

c) Podiatry   X Yes 

d) Targeted Case Management (High Risk Pregnant Women, Several Disabling Mental Illness, Developmental Disabilities, Substance Use Disorder)   X No

e) Passport, Health Improvement Program, Team Care, Nurse Advice Line, Patient Centered Medical Home   X No

HELP Program Eligibility Populations

The following populations are eligible for TPA Services:

• Childless adults between the ages of 19-64 years of age, with an income at or below 138% of the Federal Poverty Level (FPL) – i.e. $16,424 for an individual;

• May not be enrolled or eligible for Medicare;• May not be incarcerated; and• Must be a United States Citizen or documented, qualified alien.

10

HELP Program Medical and Behavioral Health Benefits

Administered by Blue Cross Blue Shield of Montana (BCBSMT):• Hospital Services

• Emergency Services• Durable Medical Equipment/Medical Supplies/Prosthetics• Mental Health and Substance Use Disorder Services • Home Heath (180 visits) and Hospice Services• Rehabilitative and Habilitative Services• Diagnostic Laboratory and X-Ray Services• Preventive Services, including Early Periodic Screening,

Diagnostic and Treatment Services (EPSDT)• Convalescent Home Services (60 days)• Surgical Services • Medical Vision Services

11

Non-TPA Expansion Populations

Benefits are administered through the Medicaid State Plan for: • Individuals determined to be medically frail; and• Individuals exempt by federal law.

Benefits may be through the Medicaid State Plan for: • Individuals who live in a geographical area with insufficient

health care providers; and• Individuals in need of continuity of care that

would not be available or cost-effective through the TPA.

12

Standard Medicaid BenefitsCurrent

• Dental: No annual treatment limit (Excludes: Dentures, Preventive/Diagnostic and Anesthesia)

• Eye Exams: 1/24 months• Eyeglasses: 1/24 months• Home Health Care: 75 visits• Hospice: Does not cover curative

services for adults• Therapies: 40 hour/annual • Cardiac Therapy: 2-1 hour

sessions/day and 36 sessions total limit

• Folic Acid: Not covered OTC• Detox Services: Up to 7 days• Chemical Dependency (Inpatient

and Outpatient): Children only• Mental Health Outpatient: 24

sessions/annual

Changes Effective 1/1/2016• Dental: $1,125 annual treatment

limit (Excludes: Dentures, Preventive/Diagnostic and Anesthesia)

• Eye Exams: 1/12 months• Eyeglasses: 1/12 months• Home Health Care: 180 visits• Hospice: Will cover curative

services for adults• Therapies: No annual limit• Cardiac Therapy: No daily or

session limit• Folic Acid: Covered OTC• Detox Services: No daily limit• Chemical Dependency (Inpatient

and Outpatient): Add Adults• Mental Health Outpatient: No

session limit

13

HELP Administrative Rules of Montana (ARMs)

• Timeline• 10-19-15 ARMs filed with Secretary of State • 10-29-15 Secretary of State Publication • 11-18-15 Public Hearing• 11-26-15 End of ARMs Public Comment Period• 12-14-15 Earliest Final Filing• 1-1-16 Effective Date

14

Public Comment Process• Public Comment• This public comment is for the benefits only.

• DPHHS/BCBSMT Role• Listen to as many public comments as possible in an organized

manner.• All comments will be reviewed and considered equally whether they

are received in person or on the phone.

• Public Role• Phone individuals, with hand raised, will speak in their sign in order.• In person attendees will speak when called upon.

Turn off cell phones; Be courteous to others by being quiet while others are

speaking; Be respectful of limited time so all may comment; and We encourage each person to submit a full copy of comments.

15

Public Comment Submittal

Comments may be submitted until midnight on November 26, 2015. You can submit in writing by mail, email, or verbally in the public meetings. All comments will be reviewed and considered equally.

By Mail:The Department of Public Health and Human Services

Attn: Rebecca CorbettP.O. Box 202951

Helena, MT 59620-2951By Email:

rcorbett@mt.gov

Additional Information:

http://dphhs.mt.gov/medicaidexpansion

16

Public Comment

17