After months of discussions with the Cabinet for Health and Family Services (CHFS) via the KHA Medicaid Technical Advisory Committee (TAC) meetings, monthly Medicaid managed care organization (MCO) issue list meetings, individual meetings with CHFS and presentations to the Medicaid Advisory Committee (MAC), the Cabinet has made a final decision regarding sepsis.

On Wednesday, Department for Medicaid Services (DMS) Medical Director Judy Ann Theriot released a memo detailing coding and reimbursement guidelines for sepsis. CHFS will follow the CMS DRG and ICD-10 definitions of sepsis. MCOs are directed to "...base utilization management for sepsis on sepsis-2 criteria until such time that CMS adopts sepsis-3 criteria."

View the memo for more details.

KHA was successful in achieving favorable amendments to the Medicaid telehealth regulation. The Department for Medicaid Services (DMS) has issued revisions to its proposed regulation on telehealth service coverage and reimbursement.

KHA is very pleased that the regulation maintains payment parity. DMS will pay for telehealth services at 100% of the amount payable for an in-person service. Medicaid managed care organizations (MCOs) must reimburse the same amount as the department unless the MCO and provider have negotiated a different rate. DMS made several changes to their proposed rule in response to comments from KHA and other organizations.

A copy of the revised rule is available at http://www.new-kyha.com/Portals/5/NewsDocs/907KAR3_170.pdf. The revised rule must be reviewed by two legislative committees before it becomes final and effective which should occur by early November.

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The Kentucky Department for Medicaid Services (DMS) has entered into 12-month MCO contracts for State Fiscal Year 2020 effective July 1, 2019, to provide health care services to Kentuckians who meet eligibility requirements for Medicaid. The contracts below have been submitted to the Centers for Medicare and Medicaid Services (CMS) for approval.

Please note, the files below are large and will take additional time to load.

Aetna

Anthem

Humana

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KHA released a report today on the performance of the five Medicaid Managed Care Organizations (MCOs) operating in Kentucky The report was compiled from public data from 2016. The report provides information on medical loss ratios, utilization review denial rates, quality scores, corrective action and prompt payment.

If you have any questions, please contact Nancy Galvagni at KHA (ngalvagni@kyha.com).

On Tuesday, June 28, Spring View Hospital in Lebanon hosted a ceremonial signing for SB 20, KHA's top priority for the 2016 legislative session. KHA is grateful for Governor Matt Bevin's insight into the issues facing hospitals and is pleased to have this new Medicaid managed care organization appeals process in place.

KHA President Mike Rust represented the Association at the event and was joined by Lieutenant Governor Jenean Hampton and Senator Jimmy Higdon as the Governor signed this important legislation.

As the 2016 Kentucky General Assembly session is coming to a close, KHA is excited to share the news that Governor Matt Bevin has signed SB 20 into law. This was KHA’s top priority during this legislative session and its passage is a huge victory for Kentucky’s hospitals. This legislative session could not have been a success without the hard work of all the Association's membership. Your advocacy was invaluable.

Additionally, KHA extends special thanks to KHA Legislative Committee Chair Joe Koch and the Association's diligent lobbying team – Sarah S. Nicholson, Ronny Pryor, Renee Craddock and Gene McClean. KHA is also grateful to Senate President Robert Stivers and House Speaker Greg Stumbo for their work on this issue. Finally, the Association is extremely appreciative of Dr. Ralph Alvarado for sponsoring...

SB 20, KHA’s priority legislation, passed the House yesterday by a unanimous vote. The legislation gives Kentucky’s medical providers a pathway to external, independent appeals of denied Medicaid managed-care claims. The bill is now on its way to Governor Matt Bevin for his signature. Please, take a moment to contact your legislator personally and thank him or her for their support. 

SB 20, sponsored by Senator Ralph Alvarado (R-Winchester) would allow medical providers to receive an independent third-party review of claims denied by Medicaid managed care organizations (MCOs). The decision of the third-party reviewer could then be appealed to the Cabinet for Health and Family Services, where the decision of an administrative hearing tribunal would be the last step before judicial review. This includes situations when a provider has continued to render care after a denial because, in their medical judgment, continued care was in the patient’s best interest. The process is needed to assure patients get...

The Centers for Medicare and Medicaid Services (CMS) has submitted a 653-page finalized rule governing Medicaid managed care to the Office of Management and Budget (OMB) for review, according to Modern Healthcare. Reports indicate that the rule will take a step to reduce the institution for mental diseases (IMD) prohibition on treating adult Medicaid patients in freestanding psychiatric hospitals by permitting states to pay managed care organizations (MCOs) for behavioral care to beneficiaries who stay 15 days or less in an IMD. Additionally, the rule is reported to contain a medical loss ratio of at least 85%, which would allow 15% to be paid to MCOs for administration, marketing and profit. The rule also contains requirements for improving network adequacy through time and distance standards for certain types of providers, including hospitals and physicians.

