09/05/2018

Medicaid

Recent Oncology Related Issues and News

PENDING MEDICAID ISSUES - UPDATED 9/4/2018

Michigan Managed Medicaid Plan Medical Benefit Drug Restrictions

MSHO continues to address the disparity in drug approvals between traditional Medicaid and the managed Medicaid plans. The managed plans are required to approve therapies that are a medical benefit with traditional Medicaid.  Thank you to those that sent in examples.  Those examples are in the hands of Medicaid and we are awaiting the next steps.  Stay tuned....

Update 9/4/18:  While many exclusions were reported on Total Health Care, it seems there has been some progress on getting some items approved.  Aloxi is still listed on the Website as EXCLUDED from coverage, however, a member office called for authorization to give it with Carbo/Taxotere regimen and they APPROVED it right away as a Medical Exception, no fuss at all.  They said they give exceptions when the treatment is listed as Highly Emetogenic and this one was on the list!  

Therefore, MSHO members should attempt to get approval for ANY/ALL drugs that are approved by traditional Medicaid and continue to report to MSHO if they have any instance when any Managed Medicaid plan does not allow the same coverage.

Update 8/6/18 - It has been reported to MSHO that Meridian Medicaid has approved Neulasta for patients that would meet medical necessity for Medicare on the first request - Progress.  MSHO is continuing to work with traditional Medicaid to address other disparities with Managed Medicaid Plans.

Update 7/10/18 - MSHO continues to work with traditional Medicaid to address issues with Managed Medicaid plans not offering the same benefits as traditional Medicaid.  There has been some success with approvals on a case by case basis for Meridian Medicaid.  Efforts continue.

Update 6/4/18 - MSHO has submitted the first case to traditional Medicaid who has agreed to follow up with the managed plan, Total Healh Care, within 30 days.  Stay tuned.

Update 5/15/18 - MSHO conferenced with traditional Medicaid and established a plan to address the disparities and step edits in place with many of the Managed Medicaid plans.  This process will begin later this week addressing a couple of companies at a time.  We will continue to update as issues are resolved.

5/1/18 - MSHO and Medicaid have set a call to discuss the best approach to address the outstanding issues.  This call will occur next week.

Proposed Medicaid Policy Effective January 1, 2019 
Claims for Medicaid Beneficiaries Eligible for Medicare

To View Policy, CLICK HERE

NOTE from Vernell Hester, COC, CHONC, Billing Specialist, Beaumont Health Hematology Oncology:  
Good News - If this goes through and starts in January, it will be a great help for all of those patients to neglect to enroll in Medicare because they think they are fully covered by Medicaid and don’t want that extra expense of Part B premiums!  As of now, we have to bill the patient for 100% of the charges, since Medicaid will not pay anything without Medicare being active and paying first, and hope the patient is able to get retro coverage.  Then we have to jump through hoops to get the patient to enroll themselves or get Medicaid Buy-In.  Sometimes patients have even stopped treatment when they learned they were not covered!

Public Comment on MDHHS Medicaid Health Plan Common Formulary

The Michigan Department of Health and Human Services (MDHHS) is soliciting comments from the public on the Michigan Medicaid Health Plan Common Formulary.  The Common Formulary applies to pharmacy claims paid by Medicaid Managed Care Organizations – it will not apply to claims paid through Fee-for-Service.  The public may submit comments on the drugs included or not included on the Common Formulary, new drug products, prior authorization criteria, step therapy criteria and other topics related to drug coverage under the Common Formulary.  The comments will be reviewed by MDHHS and the Michigan Medicaid Health Plan Common Formulary Workgroup. The next drug classes to be reviewed by the Workgroup include Diabetes, GI and Endocrine & Metabolic. Changes may be made to the Common Formulary based on comments received.  Comments will be solicited once per calendar quarter. 

To view the Michigan Medicaid Health Plan Common Formulary CLICK HERE

Please send your comments by August 24, 2018 to:

Linda VanCamp, Formulary Analyst
Bureau of Medicaid Care Management & Quality Assurance
Medical Services Administration
P.O. Box 30479
Lansing, Michigan 48909-7979

Telephone Number: 517-373-9252
Fax Number: 517-763-0142
E-mail Address: MDHHSCommonFormulary@michigan.gov

Most Recent Bulletins That May Affect Medical Oncology

August 31, 2018 - MSA 18-32 - Updates to the Medicaid Provider Manual; Clarification to Bulletin MSA 17-21;Code Updates

August 31, 2018 - MSA 18-31 - Update to the Coverage of Physician Assistant Services

 CLICK HERE  to review all MSA Bulletins

August 29, 2018: Attention ALL Providers: Health care providers that serve Medicaid beneficiaries are facing an upcoming enrollment deadline that is necessary for them to continue to receive payments from Medicaid. While the Michigan Department of Health and Human Services (MDHHS) has revised the timeline to give providers more time to enroll, the department is urging providers to complete the screening and enrollment process as soon as possible.

August 22,2018: Attention Rural Health Clinic (RHC) Providers: It has been determined that the reduction factor for Medicaid secondary and tertiary claims has not been properly adjudicating payments. MDHHS is aware of the issue and will keep providers updated, when corrected. 

To visit the Biller "B" Aware website CLICK HERE