Family Planning Eligibility Family Planning Eligibility and Billingand Billing

Travis DukeTravis Duke

GoalsGoals

Understand changes to Title V, X, and XX Understand changes to Title V, X, and XX eligibility guidelineseligibility guidelines

Understand changes to Title V, X and XX billing Understand changes to Title V, X and XX billing policypolicy

Discuss Title V, X and XX payment for “wrap Discuss Title V, X and XX payment for “wrap around” services provided to WHP clients.around” services provided to WHP clients.

Discuss common billing issuesDiscuss common billing issues

Presentation StructurePresentation Structure

Eligibility OverviewEligibility OverviewChanges to Eligibility GuidelinesChanges to Eligibility GuidelinesBilling OverviewBilling OverviewChanges to Billing GuidelinesChanges to Billing GuidelinesWHP Wrap Around ServicesWHP Wrap Around ServicesNew ProceduresNew ProceduresCommon Billing IssuesCommon Billing IssuesQ & AQ & A

Females (of childbearing age) and males, Females (of childbearing age) and males, who have not had sterilization surgery or who have not had sterilization surgery or other condition resulting sterilization and other condition resulting sterilization and

who are seeking family planning services. who are seeking family planning services.

Eligibility OverviewEligibility OverviewEligible PopulationEligible Population

Eligibility OverviewEligibility OverviewTitle VTitle V

Income at or below 185% FPLIncome at or below 185% FPL

Texas resident Texas resident

No fee or co-pay for clients at or below No fee or co-pay for clients at or below 100% FPL.100% FPL.

Co-pay may not exceed 25% of the Co-pay may not exceed 25% of the authorized payment amount for services authorized payment amount for services for clients between 101-185% FPL.for clients between 101-185% FPL.

Eligibility OverviewEligibility OverviewTitle XXTitle XX

Income at or below 185% FPLIncome at or below 185% FPL

Texas residentTexas resident

No co-pay for any client with zero income.No co-pay for any client with zero income.

Client co-pay may not exceed 25% of the Client co-pay may not exceed 25% of the authorized payment amount for services. authorized payment amount for services. (Note: in a a X/XX clinic this requirement (Note: in a a X/XX clinic this requirement does not apply)does not apply)

Eligibility OverviewEligibility OverviewTitle XTitle X

Income at or below 250% FPLIncome at or below 250% FPL

No residency requirementNo residency requirement

No fee or co-pay for clients at or below No fee or co-pay for clients at or below 100% FPL.100% FPL.

A discounted fee schedule for clients A discounted fee schedule for clients between 101% FPL and 250% FPL.between 101% FPL and 250% FPL.

Changes to Eligibility GuidelinesChanges to Eligibility GuidelinesFamily CompositionFamily Composition

The budget group consists of the applicant, his/her The budget group consists of the applicant, his/her spouse, and all mutual and non-mutual children. If an spouse, and all mutual and non-mutual children. If an unmarried applicant lives with a partner, ONLY count the unmarried applicant lives with a partner, ONLY count the partner’s income and children as part of the budget partner’s income and children as part of the budget group IF the applicant and his/her partner have mutual group IF the applicant and his/her partner have mutual children together. Treat applicants who are 18 years of children together. Treat applicants who are 18 years of age as adults. No children aged 19 and older or other age as adults. No children aged 19 and older or other adults living in the household should be counted as part adults living in the household should be counted as part

of the budget group.of the budget group.

Changes to Eligibility GuidelinesChanges to Eligibility GuidelinesIncomeIncome

For unemancipated, unmarried clients UNDER 18 For unemancipated, unmarried clients UNDER 18 years of age, if confidential services without the years of age, if confidential services without the involvement of a principal family member are involvement of a principal family member are requested, only the client's income is used to requested, only the client's income is used to assess eligibility. assess eligibility.

For clients who are married or are 18 years of age For clients who are married or are 18 years of age or older the income of all family members must be or older the income of all family members must be used.used.

