Healthy Connections Checkup

South Carolina Healthy Connections Medicaid

Overview and Enhancement

Overview

• What is Checkup? • Healthy Connections Checkup is a Medicaid limited benefit

program. This program was previously called “Family Planning”.

• Who is Eligible for Checkup? • Men and Women in South Carolina with an income at or below

194% FPL who are ineligible for any other Medicaid program.

• Why the New Name? • Beginning Aug. 1, 2014, Healthy Connections Checkup will include

benefits that enable a more holistic and comprehensive provision of not only Family Planning and Family Planning-related services, but also new preventive health screenings.

• The new name helps communicates the enhancement in addition to the importance of preventive health care for the eligible population.

Introducing Healthy Connections Checkup

Enhancement

• Enhancement • Update the benefit structure for the current Family Planning-Only

benefit category to include a comprehensive biennial (once every two years) physical examination and screenings/labs recommended by the U.S. Preventive Services Task Force

• Goals • Enable providers to make informed decisions regarding the

selection of an appropriate contraceptive method • Promote the utilization of preventive health care in order to

improve health outcomes for families in South Carolina • Expected Outcomes

• Regular preventive screening of members • Identification of health problems that may negatively impact

members in this eligibility category • Strong referral network to connect members to systems of care

Enhanced Benefit for Healthy Connections Checkup

New Screenings Behavioral & Mental Health screenings Cholesterol abnormalities screening Diabetes screening Hepatitis C virus infection screening Obesity screening and counseling Breast cancer screening (mammography) Abdominal Aortic Aneurysm screening Colorectal cancer screening Lung cancer screening for smokers

*Please refer to the U.S. Preventive Services Task Force guidelines (Grade A & B) for preventative screening standards. Screenings vary

by age, gender and risk factor.

Cards

Healthy Connections Checkup Cards

Goals

Goals

Increase the number of beneficiaries enrolled in Checkup

• Estimated eligible ~ 447,000 • Currently enrolled ~ 110,000 • Target is to raise total enrollment to

~ 200,000 by end of SFY15

Goals

Ensure that Healthy Connections Checkup members have access to and

receive biennial, comprehensive physical examinations and appropriate

screenings

(according to U.S. Preventive Services Task Force recommendations by age, gender and risk

factor)

Goals

Connect Healthy Connections Checkup members to systems of care (including

FQHCs, RHCs, free clinics, hospital clinics etc.) by strengthening the referral system that serves this population

Goals

Identify the health status of Healthy Connections Checkup members in order

to gain a better understanding of the existing conditions/problems in the uninsured population in the state

Data Needs

Data

• Enrollment • Total number enrolled • Newly enrolled • % of total eligible enrolled • Utilization of those enrolled

• Referrals • Number of referrals made • Number of referrals attended

• Screenings • Prevalence per disease/positive screen • Incidence per disease/positive screen

Data

• Providers • Type (PA, NP, MD/DO) • Practice structure (FQHC, RHC, free

clinic etc.) • Location • Patient volume

• Pregnancy • Incidence • Medicaid status

Referral Process

Referrals

• Importance of Referrals • Checkup members have Medicaid coverage for certain preventive

screenings. • Checkup members do NOT have coverage for follow-up

care/treatment. • Where to Refer Checkup Patients

• Providers that can offer care based on the patient’s income. • Examples include free clinics, FQHCs, RHCs, Hospital clinics that

provide charity care, etc. • Referral Procedures

• SCDHHS allows provider to bill for referrals (face-to-face and phone).

• This process was established to compensate providers for administrative costs associated with referrals AND to collect important data on the health status of the Checkup population.

Referral Process for Healthy Connections Checkup

Referral Process for Healthy Connections

Checkup Providers

Referral Types

Referral Type 1

Preventive health screening performed during physical exam

Provider receives screening results

immediately

*Referral made immediately (or same day) following exam

* Referral code billed on the same claim as

the physical exam

Same-Day Referral

Examples Include: • A1C (Instant) • HIV (Instant) • Mental / Behavioral Health Screening

Referral Type 2

Different Day Referral

Preventive health screening performed during physical exam

Provider receives screenings results 1 or

more days after the physical exam is

performed (i.e. no lab on site)

*Referral made on a different day than exam

* Referral billed on a separate claim that contains ONLY the referral code and

diagnosis code (V70.0)

Examples Include: • Hepatitis C • Cancer screenings • Other non-instant blood tests (diabetes / lipid)

Referral Type 3

Referral for Another Preventive Screening

Physical performed

Provider does not have the ability to perform

certain preventive, age-specific health

screenings

*Provider refers patient to a different provider who has the ability to

perform the preventive health screening

* Providers cannot bill for this type of referral

Examples Include: • Mammography • Colonoscopy • AAA Screening • Lung Cancer Screening

Billing for Referrals

Billing for Referrals

• Telephone Referral • Can be performed by RN or above • Does not require the patient to

come back to receive test results • Can be used for the following:

– Same-Day Referrals – Different-Day referral where

patient results can be explained over the phone

– Examples include referrals for instant results, referrals for different day diabetes, etc.

• In-Person Referral • Can be performed by NP/PA or

above • Requires face-to-face interaction

with the patient • Can be used for the following:

– Different-Day referral where patient results must be explained in-person before a referral to a new provider is made

– Examples include referrals for positive cancer screen, referrals for positive HIV screen, etc.

S0320 – Telephone Referrals S0316 – Face-to-Face Referrals

Referral Codes

Billing for Referrals

Referral Code Modifiers • Both Referral Codes (S0320 & S0316) must contain the

diagnosis code (V70.0) and 1 or more modifiers • Claims without at least 1 modifier will be rejected • Modifiers are required to specify the type of positive

screenings that resulted in a referral to a new provider • Up to 4 modifiers can be used with the referral code

Billing for Referrals

• P1 = Referral made for Diabetes Screening • P2 = Referral made for Cardiovascular Disease • P3 = Referral made for results of any cancer screening

(breast, colon, lung) • P4 = Referral made for any mental health / behavioral

health / substance abuse screening • P5 = Referral for other condition

Referral Code Modifier Options

Timeline

Timeline

Aug. 1, 2014: Effective date of benefit enhancement

• Provider education and training • Current member education • Strengthen referral network