MHCP provider news and updates

SCHA will no longer be a health plan option for Minnesota Health Care Programs (MHCP) members living in Morrison, Todd and Wadena counties effective Jan. 1, 2020. SCHA members in the following programs must choose a new health plan during the annual health plan selection (AHPS) period beginning in October 2019:

• Families and Children 
• MinnesotaCare 
• Minnesota Senior Care Plus (MSC+) 
• Minnesota Senior Health Options (MSHO) 

SCHA members in Families and Children, MinnesotaCare, MSC+ and MSHO who do not select a new health plan will be assigned into a system-generated default plan effective Jan. 1, 2020.

SCHA members in Special Needs BasicCare (SNBC), known as SingleCare, SharedCare or AbilityCare, will be moved to and access their health care services through Medical Assistance fee-for-service effective Jan. 1, 2020.

MSHO and Integrated SNBC members living in Morrison, Todd and Wadena counties have Medicare coverage through SCHA and received a letter from SCHA in early October explaining their options. These members can call the Senior Linkage Line at 800-333-2433 for assistance in enrollment into a new Medicare Advantage Plan or New Part D Plan effective Jan. 1, 2020.

Minnesota Department of Human Services is working with SCHA on the transition of their Morrison, Todd and Wadena county members’ current services and authorizations.

SCHA remains a health plan option in Brown, Dodge, Freeborn, Goodhue, Kanabec, Sibley, Steele, Wabasha and Waseca counties for 2020. SCHA members and providers in these counties do not need to take action at this time. Providers should contact the MHCP Provider Call Center at 800-366-5411 with questions. (pub. 10/15/19)

Minnesota Health Care Programs (MHCP) is providing free billing training for IEP providers. We will provide training in person and online through a webinar.

Training is scheduled from 9 a.m. until 3 p.m. on the following dates:

• Wednesday, Oct. 16, 2019
• Monday, Nov. 18, 2019
• Wednesday, Dec. 18, 2019

In-person training will be held at the Minnesota Department of Human Services, 444 Lafayette Rd., St. Paul, 55101. See the Individualized Education Program (IEP) Services Billing Lab web page for registration and more information.

For help registering for this training, contact the MHCP Provider Call Center at 651-431-2700 or 800-366-5411. (pub. 10/9/19)

MHCP FFS will no longer allow payment for HCPCS G0101 (Cervical or vaginal cancer screening) or Q0091 (Screening Pap smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) beginning Jan. 1, 2020.

Obtaining a screening pap smear is part of a comprehensive preventive service and should not be reported separately. Collection of a diagnostic pap smear due to symptoms or illness is included in the physical exam portion of a problem-oriented Evaluation and Management service and is not separately reportable.

Continue using the appropriate CPT codes for pap smears for the pathologist’s interpretation of the cytology specimen. (pub. 10/7/19, rev. 10/14/19)

MHCP members may change their health plan during AHPS to be effective for Jan. 1, 2020. We will begin mailing AHPS forms to members beginning in October.

Members who want to change their health plan must return the form by Thursday, Dec. 5, 2019. If members do not want to make changes, they do not have to do anything. Members will be reenrolled in the same health plan as long as the member is eligible. Members are not required to change their health plan during open enrollment unless their current health plan will not be available the following year.

Members in counties with only one health plan choice will receive notice of the opportunity to change their primary care physician. (pub. 10/3/19)

Beginning Jan. 1, 2020, MinnesotaCare members on fee-for-service (FFS) who are 19 or 20 years old will no longer receive the following services:

• Home care nursing
• Orthodontics
• Nonemergency medical transportation
• Personal care assistance
• Case management
• Nursing home

Additionally, the dental benefit will be limited to receive only the following:

• Diagnostic, preventive and restorative services
• Endodontics, periodontics, prosthodontics, removable prostheses
• Dental X-rays
• Oral surgery and outpatient dental surgery

