Respite Service Expansion. Effective January 1, 2017, eligibility for respite services was expanded so that more children may access the benefit. This service expansion included both SSI and non-SSI children. Eligibility is based on severe emotional disturbance (SED) and substance-use disorder (SUD) diagnosis criteria established by ODM. IMD as an “In Lieu of” Service. Effective July 1, 2017, ODM began permitting the use of IMDs as an “in lieu of” service for the 21 to 64-year-old population for up to 15 days per month. This program change was implemented in compliance with the conditions outlined in the final Medicaid managed care regulations. Consistent with the rate-setting guidance published by CMS, in reviewing the impact of this program adjustment we did not use the unit cost of the IMD. The unit cost for IMD services was developed based on the cost per admit of Inpatient Psychiatric/SA services for non-teaching hospitals. Semi-annual Nursing Facility Cost Per Diem Updates. ODM updates nursing facility (NF) payment rates and acuity scores on a semi-annual basis. We applied retrospective adjustments to reflect the impact of the semi- annual per diem update on July 1, 2018. Adjustments were applied to the nursing facility category of service, and vary based on differences in base nursing facility experience by rate cell and region. Serious Mental Illness (SMI) Health Home. Effective July 1, 2018, ODM discontinued its SMI Health Home program. These services, which were previously billed under HCPCS S0281, were primarily utilized by members residing the North Central region. We reviewed first-half (1H) and second-half (2H) 2018 utilization for the providers who previously rendered S0281, and observed material increases in utilization for services other than S0281 following the sunset of the SMI Health Home. For these codes, we calculated the impact of 1H 2018 utilization increasing to levels consistent with 2H 2018. Pharmacy Pass-Through Pricing. Effective January 1, 2019, ODM required that MCP contracting arrangements with pharmacy benefit managers (PBM) be structured as a pass-through pricing model, consistent with the definition included in Appendix C of the Provider Agreement. Pass-through pricing resulted in increased administrative expenses corresponding with decreases in MCP paid amounts for prescription drugs. During the CY 2018 base period, MCP PBM contracts were structured as a spread-pricing arrangement and MCP encounters reflected spread pricing. To adjust for the impa...
Respite Service Expansion. Effective January 1, 2017, eligibility for respite services was expanded so that more children may access the benefit. This service expansion included both SSI and non-SSI children. Eligibility is based on severe emotional disturbance (SED) and substance-use disorder (SUD) diagnosis criteria established by ODM. We reviewed historical experience for respite services, and adjusted our assumed take-up rates based on the low utilization observed as of June 2017. In aggregate, the CY 2018 capitation rates include approximately $2 million for respite services. Calendar Year 2018
Respite Service Expansion. Effective January 1, 2017, eligibility for respite services was expanded so that more children may access the benefit. This service expansion included both SSI and non-SSI children. Eligibility is based on severe emotional disturbance (SED) and substance-use disorder (SUD) diagnosis criteria established by ODM. Inpatient Reimbursement Changes. Effective January 1, 2021, ODM will rebase its inpatient hospital base rates through the continued use of All Patients Refined Diagnosis Related Groups (APR DRG). This includes revised APR DRG relative weights along with updated hospital base rates. In addition, ODM will continue to include an enhanced reimbursement methodology to ensure adequate and continued access to inpatient hospital services from funds appropriated in the biennial budget (Am. Sub. HB 166 of the 133rd General Assembly), which will be reflected in inpatient reimbursement through an add-on to the hospital base rates.
