BENEFIT REDESIGN IMPLEMENTATION - DRAFT AHCCCS SYSTEM IMPACTS SUMMARY
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- Rolf Benson
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1 Insulin Pumps will eliminate coverage of Insulin pumps Will individuals who currently have an insulin pump be grandfathered? A. Adults who currently have an insulin pump. B. Members who receive under EPSDT who become an adult? Decision: Members will retain the item when it has been purchased prior to age 21. Replacement and rental is not allowed. Members may continue to receive maintenance on the item and associated supplies beyond their 21st b'day. Percussive Vests will eliminate coverage of percussive vests. Will individuals who currently have a percussive vest be grandfathered? A. Adults who currently have a percussive vest. B. Members who receive under EPSDT who become an adult? Decision: Members will retain the item when it has been purchased prior to age 21. CODES - E0784. Bone- Anchored Hearing Aid will eliminate coverage of Bone- Anchored Hearing AID (BAHA) CODES - E0483. Will individuals who currently have a BAHA be grandfathered? A. Adults who currently have a BAHA? B. Members who receive under EPSDT who become an adult? Decision: Members will retain the item when it has been purchased prior to age 21. CODES - L8690 and L /22/2010 C:\Documents and Settings\jadoyle\Local Settings\Temporary Internet Files\OLKD02\ Re-design Implement System considerations - Plans 5-19.xls 1
2 Cochlear Implant will eliminate coverage of cochlear implant Will individuals who currently have a cochlear implant be grandfathered? A. Adults who currently have a cochlear implant? B. Members who receive under EPSDT who become an adult? Decision: Members will retain the item when it has been purchased prior to age 21. Prosthetics Excluding prosthetic implants may implement a cap on prosthetics. The Agency has already determined that a revision of policy is more appropriate. The appears permissive. Does the Agency choose to pursue current course of limiting by policy or does the Agency choose to impose a monetary limit? Decision: will continue its decision to limit prosthetics by policy. CODES - L8614. Orthotics CODES - L5856, L5857, L5858 and L5973. What does the Agency consider an orthotic? Action: OIR letter to CMS can the Agency exclude all orthotics? Or partially excluded certain orthotic items? Follow up- 3/30/10 OIR is moving forward with SPA not letter. This will hold CMS to 90 day timeline. An inquiry to CMS has no timeline. ADHOC TABLE UPDATES AND 6/22/2010 C:\Documents and Settings\jadoyle\Local Settings\Temporary Internet Files\OLKD02\ Re-design Implement System considerations - Plans 5-19.xls 2
3 CODES - L L4999; Excluding L0859, L0861, L0980, L0982, L0984, L2810, L2840, L2850, L4000, L4002, L4010, L4020, L4030, L4060, L4070, L4080, L4090, L4100, L4110, L4130, L4205, L4210, L4390, L4392 AND L4394. Emergency Dental Service A. (5) Emergency dental care and extractions for persons who are at least twenty-one years of age. Will the Agency request a waiver for FFS American Indians? Decision: Undetermined Action: OIR letter to CMS for clarification as to the degree can limit emergency dental for adults. Follow up OIR will move forward with SPA not letter. This will hold CMS to 90 day timeline. An inquiry to CMS has no timeline. Matt working on policy definition. CODE LIST ATTACHED. CODING. Will require ISD coding of revisions of identified edits - 1 claims and 1 encounters. Provider Type (10) based. Services by Podiatrist B (2) (e) Podiatry services do not include services performed by a podiatrist. Services provided by a podiatrist are no longer covered. CODES - PROVIDER TYPE BASED. 6/22/2010 C:\Documents and Settings\jadoyle\Local Settings\Temporary Internet Files\OLKD02\ Re-design Implement System considerations - Plans 5-19.xls 3
4 Well Exams B (2) (h) Well exams are not a covered health Well visits are no longer and medical service, except mammograms, pap covered. smears and colonoscopies. Would well exams that include a mammogram, pap smear or colonoscopy be covered? Decision: These are procedure and an exam that includes a referral under the well visits codes would not be covered. Action: Matt/ALS believes that the new federal health reform bill may preclude from eliminating this service. Matt will follow up and report back to the team. Transplants B (2)(f) NONEXPERIMENTAL TRANSPLANTS Interpretation issue-# iv Action: Determine interpretation for DO NOT INCLUDE THE FOLLOWING: & v should be one item. implementation i) PANCREAS ONLY TRANSPLANTS. As currently all bone (ii) PANCREAS AFTER KIDNEY morrow and solid organ TRANSPLANTS. transplants would be dis- (iii) LUNG TRANSPLANTS. allowed- (iv) HEMOPOETIC CELL TRANSPLANTS. (v) ALLOGENIC UNRELATED TRANSPLANTS. (vi) HEART TRANSPLANTS FOR NON-ISCHEMIC CARDIOMYOPATHY. (vii) LIVER TRANSPLANTS FOR DIAGNOSIS OF HEPATITIS C. CODES , 99386, 99387, 99395, 99396, and S5190 OR Diagnosis Code of V72.31 or V Reinsurance table updates and Operational policy changes. CODES - RI TABLES 6/22/2010 C:\Documents and Settings\jadoyle\Local Settings\Temporary Internet Files\OLKD02\ Re-design Implement System considerations - Plans 5-19.xls 4
5 Imposition of visit limitation in process TBD TBD Physical Therapy Not addressed in legislation Bariatric Surgery B. (2) (g) Beginning October 1, 2011, bariatric will eliminate surgery procedures, including laparoscopic and coverage of bariatric open gastric bypass and restrictive procedures, surgery. are not covered health and medical Why was this delayed by one year? Could it be implemented by policy earlier? Answer: unknown and no CODES - TBD TBD Will implement by policy; no system impacts. October CODES - TBD 6/22/2010 C:\Documents and Settings\jadoyle\Local Settings\Temporary Internet Files\OLKD02\ Re-design Implement System considerations - Plans 5-19.xls 5
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