State of West Virginia Bureau for Medical Services

December 18, 2013

COST SHARING WEBINAR

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AGENDA

Welcome

Cost Sharing Overview

Cost Sharing Structure

Maximum Out of Pocket (OOP)

Exemptions

Molina Web Portal

Eligibility Response

Member Proof of Coverage

Discussion

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COST SHARING OVERVIEW • Beginning January 1, 2014, some services will be assigned cost sharing

(copay) amounts for Medicaid members which will effect the following provider types:

Practitioner

Hospital

Pharmacy

Rural Health Clinic

Federally Qualified Health Clinic

Ambulatory Surgical Center

• Cost Sharing applies to current and newly eligible individuals.

• Services cannot be refused for populations with income at or below 100% FPL if the member is unable to pay the copay amount.

• Maximum Out of Pocket (OOP) cannot exceed 5% of the Members’ quarterly household income.

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COST SHARING STRUCTURE MEDICAL/DENTAL

• Tiered Cost Sharing Structure

Tier 1 (Up to 50.00% FPL)

Tier 2 (51.00 – 100.00% FPL)

Tier 3 (101.00% FPL and above)

Service TIER 1 TIER 2 TIER 3

Inpatient Hospital (Acute Care 11x) $0 $35 $75

Office Visit (Physicians and Nurse Practitioners) (99201-99205, 99212-99215 only for office visits for new and established patients based

on level of care)

$0 $2 $4

Non-Emergency use of Emergency Department - Hospital only (Lowest level (99281) of Emergency Room visits in hospitals. The definition of this visit

is an emergency department visit for the evaluation and management of a patient, which

requires these 3 key components: A problem focused history; A problem focused

examination; and straightforward medical decision making.)

$8 $8 $8

Any outpatient surgical services rendered in a physician’s office, ASC

or Outpatient Hospital excluding emergency rooms. $0 $2 $4

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COST SHARING STRUCTURE PHARMACY

• Effective May 1, 2014, co-payments will be assessed on the total allowed charge for the prescription, regardless of preferred or non-preferred status.

• The table below displays the new co-payment structure. All member categories previously excluded from co-pays will continue to be excluded.

Total Allowed Charge Co-payment

$0.00-$5.00 $0.00

$5.01-$10.00 $0.50

$10.01-$25.00 $1.00

$25.01-$50.00 $2.00

$50.01 and above $3.00

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• The OOP is the most the Member will ever be required to pay in any given quarter regardless of the number of healthcare services received.

• Cost sharing cannot exceed 5% of the Medicaid members’ quarterly household income.

• Each calendar year quarter, Members will have a maximum out of pocket (OOP) payment respective to their tier level.

• After July 1, 2014, members’ quarterly OOP maximum costs will be based on pharmacy, medical and dental co-payments combined.

MAXIMUM OUT OF POCKET (OOP)

Tier Level Out of Pocket Maximum

1 $8

2 $71

3 $143

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EXEMPTIONS • The following populations and services are exempt from copays:

Pregnant Women including pregnancy-related services up to 60 days post-partum;

Children under age 21;

Native American and Alaska natives;

Intermediate Care Facility or MR services;

Preventive services;

Individuals in Nursing Homes,

Receiving Hospice services,

Medicaid Waiver services,

Breast and Cervical Cancer Treatment Program;

Family Planning services; and

Emergency services.

• Additional exemptions for Pharmacy include diabetic testing supplies syringes and needles, BMS approved Home Infusion supplies and 3-day emergency supplies.

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ELIGIBILITY RESPONSE

• Cost sharing information will be listed on the following:

AVRS

271 transaction

Molina Web Portal

• Molina will return a copay amount for the start date of service if the provider inquires on a date range.

• No copays will be listed for members on the exemption list.

• Remittance advices will be modified to include the copay amount that was deducted.

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MEMBER PROOF OF COVERAGE WEB PORTAL VIEW

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MEMBER PROOF OF COVERAGE PRINTED VIEW

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ELIGIBILITY RESPONSE PROVIDER WEB PORTAL VIEW

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DISCUSSION

For more information or updates, please visit the following:

www.dhhr.wv.gov/bms/Pages/default.aspx

OR

www.wvmmis.com