See the MHCP Benefits at-a-glance webpage for more information about Minnesota Health Care Programs covered services for FFS members. (pub. 9/25/19)

Minnesota Department of Human Services (DHS) is considering amendments to its rules governing use of random sample extrapolation in monetary recovery and seeks public comment. The Surveillance and Integrity Review Section (SIRS) at DHS uses random sample extrapolation to identify and recover overpaid Minnesota Health Care Programs (MHCP) funds. You can find a summary of the proposed amendments, the official Notice of Request for Comments, the draft amendments and other information under Surveillance and Integrity Review Section (SIRS) on the Rulemaking Docket webpage.

You can submit comments on the proposed amendments via:

• Email to elizabeth.oji@state.mn.us
• U.S. Postal Service to:
  Elizabeth Oji
  Office of the Inspector General, Minnesota Department of Human Services
  P.O. Box 64982
  St. Paul, MN 55164-0982
• Posting on the Office of Administrative Hearings website
• Calling 651-431-6316. TTY users may call 800-627-3529
• Faxing 651-431-7569

We will accept comments until further notice that we intend to adopt or withdraw the rules. (pub. 9/25/19)

The 30-day quantity limit of diabetic testing strips will decrease from 200 strips to 100 strips (or 102 depending on the package size) beginning Nov. 1, 2019. Prior authorization is required if members need more than 100 strips (or 102 depending on the package size) per 30 days.

The National Drug Code (NDC) list of preferred blood glucose meters and preferred blood glucose testing strips has also changed. See the Point of Sale Diabetic Testing Supply Program section of the Minnesota Health Care Programs Provider Manual or the Diabetic Testing Supplies webpage for the NDC list of preferred products. (pub. 9/25/19)

We have posted the 2019 Provider Legislative Update. It includes a summary of key provisions passed during the 2019 Minnesota Legislative Session that affect you. See the 2019 Provider Legislative Update (DHS-7607A) (PDF) to read the update. (pub. 9/19/19)

The Minnesota Department of Human Services (DHS) will send letters beginning Oct. 17, 2019, to providers that may have received payment from both DHS and from another health plan without coordinating benefits. You are required to coordinate benefits of members covered by more than one insurance plan. Coordination of benefits ensures that Medical Assistance (MA) is the payer of last resort. We will send you a letter to your MN–ITS mailbox and via the U.S. Postal Service. You will be instructed to replace your MA paid claims with the coordination of benefits information within 30 days from the date of the letter. If the claim is more than a year from the date of service, you will need to attach the letter to your claim. (pub. 9/17/19)

The FQHC and RHC section of the MHCP Provider Manual has been updated to reflect changes in legislation that became effective July 1, 2019.

The following changes are effective for dates of service beginning on or after July 1, 2019:

• MinnesotaCare major program claims will be submitted to and paid by managed care organizations (MCOs).
• For FQHCs only, claims with Medical Assistance major programs will be submitted directly to MHCP. However, if the member is also enrolled in an MCO and has Medicare primary, the claim will still be submitted to the MCO.

For FQHC and RHC changes made to the billing process, see the Federally Qualified Health Center and Rural Health Clinics section of the MHCP Provider Manual. (pub. 9/17/19)

The Minnesota Department of Human Services (DHS) must change a fee-for-service (FFS) Medical Assistance (MA) member’s major program and eligibility span when the member is admitted to or discharged from an IMD facility for SUD treatment services. The procedure for notifying DHS of FFS MA members being admitted to or discharged from an IMD for SUD treatment services has changed.

Beginning Sept. 11, 2019, when you admit or discharge FFS MA members to or from an IMD facility for SUD treatment services, you are required to complete the County Notice of IMD Status (DHS-4145) (PDF) form and fax the completed form to the county or tribe of financial responsibility who completes the service agreements for that agency. Fax each request separately. The county or tribal agency will notify DHS to update the member’s major program and eligibility span.

