2014 Provider Expo. Karen Geiger Associate General Counsel, Anthem Blue Cross and Blue Shield of Wisconsin

Transcription

1 Change 2014 Provider Expo Karen Geiger Associate General Counsel, Anthem Blue Cross and Blue Shield of Wisconsin This presentation contains proprietary information of Anthem Blue Cross and Blue Shield. It is intended for Anthem providers. Any redistribution or other use is strictly forbidden. Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin ("BCBSWi") which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 1

2 Agenda Purpose Benefit Impact 2014 Administrative Impact 2

3 Purpose Prevent health plans from imposing less favorable benefit limitations on behavioral health benefits than on medical benefits Impacts 2010 large group health plans January 1, 2014 ACA compliant plans Renewals on or after July 1, 2014 most individual and small group plans Not impacted Transitional individual and small group policies Retiree only plans 3

4 Benefit Impacts 2014 Cost-sharing changes Residential treatment centers Methadone treatment Nutritional counseling for eating disorders 4

5 Administrative Impact Non-quantitative treatment limitations administrative processes that could limit access Provider network Utilization management Drug formulary Provider payment We must apply the same processes and procedures in developing/applying these limitations as we do for medical. 5

6 Questions? Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin ("BCBSWi") which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 6

7 Change 2014 Provider Expo Christine Baldas, Manager Behavioral Health Services and Melissa Walker, Network Support Consultant This presentation contains proprietary information of Anthem Blue Cross and Blue Shield. It is intended for Anthem providers. Any redistribution or other use is strictly forbidden. Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin ("BCBSWi") which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 7

8 Agenda What this means for our members What this means for providers Levels of care that require authorization How to obtain authorization Residential Psychiatric Care Symptoms & Behaviors Residential Substance Abuse Care Symptoms & Behaviors Residential Eating Disorder Care Symptoms & Behaviors Other considerations 8

9 What this means for our members Expansion of benefits to include Residential Treatment Centers Coverage for Methadone Coverage for nutritional counseling for Eating Disorders 9

10 What this means for providers Ability to obtain Residential Treatment Center (RTC) services for members Ability to obtain reimbursement for Methadone services 10

11 Levels of care requiring precertification Authorization is based on medical necessity Inpatient: Always Residential Care: Sometimes Call to confirm Partial Hospitalization (PHP): Sometimes Call to confirm Intensive Outpatient (IOP): Sometimes Call to confirm Applied Behavioral Analysis: Not currently Outpatient Office Visits: No precert required Methadone Maintenance: No precert required Other procedures or types of treatment: Call to confirm 11

12 How to obtain authorization Call the number of the back of the member s identification card Call the precertification number listed on the Wisconsin Ready Reference Guide and select Behavioral Health To verify status of an authorization, use the Interactive Care Reviewer located under Auths and Referrals on Availity 12

13 Residential Psychiatric Care Symptoms & Behaviors Behaviors consistent with clinical guidelines Typically child/adolescent under 18 years High risk or self injurious behavior that is a deterioration from the member s usual status Member s social environment includes temporary stressors or limitations that would undermine treatment with the expectation the situation will improve while member is in a residential treatment center A reasonable expectation that the illness or condition or level of functioning will stabilize and improve, and that the member will be able to return to outpatient treatment 13

14 Residential Substance Abuse Care Symptoms & Behaviors Behaviors consistent with clinical guidelines Member s condition meets the diagnostic criteria for a DSM Axis I or ICD-9 Substance Abuse and/or Dependence diagnosis Acute psychiatric symptoms that would interfere with maintaining abstinence Acute medical symptoms that would interfere with maintaining abstinence Evidence of major functional impairment in 2 domains 14

15 Residential Eating Disorder Care Symptoms & Behaviors Behaviors consistent with clinical guidelines For weight restoration BMI between or weight between 75%- 85% of ideal range and no medical instability Other symptoms are controlled and eating disorder is the focus of treatment Continued restricting and purging is leading to weight loss which will lead to medical instability and inpatient admission Significant functional disruption from baseline in 2 domains There is reasonable expectation that the member will benefit from placement in a residential treatment center Environment and support have significant deficits or conflicts that would undermine the goals of treatment such that lower level of care is unlikely to be successful 15

16 Other Considerations Networks vary depending on member s plan Verify facility is in-network status for a member s plan Use Anthem s online provider directory Call provider service Authorization Requirements View on Precertification Guidelines page on the WI public provider website Behavioral Health Clinical UM Guidelines View on the Behavioral Health Provider Resources page on the WI public provider website 16

17 Questions? Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin ("BCBSWi") which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 17