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NYC FIDA PROGRAM TO CLOSE DEC. 31, 2019


FIDA is the New York demonstration program to coordinate long term care and medical care from both Medicare and Medicaid. The demonstration began in 2014 and was only implemented in NYC, Long Island and Westchester. FIDA plans provide all Medicaid and Medicare services through one managed care insurance plan, a combination of an MLTC plan with a Medicare Advantage Plan. 

— Effective July 2019, no new enrollment is permitted into FIDA plans.

— In March 2019, FIDA plans were permitted to begin marketing to their FIDA members to promote their Medicaid Advantage Plus (MAP) products, as an alternative to FIDA. MAP plans are similar to FIDA in that they control and authorize all Medicaid and Medicare services. They are a combination of a Medicare Advantage Dual Special Needs Plan ("Dual-SNP") and an MLTC plan all in one. See ICAN Information on types of plans, including Medicaid Advantage Plus.

— October 2019 - If CMS finds that the Medicaid Advantage Plus plans in NYC, Nassau and Westchester Counties are equivalent to their sister FIDA plans, using a three-pronged test, members of those FIDA plans in the approved conties will be "crosswalked" (passively enrolled) in the sister Medicaid Advantage Plus plan of their FIDA plan. This means they will receive notice of their options, and if they do not choose another option, they will be auto-assigned to the MAP plan affiliated with their FIDA plan.

If a county or plan does not pass the equivalency test, those FIDA members will be passively enrolled into an MLTC plan effective Jan. 1, 2020.

In choosing the type of plan, members need to remember that a FIDA or MAP plan includes all medical providers and prescription drugs. A prospective enrollee should make sure their preferred doctors and other providers are in the plan's network, and that their prescription drugs are on the plan's formulary. As an alternative, an individual may join an MLTC plan and retain their separate Medicare coverage - whether Original Medicare plus a Part D drug plan or a Medicare Advantage plan.

Please advise your FIDA patients. For Credentialing  questions please contact us!

Source:  http://www.wnylc.com/health/news/78


INTRODUCING THE HORIZON BCBSNJ CHIROPRACTIC & PHYSICAL MEDICINE SERVICES PROGRAM with AMERICAN SPECIALTY HEALTH GROUP

Horizon Blue Cross Blue Shield of New Jersey has contracted with American Specialty Health Group, Inc. (ASH Group) with plans to administer our Chiropractic & Physical Medicine Services Program beginning on January 1, 2020. Pending regulatory approval, ASH Group will be responsible for practitioner contracting, contract administration, medical necessity review and claims processing for in-scope Horizon BCBSNJ members.

As part of this program, impacted practitioners will need to submit claims for Medical Necessity Determination (MND) review to ASH for the following services:
• Acupuncture
• Chiropractic
• Occupational Therapy
• Physical Therapy

Impacted Members
The guidelines of this program is planned to apply to  members who are enrolled in fully insured, Federal Employee Program® (FEP®), Medicare Advantage, and self-funded Administrative Services Only (ASO) groups. The guidelines of this program will apply to fully insured members enrolled in programs through other Blue Cross and Blue Shield plans that include BlueCard benefits when these members reside or travel in Horizon BCBSNJ's local service area and receive services from a participating practitioner. Members enrolled in the following plans/products are NOT included:
• Horizon NJ Health plans
• Horizon NJ TotalCare (HMO SNP)
• Medicare Supplement

What to Know
In anticipation of the January 1 launch, providers must complete the Horizon BCBSNJ amendment and ASH recruitment package sent by ASH by November 1, 2019. This package includes ASH’s credentialing application and contracting materials.

The eligible in-scope practitioners who return the required materials to ASH by November 1, 2019 can continue to treat members at an in-network level of benefits. Credentialed practitioners will become effective with the ASH network on January 1, 2020.

Horizon BCBSNJ will continue to manage services through December 31, 2019 for practitioners who treat members with managed care benefit plans.

After January 1, 2020, all contracted and credentialed providers will follow ASH’s clinical performance program and medical necessity review guidelines.

What if I don’t contract with ASH? In order for you to continue to  be a credentialed practitioner with Horizon BCBSNJ, you must sign the Horizon BCBSNJ Subordination Agreement Amendment and contract with ASH by November 1, 2019.

If you do not sign the Horizon BCBSNJ Subordination Agreement Amendment and contract with ASH by November 1, 2019, your Horizon BCBSNJ Provider Agreement(s) will terminate in accordance with your agreement.

The Horizon BCBSNJ Chiropractic & Physical Medicine Services Program is subject to regulatory approval.

For questions about this program

•Access program FAQs
•Call ASH at 1-888-511-2743 Monday through Friday from 10 a.m. to
8 p.m. Eastern Time (ET), or Horizon BCBSNJ Physician Services at
1-800-624-1110, Monday through Friday, 8 a.m. to 5 p.m. ET.

American Specialty Health Group, Inc. is an independent company that supports Horizon Blue Cross Blue Shield of New Jersey in the administration of chiropractic and physical medicine services. American Specialty Group, Inc. is independent from and not affiliated with Horizon Blue Cross Blue Shield of New Jersey.

Source: https://www.horizonblue.com/providers/news/news-legal-notices/introducing-horizon-bcbsnj-chiropractic-physical-medicine-services-program-american-specialty-health



NEW MODIFIERS TO IDENTIFY SERVICES FURNISHED BY PTA/OTA COMING SOON!

In the CY 2019 PFS proposed and final rules CMS  established two modifiers—one to identify services furnished in whole or in part by a physical therapist assistant (PTA) and the other to identify services furnished in whole or in part by an occupational therapy assistant (OTA).

The modifiers are defined as follows:
CQ Modifier: Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant.
CO Modifier: Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant.

In the CY 2019 PFS final rule, CMS clarified that  the CQ and CO modifiers are required to be used when applicable for services furnished on or after January 1, 2020, on the claim line of the service alongside the respective GP or GO therapy modifier to identify services furnished under a PT or OT plan of care.

In PFS rulemaking for CY 2019, CMS identified  certain situations when the therapy assistant modifiers do apply. The modifiers are applicable to:
• Therapeutic portions of outpatient therapy services furnished by PTAs/ OTAs, as opposed to administrative or other non-therapeutic services that can be performed by others without the education and training of OTAs and PTAs.
• Services wholly furnished by PTAs or OTAs without physical or occupational therapists.
• Evaluative services that are furnished in part by PTAs/OTAs (keeping in mind that PTAs/OTAs are not recognized to wholly furnish PT and OT evaluation or re-evaluations).
CMS also identified some situations when the therapy assistant modifiers do not apply. They do not apply when:
• PTAs/OTAs furnish services that can be done by a technician or aide who does not have the training and education of a PTA/OTA.
• Therapists exclusively furnish services without the involvement of PTAs/OTAs.

CMS finalized a de minimis standard under which a service is  considered to be furnished in whole or in part by a PTA or OTA when more than 10 percent of the service is furnished by the PTA or OTA.
Beginning January 1, 2020, in order to provide support for application of the CQ/CO modifier(s) to the claim CMS proposes to add a requirement that the treatment notes explain, via a short phrase or statement, the application or non-application of the CQ/CO modifier for each service furnished that day.
CMS also clarified in the CY 2019 PFS final rule that the CQ and CO modifiers will trigger application of the reduced payment rate for outpatient therapy services furnished in whole or in part by a PTA or OTA, beginning for services furnished in CY 2022.

Source: https://www.govinfo.gov/content/pkg/FR-2019-08-14/pdf/2019-16041.pdf


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September 2019