Post on 26-May-2020
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