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Summer 2016
The Second Session of the 55th Oklahoma Legislature adjourned on May 27, 2016.
With a $1.3 billion budget hole in an election year, the Legislature had their work cut out for them before they arrived on day 1. The state experienced not just one but two revenue failures during state fiscal year (SFY) 2016 (July 1, 2015 – June 30, 2016). These mid-fiscal year cuts impacted agencies differently and set up the legislature with more work than anticipated. The Oklahoma Health Care Authority (OHCA) lost approximately $63 million in state appropriations due to the revenue failures.
From a legislative standpoint, OHCA was involved with the requests for two high-profile measures – the “Medicaid Rebalancing Act of 2020” and the $1.50 cigarette tax increase. Throughout the first few weeks of the legislative session, budget cuts to most agencies were rumored to be between 10 to 15 percent of the previous year’s appropriation. For OHCA, a cut of this magnitude equated to a large provider rate cut - up to 25 percent. State legislators heard directly from SoonerCare providers, members and the business community on their shared concerns of how a 25 percent provider rate cut would impact patients, facilities and communities as a whole. While our request bills did not receive final passage from the legislature, we moved the needle in terms of prioritizing health care in the state’s upcoming budget.
Senate Bill 1616 (SB 1616), the SFY 2017 general appropriations bill, was introduced on May 17, 10 days before the state constitutionally required adjournment (also known as sine die). SB 1616 appropriated $6.8 billion out to agencies for SFY 2017. With an appropriation of $991 million, OHCA was one of only a handful of agencies that received an increase in appropriations and/or a flat appropriation. There are no additional provider rates cuts scheduled due to the approved budget agreement.
Click here for an issue statement on the budget agreement from OHCA CEO Nico Gomez.
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Rule changes in effect
Gov. Mary Fallin signed and certified the OHCA’s 2016 permanent rule changes on June 9, 2016. All policy changes are effective Sept. 1, 2016, and will post to the policy webpage on that date.
2016 changes to the OHCA’s permanent rules were available for review and input in two rounds - Dec. 16, 2015, through Jan. 15, 2016, or January 15 - Feb. 16, 2016. The rules include new regulations requested by the public, members, providers, other state agencies and OHCA staff and leadership. (Visit our Proposed Policy Changes Archive for rule impact summaries.)
Simultaneously, we considered rules previously promulgated on an emergency basis.
The OHCA Board considered and voted on the rules at the Feb. 11, 2016, and March 24, 2016 meetings. Afterward, the rules were forwarded to the Legislature and governor for action.
There is a total of 43 permanent rule changes for 2016. Among them are:
Obstetrical policy at OAC 317:35-5-2 and 317:35-22-2 is amended to unbundle the reimbursement structure for OB services. Currently the agency utilizes the global care CPT codes for routine obstetrical care billing, which can be used if the provider rendered care for a member for greater than one trimester. The proposed policy will require obstetrical care be billed using the appropriate evaluation and management codes for antepartum care, as well as the appropriate delivery only and postpartum care services when rendered. The change allows for more accurate tracking of antepartum and postpartum services.
(Reference APA WF #15-07B)
Optical supplies policy at OAC 317:30-5-432.1 and at OAC 317:30-5-450 is revised to clarify that eyeglasses meant as a backup are not covered, clarify that high-index lenses require prior authorization and other language only changes for clarity. Proposed policy changes clarify that members can select eyeglasses with special features that exceed the SoonerCare allowable fee as long as the provider obtains signed consent from the member. The member will be responsible for the excess cost and the provider must be able to dispense standard eyeglasses for which SoonerCare would fully reimburse.
(Reference APA WF # 15-17)
Freedom of choice policy at OAC 317:30-3-14 is revised to strengthen the consequences of not adhering to the lock-in restrictions by sanctioning members who have been locked in with a single prescriber and pharmacy.
(Reference APA WF #15-56)
Laboratory services and urine drug screening/testing policy at OAC 317:30-5-20 and 317:30-5-20.1 is amended to establish rules for the appropriate administration of urine drug screening and testing to align with recommended allowances based on clinical evidence and standards of care. Further revisions clarify the difference between quantitative and qualitative testing and when quantitative urine drug screening is an appropriate test to utilize. Also, changes to general laboratory services clarify appropriate billing for detection of individual infectious organisms.