OMB can take up to 90 days to review the rule, therefore, it could be published sometime in May. KHA’s comments were among the 900 comment letters CMS received on proposed rule....

KHA's priority legislation, SB 20, addresses the need for a Medicaid managed care organization (MCO) appeals process. Nina Eisner, CEO of Ridge Behavioral Health System in Lexington, testified before the Senate Health and Welfare Committee on January 13 and gave examples of why this legislation is desperately needed.

The HMO Indicators Report by KHA is now the Kentucky MCO and HMO Financial Results Report. The report has been restructured to include more concise information on all health care management organizations (HMOs) and Medicaid managed care organizations (MCOs) doing business in the state.   The Medicaid MCOs will be presented side-by-side for a quick comparison with the remaining HMOs doing business in Kentucky presented similarly. The indicators will be updated on a quarterly basis as the data becomes available from the Kentucky Department of Insurance.

A full report for the quarters through all of 2014 is now available. The document can be found in the Members Only section of www.kyha.com under Special Publications and Presentations.

If you have any questions regarding the Kentucky MCO & HMO Financial Results Report, please contact Steve Miller at KHA (502-426-6220 or 800-945-4542 or via e-mail at smiller@kyha.com).

By a letter dated December 16, 2014, The Department for Medicaid Services (DMS) distributed preliminary reconciliation of the Wrap-around payments made to Rural Health Centers (RHCs) and Federally Qualified Health Centers (FQHCs) for the for dates of service November 1, 2011, through June 30, 2014.  

DMS is unable to provide KHA with a list of hospitals that received the letter, therefore, yesterday KHA sent this correspondence to all Kentucky hospital chief financial officers.   

There are at least three significant problem areas in the reconciliations that DMS distributed to providers: the Coventry Claims for all practical purposes are excluded from the reconciliation, many dental-related claims are not included and Dual Eligibles are understated as a result of the Medicaid managed care organizations (MCOs) initially denying the claims instead of processing them as “Zero Pay” that would have allowed that visit to be included in the volume count.

A 30-day extension will be granted to all hospitals that make a request to DMS. Requests are to be sent to David Dennis and he will forward them to Myers and Stauffer.  E-mailed requests for an extension will be accepted.  David Dennis’ email is:  David.Dennis@ky.gov...

KHA has received an advance copy of this notice that is being sent to all providers from MHNet (Coventry's behavioral health care vendor) announcing MHNet will be changing their Medical Necessity Criteria (MNC) to the criteria used by Aetna for adult and child/adolescent behavioral health services.  The change will be effective on January 1, 2015.  The notice has links to the new criteria.  

KHA has asked MHNet to discuss the changes in criteria at the next meeting with Medicaid managed care organizations (MCOs) on December 19 at KHA.  Hospitals with behavioral health services should review the criteria and either attend, or conference call into the meeting on December 19 with any specific questions about the criteria, or how it will be applied.  The meeting will be held at 10:15 a.m. (EST) at the KHA office, or your staff may...

The Kentucky Department for Medicaid Services (DMS) is conducting Open Enrollment for ALL Medicaid managed care enrollees from October 27 through December 12.  Earlier this week, all chief executive officers and chief financial officers received a legal opinion obtained by KHA from Wyatt, Tarrant & Combs which addressed hospital communication with Medicaid beneficiaries regarding their ability to switch Medicaid managed care organizations (MCOs) during this time.  This legal opinion was also provided to hospitals earlier this year in response to a more limited Medicaid Open Enrollment and, at that time, KHA held a webinar to summarize the information contained in the opinion, as well as to answer member questions.  A replay of that webinar is now available on the Members Only section of the KHA Website.  

If you have any questions about accessing the Members Only section of the KHA Website, please contact Pam Kirchem at KHA (502-426-6220 or 800-945-4542 or via email at pkirchem@kyha.com).

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The HMO Indicators Report by KHA is now the Kentucky MCO and HMO Financial Results Report. The report has been restructured to include more concise information on all health care management organizations (HMOs) and Medicaid managed care organizations (MCOs) doing business in the state.   The Medicaid MCOs will be presented side-by-side for a quick comparison with the remaining HMOs doing business in Kentucky presented similarly. The indicators will be updated on a quarterly basis as the data becomes available from the Kentucky Department of Insurance.

A full report for the quarters through the Second Quarter of 2014 is now available. The document can be found in the Members Only section of www.kyha.com under Special Publications and Presentations.

