- Physical health services are delivered through managed care organizations (MCOs) and on a fee-for-service basis. The MCO program operates only in Clark County (Las Vegas) and urban Washoe County (Reno). In these areas children and adults who qualify for Medicaid because they belong to an income-eligible family are required to enroll into one of two MCOs, as are children who participate in the Child Health Assurance Program (CHAP). A few groups within these broad categories may choose between an MCO and fee-for-service, including children with special health care needs and severely emotionally disturbed children. There were 297,640 eligibles receiving Medicaid as of July 2011. Of these 168,851were enrolled in MCOs. The remainder received physical health services through fee-for-service.
- Mental health and substance abuse services are delivered through MCOs to beneficiaries enrolled in MCOs, and all others receive these services through fee-for-service. In addition, children and adults with significant behavioral health needs may disenroll from their MCO at any time.
- Most dental services are delivered through MCOs to beneficiaries enrolled in MCOs, while all others receive these services on a fee-for-service basis. Orthodontic services, however, are delivered on a fee-for-service basis to all beneficiaries, including those enrolled in MCOs.
- Non-emergency transportation services are delivered through a Pre-paid Ambulatory Health Plan (PAHP) that operates statewide and delivers only transportation services. Nevada reported that, in July 2011, 248,819 beneficiaries were enrolled in this PAHP.
Nevada’s Medicaid Services Manual defines medical necessity as:
“A health care service or product that is provided for under the Medicaid State Plan and is necessary and consistent with generally accepted professional standards to: diagnose, treat or prevent illness or disease; regain functional capacity; or reduce or ameliorate effects of an illness, injury or disability.
The determination of medical necessity is made on the basis of the individual case and takes into account:
Medical Necessity shall take into account the ability of the service to allow recipients to remain in a community based setting, when such a setting is safe, and there is no less costly, more conservative or more effective setting. “
|Initiatives to Improve Access
|Reporting & Data Collection||
Nevada is modifying its Medicaid Management Information System (MMIS). As part of a long-range effort, EPSDT staff have developed an electronic version of an EPSDT screening form. Eventually, the form will be completed online and the information will be fed directly into the MMIS system.
Managed care organizations (MCOs) in Nevada are required to report on child-specific performance measures. They can receive incentive payments (see page 11) based on performance on Health Effectiveness Data and Information Set (HEDIS) measures for well-child visits and childhood immunization status. They must also report on a non-incentive measure for children and adolescents’ access to primary care practitioners.
In late 2011 Nevada Medicaid implemented payment for developmental screens (including those that focus on social/emotional development) billed under CPT code 96110 in their state (See Nevada EPSDT Provider Manual, Section 1503.3A(2)). Providers must use a valid, standardized developmental screening tool. While Nevada does not include a list of tools they do explicitly reference the AAP’s policy that establishes criteria for screening tools. Nevada has also developed EPSDT well child visit forms that prompt pediatricians to use a validated developmental screening tool, and to identify which tool was used.
|Support to Providers and Families||
Nevada Medicaid has produced a number of handouts and brochures on the EPSDT benefit for families and for providers as part of a Healthy Kids Toolkit. The toolkit contains information on screening schedules, BMI Growth Charts, immunization schedules, lead poisoning and development screening, oral health, billing information, and other resources.
Nevada has begun work to track referrals for EPSDT-eligible children using code modifiers: providers are instructed to use a specific modifier (TS) along with the well-child code to indicate that a referral or follow up is needed.
Managed care contracts in the state require managed care organizations (MCOs) to “put a basic system in place, which promotes continuity of care and case management.” Under this continuity of care system, MCOs must have partnerships with primary care providers and specialists to “holistically address members’ health needs.” The contracts specify that “care coordination must include not only the specific diagnosis, but also the complexities of multiple co-morbid conditions, including behavioral health, and related issues such as the lack of social or family support.”
Nevada Medicaid is currently in the process of seeking approval from CMS for a section 1115 waiver. The 1115 waiver is designed to encompass all services and eligible populations under a single authority that will provide the state broad flexibility to manage Medicaid and CHIP more efficiently. Through the use of the 1115 waiver, Nevada Medicaid intends to phase in managed care for all eligible recipients. As a part of its waiver initiative, Nevada Medicaid plans to implement medical homes and health homes for non-MCO enrollees, including those with chronic conditions, severe mental health issues, or patterns of utilization that indicate the enrollee may benefit from case management.
Nevada delivers most oral health services through MCOs to children enrolled in these plans; the remainder receive the services through fee-for-service. Orthodontia is carved out of the MCO contract and all children receive those services through fee-for-service—all orthodontia services require prior authorization (see 1003.9 of the dental handbook.)
Nevada Medicaid reimburses for fluoride varnish provided by physicians and other providers who administer Healthy Kids screens (e.g., Federally Qualified Health Centers).