(Reference APA WF #15-08)
In addition to OHCA program and policy updates, there are also specific rules changes affecting independent diagnostic testing facilities (IDTFs), as well as dental and behavioral health providers.
OHCA will send you complete details on all 2016 permanent rule changes in the next few weeks.
Rate and method changes starting in July
The OHCA State Plan Amendment Rate Committee (SPARC) makes recommendations for changes to rates and/or methodology that necessitate a State Plan Amendment. SPARC serves the rate-setting process by conducting hearings at which the public, vendors and OHCA staff have the opportunity to provide testimony and documented evidence in support of rate recommendations.
SPARC approved the following rate and method changes at the June 27, 2016, public meeting. The OHCA Board of Directors then considered and voted upon SPARC’s recommendations on June 30. The Board approved the following (See complete details on each change in the Board meeting agenda):
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Regular nursing facilities rates - A rate increase for regular nursing facilities, a result of the required annual recalculation of the Quality of Care (QOC) fee and the annual reallocation of the pool for the “Direct” and “Other” Care components of the rates per the State Plan. (Effective July 1, 2016)
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Acquired immune deficiency syndrome (AIDS) nursing facilities rates – A rate increase for nursing facilities serving residents with AIDS patients, a result of the required annual recalculation of the QOC fee. (Effective July 1, 2016)
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Acute (16 beds or less) intermediate care facilities for individuals with intellectual disabilities (ICF/IID) rates – A rate increase for acute ICF/IID facilities, a result of the required annual recalculation of the QOC fee. (Effective July 1, 2016)
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Regular intermediate care facilities for individuals with intellectual disabilities (ICF/IID) rates – A rate increase for Regular ICF/IID facilities, a result of the annual recalculation of the QOC fee. (Effective July 1, 2016)
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Unbundling of obstetrical (OB) services - New rate methodology will be billing individual visits rendered based on the appropriate evaluation and management CPT code, as well as the delivery and postpartum services provided. Note: Providers treating women for prenatal care prior to Sept. 1, 2016, who have not delivered by this date will continue to utilize the global methodology. (Effective Sept. 1, 2016)
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Reimbursement for eyeglasses - Total reimbursement for a set of eyeglasses, including refraction and fitting = $83.01. New rate methodology change for HCPCS codes:
- V2020 – Eyeglass frame = $10 per frame
- V2100-V2114 and V2200-V2214 – lens = $13.95 per lens (x2 per one set of eyeglasses)
- V2784 - Polycarbonate lens = $0.00, as all lens would be polycarbonate material
And CPT codes:
- 92015 – Refraction = reimbursement of $16.63
- 92340 – Monofocal fitting fee = reimbursement of $28.48
(Effective Sept. 1, 2016)
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Physicians can renew early!
REMINDER: Physicians’ contracts are set to expire on Sept. 30, 2016. However, these providers can log on to the secure OHCA Provider Portal to start renewing their contracts on July 18, 2016.
Physicians are OHCA's larger provider type. If you are a physician, please begin your renewal as early as possible.
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In case you missed it ...
The OHCA would like to make you aware of the following policy changes affecting behavioral health providers:
1. Change in limits for psychotherapy and service plan updates provided by outpatient behavioral health agencies. As of June 1, 2016:
- Individual therapy is now limited to four (4) units per day per client; family therapy is limited to 4 units per day per client; and group therapy is limited to six (6) units per day per client.
- Group therapy has a weekly limit of no more than three (3) hours per week per client.
- Individual and family therapy have a cumulative weekly limit of no more than 2 hours combined per week per client.
- Service plan updates will only be reimbursable every six (6) months.
2. Change in limits for psychotherapy provided by independent licensed behavioral health practitioners (LBHPs).
- As of June 1, 2016, psychotherapy is now limited to four (4) units/session per client per month.
3. Psychiatric residential treatment facilities attestation is required.
- As required by OAC 317:30-5-95, psychiatric residential treatment facilities must submit an attestation statement to OHCA as part of their established provider agreement.
- Annual submission of attestation statements is required. Make sure to upload them to the facility’s provider file through the Electronic Provider Enrollment System by the first of each fiscal year, July 1.