If you have any questions regarding the Kentucky MCO & HMO Financial Results Report, please contact Steve Miller at KHA (502-426-6220 or 800-945-4542 or via e-mail at smiller@kyha.com).

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The Interim Joint Committee on Health and Welfare met in Frankfort on August 4. During the meeting, Cabinet for Health and Family Services (CHFS) Executive Director of Policy and Budget Beth Jurek discussed the July 1 Executive Order to reorganize CHFS and the administration of Medicaid. She stated the Cabinet is restructuring the department to reflect the change to managed care from fee for service in order to ensure managed care organizations (MCOs) are meeting the requirements of the contracts and monitor the way that clients are receiving services. CHFS is reducing the number of divisions from eight to six, which according to Jurek, will be a net decrease, with no increase in the agency. CHFS is also consolidating information technology services.

The Committee also discussed and approved the Executive Order to reorganize the Health Benefit Exchange. Under the plan, the Office of Health Information Exchange will be included in the newly established Kentucky Office of Health Benefit and Health...

Last year, Governor Steve Beshear directed the Cabinet for Health and Family Services (CHFS) to initiate enhanced educational efforts to improve the continued implementation of Medicaid managed care. CHFS, in partnership with the managed care organizations (MCOs), is sponsoring the second round of these forums across Kentucky in August and September. These forums are designed to allow any and all health care providers who have contracts with MCOs and serve Medicaid consumers to meet face-to-face and discuss concerns about proper billing, prior authorizations, prompt pay, appeals processes or any other specific issues related to managed care.

In attendance will be senior level staff from each MCO, senior staff from the Department of Insurance (DOI), Office of the Inspector General, Department for Medicaid Services, Department for Public Health, Department for Behavioral Health, Developmental and Intellectual Disabilities and the Office of the Secretary.

Pre-registration (at least five days in advance...

The Interim Joint Committee on Health and Welfare met in its first interim meeting on June 18 in Frankfort.

Commissioner Mary Begley, Dr. Alan Brenzel, Lisa Lee and staff from the Department for Behavioral Health, Development and Intellectual Disabilities (DBHDID) testified on the closing of the IMPACT Plus Program in Kentucky. IMPACT Plus was created as a Title V “funding stream” for additional behavioral health services with additional providers outside the 14 Community Mental Health Centers in 1997. IMPACT Plus was designed to serve children with high intensity behavioral health needs, who were in or at risk of out-of-home placement, after being required to meet eligibility criteria.

The DBHDID determined that, in current practice, the program is duplicative of the Medicaid managed care organizations (MCOs), which creates inefficiency in program administration and increases cost.

On January 1, 2014, the Centers for Medicare and Medicaid Services (CMS) authorized a Medicaid State...

KHA has produced  a report for its members on payments and denials from Medicaid managed care organizations (MCOs). The report includes prompt pay and prior authorization data from the second quarter of 2012 through the third quarter of 2013. The data is all derived from state sources.

The report is available in the Members Only section of the KHA website, www.kyha.com. Chief executive officers can obtain a user name and password from Ginger Dreyer at KHA (502-426-6220 or 800-945-4542 or via email at gdreyer@kyha.com). KHA encourages CEOs to share their facility's passwords with their staff at their discretion.

The HMO Indicators Report by KHA is now the Kentucky MCO and HMO Financial Results Report. The report has been restructured to include more concise information on all health care management organizations (HMOs) and Medicaid managed care organizations (MCOs) doing business in the state.

The Medicaid MCOs will be presented side-by-side for a quick comparison with the remaining HMOs doing business in Kentucky presented similarly. The indicators will be updated on a quarterly basis as the data becomes available from the Kentucky Department of Insurance.

A full report for the first three quarters for 2013 is now available. The document can be found in the Members Only section of www.kyha.com under Special Publications and Presentations.

If you have any questions regarding the Kentucky MCO & HMO Financial Results Report, please contact Steve Miller at KHA (502-426-6220 or 800-945-4542 or via e-mail at smiller@kyha.com).

The HMO Indicators Report by KHA is now the Kentucky MCO and HMO Financial Results Report. The report has been restructured to include more concise information on all health care management organizations (HMOs) and Medicaid managed care organizations (MCOs) doing business in the state.

The Medicaid MCOs will be presented side-by-side for a quick comparison with the remaining HMOs doing business in Kentucky presented similarly. The indicators will be updated on a quarterly basis as the data becomes available from the Kentucky Department of Insurance.

A full report for 2012 as well as report with the first two quarters for 2013 is now available. The documents can be found in the Members Only section of www.kyha.com under Special Publications and Presentations.

If you have any questions regarding the Kentucky MCO & HMO Financial Results Report, please contact Steve Miller at KHA (502-426-6220 or 800-945-4542 or via e-mail at smiller@kyha.com).