Family Planning Eligibility and Billing

1. Family Planning Eligibility and Billing Travis Duke

2. Goals • Understand changes to Title V, X, and XX eligibility guidelines • Understand changes to Title V, X and XX billing policy • Discuss Title V, X and XX payment for “wrap around” services provided to WHP clients. • Discuss common billing issues

3. Presentation Structure • Eligibility Overview • Changes to Eligibility Guidelines • Billing Overview • Changes to Billing Guidelines • WHP Wrap Around Services • New Procedures • Common Billing Issues • Q & A

4. Eligibility OverviewEligible Population Females (of childbearing age) and males, who have not had sterilization surgery or other condition resulting sterilization and who are seeking family planning services.

5. Eligibility OverviewTitle V • Income at or below 185% FPL • Texas resident • No fee or co-pay for clients at or below 100% FPL. • Co-pay may not exceed 25% of the authorized payment amount for services for clients between 101-185% FPL.

6. Eligibility OverviewTitle XX • Income at or below 185% FPL • Texas resident • No co-pay for any client with zero income. • Client co-pay may not exceed 25% of the authorized payment amount for services. (Note: in a a X/XX clinic this requirement does not apply)

7. Eligibility OverviewTitle X • Income at or below 250% FPL • No residency requirement • No fee or co-pay for clients at or below 100% FPL. • A discounted fee schedule for clients between 101% FPL and 250% FPL.

8. Changes to Eligibility GuidelinesFamily Composition The budget group consists of the applicant, his/her spouse, and all mutual and non-mutual children. If an unmarried applicant lives with a partner, ONLY count the partner’s income and children as part of the budget group IF the applicant and his/her partner have mutual children together. Treat applicants who are 18 years of age as adults. No children aged 19 and older or other adults living in the household should be counted as part of the budget group.

9. Changes to Eligibility GuidelinesIncome • For unemancipated, unmarried clients UNDER 18 years of age, if confidential services without the involvement of a principal family member are requested, only the client's income is used to assess eligibility. • For clients who are married or are 18 years of age or older the income of all family members must be used.

10. Changes to Eligibility GuidelinesIncome Deductions • Dependent Care Expenses • $200 Per Month for Children Under 2 • $175 Per for Children Age 2 or Older

11. Changes to Eligibility GuidelinesTitle XX Co-payment at a Title X/XX Clinic • Co-payment is no longer capped at 25% of the reimbursable cost of providing services • Enables Title X/XX clinics to better implement the required sliding fee scale

12. Billing Overview • 2017 Family Planning Claim Form Filing Deadlines • Initial Claims: 60 days from date of service on the claim • Appeals: 120 days from date of the Remittance and Status report on which the claim reached a finalized status

13. Billing Overview • WHP claims must be held until the client is determined WHP eligible by HHSC • If WHP eligibility has not been determined within 35 calendar days from the date of service, a Title V or XX claim or a Title X encounter may be filed for the service

14. Billing Overview Contractors must continue to file claims and encounters even if they have exhausted their budget

15. Changes to Billing Guidelines • After 35 days from the date of service contractors may file a Title V or XX claim or Title X encounter without verifying and documenting that a client is ineligible for WHP. • Sterilization Complications

16. WHP Wrap Around Services See Handout

17. New Procedures • J7303 – Hormonal Vaginal ring, each - $35.80 (9-1-07) • S0180 – Implantable contraceptive capsules (Implanon) - $585.11 (12-1-07) • 11975 – Insertion, implantable contraceptive capsules - $152.25 (12-1-07) • 11977 – Removal with reinsertion, implantable contraceptive capsules (12-1-07)

18. New Procedures • 87490 – Chlamydia test, direct probe technique - $27.71 (12-1-07) • 87491 – Chlamydia test, amplified probe technique - $27.71 (12-1-07) • 87590 – Gonorrhea test, direct probe technique - $27.71 (12-1-07) • 87591 – Gonorrhea test, amplified probe technique - $27.71 (12-1-07)

19. Rate Changes For IUDs • J7300 Rate prior to 4-1-07 = $321.13 Rate after 4-1-07 = $387.60 • J7302 Rate prior to 4-1-07 = $426.97 Rate after 4-1-07 = $487.76

20. Common Billing Issues • CLIA Certification • Family planning agencies can bill some lab codes to Title V and XX that can not be billed to Title XIX • Most obvious when XIX retro-eligiblity occurs • Retro-eligibility and rate differences between Title V/XX vs. XIX • Appeals vs. Resubmission of New Claims

21. Common Billing Issues • Importance of submitting correct TPI/NPI at the beginning of the fiscal year • NPI implementation and 3rd party billers • Matching R&S reports to payments

22. Questions & Discussion

23. The End Travis Duke Travis.duke@dshs.state.tx.us