Be sure to check our Global Messages for further details and additional updates.
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Caries Risk Assessment update
OHCA has revised our Caries Risk Assessment (CRA) form for SoonerCare dental partners, to make it more user friendly. The tool is a modified version of one originated by the American Dental Association (ADA) for its members. It is our hope that the CRA opens a dialogue between the parent/member and the dentist. The Caries Risk Assessment form and instructions are on our website.
Please note that the assessment cannot address every aspect of a patient’s health. As with other forms, this assessment may only be a starting point for evaluating the patient’s health status.
OHCA partner dentists are encouraged to complete and upload this information yearly through the secure Provider Portal.
Required for orthodontics, the CRA should be submitted along with the orthodontic prior authorization (PA) request. The dental home is the preferred choice to complete the assessment, but the orthodontist may complete as a last resort.
For payment, submit the CRA as a PA, via the OHCA Provider Portal or by mail. Mailed CRA submissions must have the HCA-13D and a completed ADA claim form attached. After PA approval, a claim may be filed.
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Earn FREE CME for buprenorphine waiver training
In an effort to help fight prescription opioid dependence and addiction, clinicians have the opportunity to obtain training in medication-assisted treatment AT NO COST.
In order to prescribe or dispense buprenorphine, physicians must qualify for a physician waiver, which includes completing eight hours of required training. You may participate in this training during a special class on Aug. 27, 2016, from 8 a.m. – 5:30 p.m., at the Embassy Suites Downtown/Medical Center in Oklahoma City (located at 741 N. Phillips Ave.). The course is free of charge to registrants, and lunch will be provided. Click here to register online by August 19.
Please direct questions about this training to Justina Andonian at 401-524-3076 or justina@aaap.org.
This Medication-assisted Treatment Buprenorphine Waiver Training is brought to you by the Oklahoma Osteopathic Association, the Oklahoma Department of Mental Health and Substance Abuse Services, the Oklahoma State Department of Health, and the Oklahoma State Medical Association.
Beat the bite
As summertime rolls along, many people spend more time outside. While positive health benefits may result, some risk factors also increase. Summer is the season when dog bites are most prevalent among children under age 17, with peak incidence in August. Preschool-age children, especially one-year-olds, are at greatest risk.
Systemic antibiotic treatment is not necessary for the vast majority of dog bites. Good local care of the area reduces the risk of infection to 5 percent or less. The American Academy of Pediatrics and the Infectious Diseases Society of America offer this guidance for the care of patients suffering from dog bites:*
- Apply firm pressure until bleeding stops
- Wash area gently with soap and water
- Apply topical antibiotic, cover wound
- Verify Tetanus vaccination of victim
- Verify Rabies vaccination of animal
Patients should seek medical care if:
- wound is large, bleeding does not stop, or wound edges will not come together
- wound appears infected: presence of pus or drainage; wound is swollen/tender after three days; there are red streaks from the wound; patient has swollen glands
Experts recommend post-bite prophylactic antibiotic therapy only for patients who:
- are immunocompromised
- are asplenic
- have advanced liver disease
- have edema to the affected area
- have moderate to severe injuries (particularly to the hands and face)
- have injuries that may have penetrated the periosteum or joint capsule
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References:
Analysis of Dog Bites in Children Who Are Younger Than 17 Years. Schalamon JS, Ainoedhofer H, et al. Pediatrics. March 2006, 117 (3): e374-e379.
Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America. Stevens DL, Bisno AL, et al. IDSA Practice Guidelines for STIs.
Available at http://cid.oxfordjournals.org/content/early/2014/06/14/cid.ciu296.full.pdf
Animal Bites and Pasturella Infections. Garcia VF. Pediatrics in Review. April 1997, 18 (4): 127-130.
Micromedex
Please contact Jacki Travers, Pharm.D, at jacki-travers@ouhsc.edu or 405-271-5935 for more information on this article or to schedule a complimentary educational visit from CARE (Collaborative Advancement of Prescription Excellence). Current topics include Medication Prior Authorization Training and ADHD and Atypical Antipsychotics.
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SoonerFit.org helps bring healthy home
SoonerFit.org provides free information to help Oklahomans get fit and stay well. The SoonerFit team continuously seeks out and implements new outreach opportunities to achieve this mission. They recently launched a new series of web videos on social media to help us all eat well.