See the Behavioral Health e-Memo for more information, including details of the updated procedures. (pub. 9/13/19)

Starting on Oct. 15, 2019, Minnesota Health Care Programs (MHCP) will start sending out revalidation notices to these four provider types: counties, personal care provider organizations (PCPOs), public health nursing providers, and waiver service providers. The notices will be sent to the MN–ITS mailbox for providers who are due for revalidation.

To ensure the most effective and efficient revalidation processing and to prevent backlogs, please do not send any revalidation documents until you receive your initial revalidation notice. You will receive a revalidation notice when you are due for revalidation.

Check your MN–ITS PRVLTR folder regularly for important notices, including notices that you are due for revalidation. If you have not set up a MN–ITS mailbox, your notice of revalidation will be sent to the credentialing address on your enrollment record.

For more about revalidation, review Provider Screening Requirements in the MHCP Provider Manual. (pub. 9/13/19)

The 2019 hearing aid volume purchase contract goes into effect Sept. 1, 2019, and is available online. See the 2019 Hearing aid contract, vendors, models, prices and codes Effective 9/1/19 through 8/31/20 (DHS-7274G) (PDF) to view the contract. The 2018 contract expired Aug. 31, 2019. You have a 30-day grace period for dispensing instruments purchased, but not delivered, before the contract expired. You must dispense hearing aids obtained under the 2018 contract before the grace period ends on Sept. 30, 2019. This includes hearing aids with approved authorizations. (pub. 9/4/19)

Centers for Medicare & Medicaid Services (CMS) approved Residential Withdrawal Management Service Level 3.2 (clinically managed) and Level 3.7 (medically monitored) and we have added both service levels to Minnesota’s Medicaid benefit set beginning July 1, 2019.

The Residential Withdrawal Management Services (245F) license is a separate residential license you must obtain from our licensing division in order to provide and bill for the services. You must enroll as an eligible provider with Minnesota Health Care Programs after you receive your 245F license. We are working to complete the systems update to move forward with implementation of Residential Withdrawal Management Services and to ensure you are able to enroll and bill for services appropriately.

For managed care organizations (MCOs), Residential Withdrawal Management Services are carved out of the MCO contract until 2020. On or after Jan. 1, 2020, providers will bill the health plan for managed care members.

If you have questions about Residential Withdrawal Management Services licensing, please contact Kristi Strang at Kristi.strang@state.mn.us or 651-431-6611.

If you have questions about policy, please contact the Behavioral Health Division (BHD) at DHS.BHD.Withdrawal.Management@state.mn.us. (pub. 8/6/19, rev. 8/9/19, rev. 9/18/19)

Important changes were made to state law regarding the reimbursement rate for outpatient drugs covered by the fee-for-service (FFS) Medical Assistance (MA) program during the 2019 legislative session. See the Office of the Revisor Statutes SF 12 Bill Text Versions webpage for statutory references. Effective for claims with a date of service on or after July 1, 2019, the following changes will be incorporated into the MA reimbursement for outpatient drugs:

Drug reimbursement (ingredient cost, for example)

• The reimbursement rate for drugs is the same for all pharmacies. The differential rate paid to rural independently owned pharmacies was eliminated.
• The reimbursement rate for drugs is the lesser of the National Average Drug Acquisition Cost (brand or generic), the state maximum allowable cost or specialty maximum allowable cost, or the usual and customary charge submitted. If a drug does not have a National Average Drug Acquisition Cost, state maximum allowable cost and specialty maximum allowable cost, then the reimbursement rate is the lesser of the wholesale acquisition cost minus 2 percent or the usual and customary charge submitted.

