Medicaid Change Conference Call

Notes from Medicaid Conference Call
01/12/2011

Ms. Meyer was facilitator from DHHS

• Currently Medicaid allows 75 visits for each Rehabilitative Therapy i.e. OT, ST, and PT

• As of April 1st, Medicaid will now only allow 75 visits combined of Rehab. Therapy – i.e.  PT, OT, ST if using a private provider

• What is difference with private provider versus other provider – Hospital Systems or hospital owned ST, OT, and PT practices are not affected by this change – they will continue to get however many visits deemed necessary – Private providers will notify their clients of the amount of units used within 2 weeks of the change – it is then up to the family to seek out a medical necessity form from their child’s primary care physician.  The primary care physician completes the form and faxes it in to DHHS who in turn will have reviewing physicians look at requests and if in agreement they will authorize continuation of however many units are recommended by the physician. 

• If you find out by April that you have exceeded the 75 unit cap as this will be retroactive to July 1st, 2010 DHHS will not try to recoup that money from families or providers however you will then need to have medical necessity form filled out by your physician in order for the therapy to continue

• DHHS has to  continue to provide these therapies because of federal law with the EPDST program if deemed necessary by primary physician and reviewing physician is in agreement – if for some reason the primary physician doesn’t justify the service enough and the reviewing physicians don’t agree there is an appeals process that will be posted on DHHS website

• Please note that the therapies your children receive at school or through a hospital setting or hospital owned group does not count toward the 75 cap as they are not considered private

• 1 visit equals an hour or 4 units of therapy – 1 unit is equal to 15 minutes – so if your child only gets 30 minutes a week of therapy that will only count as half a visit – not a whole visit

• Only the providers of the therapies will have access to the system at DHHS to see how many units families have currently used of their Rehab Therapies – parents will be notified by the therapists of units used within 2 weeks of the changes effective April 1st 2011

• The reviewing physicians are Dr. Burton and Dr. Platt – they will review the medical necessity requests and have a decision within 48-72 hours – if DHHS sees that it’s going to take longer they will recruit additional doctors to help with this process so families will get notification promptly so there isn’t a lapse in therapies

• Any questions or comments can be submitted to This e-mail address is being protected from spambots. You need JavaScript enabled to view it

• A question was posed by a parent about why can’t they cut services to the illegal immigrants rather than cutting services to legal citizens especially people with disabilities – it was stated by DHHS that the only service illegal immigrants get through Medicaid is emergency services through the hospitals – which is federally mandated – the state has no control over this

• For physician to prove medical necessity they will need to provide why the service is needed, the condition, diagnosis, give their reviewing physicians goals of treatment and how long the therapy will go on

• Once authorized by reviewing physicians as requests come in this budget year, the authorizations will be good through the end of this fiscal year – i.e. June 30th of 20111 so at the start of the new fiscal year you will need to resubmit your requests for medical necessity for continued Rehab. Therapy past the 75 total units of therapy – they may require but not sure yet to resubmit these requests every 6 months or quarterly, but DHHS has not made a decision on this yet however it will not be yearly as they feel conditions change for children

• Dental and Vision services will remain for those in the MR/RD Waiver – what is happening is that regular Medicaid will no longer cover dental exams and vision exams for people over 21 – the only way this is covered is if the person has the MR/RD Waiver or a medical diagnosis such as diabetes – if so your vision exam will continue to be covered but only if you have a medical condition such as diabetes – however for dental if you are over 21 no longer will dental be covered by Medicaid unless you are MR/RD Waiver

• The comment was made by a parent regarding how DHHS can say that dental and vision services are optional when these are needed services to prevent major illnesses or death in some instances if left neglected particularly with dental issues – DHHS responded by stating the federal government are the ones defining what services are considered optional – it is not something that the state decides on as it is coming from the feds

• It was asked how these changes can be made during the middle of a budget year and DHHS said they are acting within their legal guidelines as they can make changes during the middle of the year as long as CMS approves of the changes – if CMS does not approve of the changes then they can not be made

• Hospice Care will be cut out of Medicaid – people can still get their prescriptions and such, but no longer will they have hospice care through Medicaid

• The request for additional therapy once you have med the cap of 75 combined has to come from a physician – your child’s primary care physician and not the therapist – physician will need current assessment in order to show justification for needed units of therapy

• Again there will be an appeals process for families that are denied additional units of Rehab Therapy which will be on DHHS website and a bulletin will be sent out soon with exact instructions on how request additional Rehab. Therapy – the form and process for your primary physician

• Lastly – DHHS was approved for an increase in Managed Care Options thus there will be more of a push for newly enrolled people in Medicaid to be either in Medical Health Network or Managed Care Network – however people with disabilities will still have a choice and can do fee for service if they choose however if they don’t choose they will be put in a Manage Care plan