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Medicaid changes to trigger reductions in PMPM pay,
may lower administrative hassles
e-Reports, October 12, 2010
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The ISMA has learned that on Oct. 1, Indiana Family and Social Services Administration (FSSA) instituted changes to the Care Select program for the disabled, blind and foster children. If you are a primary care physician in the program, your panel size – and your “per member per month” (PMPM) pay – may suddenly drop. But you also may cheer some reduced hassle factors.

FSSA’s changes mean only 32,000 Medicaid Care Select members will be eligible for a new disease management program. The total number in Medicaid Care Select was 73,000.

Medicaid patients who now may “voluntarily” choose the new disease management program are those with the following diseases or conditions:

  • Asthma
  • Diabetes
  • Congestive heart failure
  • Coronary artery disease
  • Hypertension
  • Chronic kidney disease
  • Severe mental illness
  • Depression

If patients do not volunteer for Care Select disease management, they move to Traditional Medicaid. Therefore, effective Oct. 1, the following patient categories exited Care Select and are covered by Traditional Medicaid:

  • Former Care Select patients who do not have an above-listed chronic disease
  • Chronic disease patients who choose not to be in the new disease management program
  • Patients on home- and community-based waivers or HCBS

“The changes affect physicians in two ways,” said Gloria Kirkham, ISMA Medicaid practice advisor. “If a provider had a large panel of Care Select patients and those patients transitioned to Traditional Medicaid, the physician no longer receives the $15 PMPM.

“Conversely for the patients who transitioned to Traditional Medicaid, the physician no longer has to worry about getting the Cert code for that group of patients – good news for those who struggle obtaining Cert codes, but possibly a financial burden for physicians who relied on PMPM payments.”

The pluses and minuses
Having more patients on Traditional Medicaid offers some administrative relief for physicians. No auto-assignment or primary care provider (PMP) selection is required. Referrals are not needed for specialty care and neither is the two-digit specialty care certification code.

However, while no communication went to physicians, the ISMA learned at the Sept. 17 Medicaid Coalition meeting that PMPM reimbursement, which has been $15 per month, would stop for those Care Select patients who switched to Traditional Medicaid – about 40,000. Each Medicaid PMP will likely be impacted by these changeovers.

“In all my conversations with our members regarding this issue,” said Kirkham, “the only concerns they expressed were about the continued care of their complicated patients. No one expressed concerns about their rates being impacted.”

Yet, FSSA expects to save $7.6 to $8 million in the current fiscal year with these changes and $10.7 to $11.3 million for fiscal years 2012 and 2013, due to “a smaller client base as well as reduced fees for the delivery of disease management versus administratively costlier care management.”

Read a press release from FSSA about the changes here.

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