Dispensing fee

• The dispensing fee for “covered outpatient drugs”, as defined by federal law, will be increased to $10.48 from $3.65.
• The dispensing fee for covered drugs that don’t meet the federal definition of a “covered outpatient drug” will remain $3.65. An example of a covered drug that doesn’t meet the definition of a “covered outpatient drug” is a covered over-the-counter (OTC) multivitamin. 
• The dispensing fee for all compounded intravenous solutions was changed to $10.48 per bag.  All other dispensing fees for compounded intravenous products were eliminated.
• The dispensing fee for covered OTC drugs will be prorated if a claim is for less than the manufacturer’s original package size.  
• The retrospective billing pharmacy OTC drug dispensing fee was eliminated.
• The Long-term care blister card system dispensing fee was eliminated.

340B reimbursement

• The reimbursement rate for outpatient drugs dispensed by a 340B covered entity is the lesser of the 340B Drug Pricing Program ceiling price, the National Average Drug Acquisition Cost (brand or generic), or the usual and customary charge submitted. If a drug does not have a 340B Drug Pricing Program ceiling price and National Average Drug Acquisition Cost, then the reimbursement rate is the lesser of the wholesale acquisition cost minus 2 percent or the usual and customary charge submitted.
• The reimbursement rate for drugs administered to FFS members by 340B covered entities will be discounted by 28.6 percent. Before July 1, 2019, these claims were discounted by 20 percent. 
• All outpatient pharmacy claims dispensed to FFS members must be submitted with a submission clarification code of ‘20’. All medical claims for 340B drugs administered to FFS members must be submitted with the ‘UD’ modifier. Minnesota Department of Human Services will use the submission clarification code and modifiers to exclude claims from the Medicaid drug rebate program.  

Over-the-counter (OTC) drugs

• Covered OTC drugs prescribed to FFS members are no longer required to be dispensed in the manufacturer’s original package. Claims for partial packages of OTC drugs will be reimbursed at the sum of the ingredient cost plus a prorated dispensing fee.

MinnesotaCare tax

• Subject to federal approval, the drug reimbursement (ingredient cost) will be increased by 1.8 percent to account for the MinnesotaCare tax applied to wholesale drug distributors. 

Additional Changes

• The definition of a provider’s usual and customary price was revised to clarify that it includes prices that are offered as part of a discount program offered by the pharmacy.
  …”The usual and customary price means the lowest price charged by the provider to a patient who pays for the prescription by cash, check, or charge account and includes prices the pharmacy charges to a patient enrolled in a prescription savings club or prescription discount club administered by the pharmacy or pharmacy chain.” 
• Minnesota Health Care Programs (MHCP) will conduct a Cost of Dispensing Survey every three years. All pharmacies enrolled with MHCP must participate in the survey and may face sanctions if they do not participate. We will provide additional information regarding the survey and survey process in the future.

All changes were moved to production as of July 19, 2019. We will reprocess those claims for dates of service from July 1, 2019 – July 18, 2019 on Aug. 29, 2019, and they will appear on your Sept. 17, 2019, remittance advice. Pharmacies may reverse and resubmit their own claims. (pub. 7/19/19) 

The Centers for Medicare & Medicaid Services National Correct Coding Initiative established a medically unlikely edit for Mental Health Partial Hospitalization HCPCS code H0035 with a maximum unit of one per day beginning Jan. 1, 2019. This change went into effect before our system work was completed.

Minnesota Health Care Programs will use the 2018 hourly rate to reimburse claims for dates of services beginning Jan. 1, 2019, through June 30, 2019. Resubmit your denied or incorrectly paid claims for dates of services Jan. 1, 2019, through June 30, 2019, as follows:

1. Change the service unit to 1 unit
2. In the “Reference” (Loop: 2300, NTE01) field, enter Updated Information “UPI” 
3. In the “Text” (Loop: 2300, NTE02) field, enter the number of hours provided

These instructions do not apply to claims submitted for dates of service on or after July 1, 2019. On July 12, 2019, a new per diem rate (PDF) was added to our system effective July 1, 2019. Resubmit claims with dates of service before July 13, 2019, to receive the new rate. Claims with dates of service on or after July 13, 2019, do not need to be resubmitted. (pub. 7/18/19)