In these videos, members of our SoonerFit team provide step-by-step instructions on how to prepare fresh fruits and vegetables, which provide a great foundation for healthy meals. These tips may benefit anyone looking to improve their cooking skills, eat healthier and save time in the kitchen. The videos are very popular with our social media followers, and we encourage you to share them with your patients. You can watch the cooking demos online at SoonerFit.org.
SoonerFit.org also helps to connect SoonerCare members to nutritional and child health services that may be covered under their plans.
Did you know that adults and children can have up to six (6) hours of nutritional counseling per year by a licensed registered dietician, if prescribed by a physician, physician assistant, advanced practice nurse or nurse midwife? Click here for benefit and payment information.
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Electronic signatures accepted for 2016 EHR attestations
The OHCA EHR Incentive Team is pleased to announce that electronic signatures will be accepted starting with the 2016 attestations. It will no longer be required to submit the SoonerCare Provider Agreement Signature Form with your uploaded documentation.
If you have questions or need more information on the upload process, please contact the EHR Incentive Team at 405-522-7347, okehrincentive@okhca.org, or visit our website: www.okhca.org/ehr-incentive.
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The OHCA will resume ABD (aged, blind and disabled) Care Coordination stakeholder meetings on July 26, 2016, as part of the Request for Proposal (RFP) development for the program.
The RFP is the result of HB1566, passed during the 2015 Oklahoma Legislative Session. The bill charged OHCA with issuing an RFP for care coordination models for its ABD populations. The intent of the legislation is to provide better access to care, improve quality and health outcomes, and control costs.
Due to a successful state fiscal year (SFY) 2017 budget agreement, activities to develop the RFP will continue. This includes, but is not limited to, evaluation of changes in the current health care environment and engagement of an actuary to develop rates. Revisions to the extended timeline of the ABD Care Coordination effort are now underway.
The July stakeholder meeting will occur on July 26, from 2-4 p.m., at the OHCA, Ed McFall Boardroom (4345 N. Lincoln Blvd, OKC). Stakeholders are welcome to attend in-person or via webinar to receive up-to-date information on next steps in the process. Information on this effort, including updated timelines and webinar connections, will be available at www.okhca.org/abdcarecoordination.
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Casey Dunham, who served as the assistant director of OHCA Provider Services for the last three years, is now the director of Provider Services.
While earning his master’s degree in Business at Oklahoma City University, Dunham began an internship at OHCA in 2005. He was hired into a permanent position with the agency in 2006.
Melody Anthony, who recently vacated the directorship, is now deputy state Medicaid director.
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OHCA dentist recognized for leadership of national organization
The OHCA congratulates Chief Dental Officer Leon Bragg, D.D.S., on his recent recognition by Delta Dental of Oklahoma for his service as president of the Medicaid Medicare CHIP (Children's Health Insurance Program) Services Dental Association (MSDA).
The award, presented during a luncheon at the annual MSDA Symposium in Washington, D.C., included a $10,000 sponsorship to the symposium in recognition of Dr. Bragg's service and leadership. Read more about this honor here.
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July 13
Drug Utilization Review (DUR) Board Meeting
July 21
Medical Advisory Committee (MAC) Meeting
August 10
DUR Board Meeting
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Text4baby (T4b) is a free, national mobile messaging service that connects new and expectant mothers to important information and resources for themselves and their babies who are under one year of age.
Oklahoma is one of four states chosen to participate in a pilot program that allows T4b enrollees to receive enhanced messages containing state-specific content. The OHCA is a partner in this program, which is supported in part by the Centers for Medicare & Medicaid Services (CMS).
Although the T4b program is not going away, the CMS pilot project ends in August 2016. In an effort to keep patients connected to these localized resources, health care providers have the opportunity to order flyers for their practices AT NO COST. T4b will even pay to ship them to you! This will help ensure that this valuable information and the mission of T4b will continue long after the pilot program ends.
These full-color, glossy flyers are available in both English and Spanish. Please email Rachael Salley at rsalley@zerotothree.org by August 1 to place your order. Be sure to list your mailing address and the number of flyers you would like to receive.
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OHCA Provider Helpline: 800-522-0114
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