Changes to Eligibility GuidelinesChanges to Eligibility GuidelinesIncome DeductionsIncome Deductions

Dependent Care ExpensesDependent Care Expenses

$200 Per Month for Children Under 2$200 Per Month for Children Under 2

$175 Per for Children Age 2 or Older$175 Per for Children Age 2 or Older

Changes to Eligibility GuidelinesChanges to Eligibility GuidelinesTitle XX Co-payment at a Title X/XX ClinicTitle XX Co-payment at a Title X/XX Clinic

Co-payment is no longer capped at 25% of the Co-payment is no longer capped at 25% of the reimbursable cost of providing servicesreimbursable cost of providing services

Enables Title X/XX clinics to better implement the Enables Title X/XX clinics to better implement the required sliding fee scalerequired sliding fee scale

Billing OverviewBilling Overview

2017 Family Planning Claim Form2017 Family Planning Claim Form

Filing DeadlinesFiling Deadlines

Initial Claims: 60 days from date of service Initial Claims: 60 days from date of service on the claimon the claim

Appeals: 120 days from date of the Appeals: 120 days from date of the Remittance and Status report on which the Remittance and Status report on which the claim reached a finalized statusclaim reached a finalized status

Billing OverviewBilling Overview

WHP claims must be held until the client is WHP claims must be held until the client is determined WHP eligible by HHSCdetermined WHP eligible by HHSC

If WHP eligibility has not been determined If WHP eligibility has not been determined within 35 calendar days from the date of within 35 calendar days from the date of service, a Title V or XX claim or a Title X service, a Title V or XX claim or a Title X encounter may be filed for the serviceencounter may be filed for the service

Billing OverviewBilling Overview

Contractors must continue to file claims Contractors must continue to file claims and encounters even if they have and encounters even if they have exhausted their budget exhausted their budget

Changes to Billing GuidelinesChanges to Billing Guidelines

After 35 days from the date of service After 35 days from the date of service contractors may file a Title V or XX claim contractors may file a Title V or XX claim or Title X encounter without verifying and or Title X encounter without verifying and documenting that a client is ineligible for documenting that a client is ineligible for WHP.WHP.

Sterilization ComplicationsSterilization Complications

WHP Wrap Around ServicesWHP Wrap Around Services

See HandoutSee Handout

New ProceduresNew Procedures

J7303 – Hormonal Vaginal ring, each - J7303 – Hormonal Vaginal ring, each - $35.80 $35.80 (9-1-07)(9-1-07)

S0180 – Implantable contraceptive S0180 – Implantable contraceptive capsules (Implanon) - $585.11 capsules (Implanon) - $585.11 (12-1-07)(12-1-07)

11975 – Insertion, implantable 11975 – Insertion, implantable contraceptive capsules - $152.25 contraceptive capsules - $152.25 (12-1-07)(12-1-07)

11977 – Removal with reinsertion, 11977 – Removal with reinsertion, implantable contraceptive capsules implantable contraceptive capsules (12-1-07)(12-1-07)

New ProceduresNew Procedures

87490 – Chlamydia test, direct probe 87490 – Chlamydia test, direct probe technique - $27.71 technique - $27.71 (12-1-07)(12-1-07)

87491 – Chlamydia test, amplified probe 87491 – Chlamydia test, amplified probe technique - $27.71 technique - $27.71 (12-1-07)(12-1-07)

87590 – Gonorrhea test, direct probe 87590 – Gonorrhea test, direct probe technique - $27.71 technique - $27.71 (12-1-07)(12-1-07)

87591 – Gonorrhea test, amplified probe 87591 – Gonorrhea test, amplified probe technique - $27.71 technique - $27.71 (12-1-07)(12-1-07)

Rate Changes For IUDsRate Changes For IUDs

J7300J7300

Rate prior to 4-1-07 = $321.13Rate prior to 4-1-07 = $321.13

Rate after 4-1-07 = $387.60Rate after 4-1-07 = $387.60

J7302J7302

Rate prior to 4-1-07 = $426.97Rate prior to 4-1-07 = $426.97

Rate after 4-1-07 = $487.76Rate after 4-1-07 = $487.76

Common Billing IssuesCommon Billing Issues

CLIA Certification CLIA Certification – Family planning agencies can bill some lab Family planning agencies can bill some lab

codes to Title V and XX that can not be billed codes to Title V and XX that can not be billed to Title XIXto Title XIX

– Most obvious when XIX retro-eligiblity occursMost obvious when XIX retro-eligiblity occurs

Retro-eligibility and rate differences Retro-eligibility and rate differences between Title V/XX vs. XIXbetween Title V/XX vs. XIX

Appeals vs. Resubmission of New ClaimsAppeals vs. Resubmission of New Claims

Common Billing IssuesCommon Billing Issues

Importance of submitting correct TPI/NPI Importance of submitting correct TPI/NPI at the beginning of the fiscal yearat the beginning of the fiscal year

NPI implementation and 3NPI implementation and 3rdrd party billers party billers

Matching R&S reports to paymentsMatching R&S reports to payments

QuestionsQuestions

& &

DiscussionDiscussion

The EndThe EndTravis DukeTravis Duke

Travis.duke@dshs.state.tx.usTravis.duke@dshs.state.tx.us