AHCCCS Reinsurance Workshop Year 39 Update

Annual AHCCCS Reinsurance Workshop RI Contract Year 39 Annual AHCCCS Reinsurance Workshop RI Contract Year 39 Presented by Tracy Thomas Friday, October 23rd, 2020

Agenda Welcome and Introductions Review Reinsurance Manual Changes for 10/01/2020 Transplant Contract Changes Miscellaneous Issues Recaps Reminders Questions 2

Introductions 3

Reinsurance Manual Changes The Addition of the submission of SNF Rates as a deliverable per the ACC Contract. o SNFs Stays consistently price above the AHCCCS Allowed. o Reinsurance needs these rates to correctly price your SNF Stays correctly. 4

Reinsurance Manual Changes 5 New Drugs added to Catastrophic BIO Case Type effective 10/01/2020 o Revcovi (added effective 10/01/2019) - for Adenosine deaminase severe combined immune deficiency (ADA-SCID) o Orkambi Cystic Fibrosis o Symdeko Cystic Fibrosis o Trikafta- Cystic Fibrosis o Ruconest - Hereditary Angioedema o Evrysdi - Spinal Muscular Atrophy 5

Reinsurance Manual Changes Request for new Biological/High Cost Specialty Drugs can be submitted to AHCCCS Reinsurance for consideration for Reinsurance purposes. Contractor must notify AHCCCS Medical Management prior to issuance of Transplant Case denials. Contractor must record Transplant Case Denials in Quarterly Transplant Log. Contractors are instructed to post their Transplant related submissions to their AHCCCS SFTP Folder and notify AHCCCS Reinsurance that the submission has been posted. 6

Reinsurance Manual Changes Clarification Regarding Transplant Outliers - Only Transplant Stages that have been adjudicated for payment and are included per the Transplant Contract can be considered for Transplant Outlier reimbursement. Donor Leukocyte Infusions (DLI) are to be billed as Harvest Stage o If a DLI occurs during Prep and Transplant to 31-60 Stage, it is to be billed as a second sequence Harvest stage. o If a DLI occurs outside of Prep and Transplant to 31-60 Stages, it is to billed as Harvest stage under a new case. 7

Reinsurance Manual Changes Clarification Regarding Multi-Organ Transplants which are not covered in the Specialty Contract o This clarifies when a covered organ transplant type is performed following another separate covered organ transplant type. o For example, a member receives a Heart Transplant and before the 31-60 Stage is completed the member needs a Lung Transplant. o The Follow-up stage for first transplant type is prorated. o A case is created for the second transplant. 8

Reinsurance Manual Changes Clarification Regarding State Only Transplants regarding member Share of Cost and Rate Code criteria When a member is on the transplant waiting list and has been denied by AHCCCS due to excess income, the member can select Option 1 or Option 2 State Only Transplant Coverage. o With ST1 coverage option, the member is enrolled under Rate Code 3100 o A ST1 case is created covering all medically necessary covered services for 12 months with no deductible at 100% . o If the member goes to Transplant during the twelve month period a Transplant Case is created and will be reimbursed less the member s share of cost. 9

Reinsurance Manual Changes Clarification Regarding State Only Transplants regarding member Share of Cost and Rate Code criteria - Continued When a member is on the transplant waiting list and has been denied by AHCCCS due to excess income, the member can select Option 1 or Option 2 State Only Transplant Coverage. o With ST2 Extended eligibility covers transplant services only. o At the time that the transplant is scheduled to be performed, the transplant candidate will reapply and will be re-enrolled with his/her previous Contractor under Rate Code 3100 to receive all covered transplant services. o The Transplant Case is created and reimbursed less the member s share of cost. 10

Reinsurance Manual Changes No Manual Replacement or Voids during Reinsurance Pricing Cycle The Reason: o When a Reinsurance associated paid encounter is replaced or voided during the Reinsurance Pricing Cycle the encounter is changed to replaced (33/78) or void (32/78) in the Encounter region but does not change to replace or void in the Reinsurance subsystem which represents an over payment. 11

Reinsurance Manual Changes AHCCCS Reinsurance must be notified of overpayments Contractor's are instructed to post their Reinsurance Action Requests and Other related documentation to their AHCCCS SFTP Folder and notify the AHCCCS Reinsurance unit that the submission has been posted. o The previous language was regarding mailing these requests USPS. o This has now changed since the Reinsurance Unit is now Virtual Office. 12

Transplant Contract Changes Transplant Contract Rates increased 3.8% 13

Transplant Contract Changes Banner University Medical Center Tucson oCurrently, there is no contract for Heart (HRT) and Heart-Lung (HLT) Transplants as Banner University Tucson has not re-certified. 14

Transplant Contract Changes Lucille Packard Children s Hospital o Added Pediatric Autologous (PAU), Related (PAL), Unrelated (PLU) Bone Marrow Transplants to their Contract with Total Body Irradiation TBI included in the Autologous and Related Case Types but paid at a rate for the Unrelated Case Type. o Added Room and Board to Contract Mayo Clinic Hospital Scottsdale o Added Pediatric Autogolous (PAU), Related (PAL), Unrelated (PLU) Bone Marrow Transplants. 15

Transplant Contract Changes Rady Children s Hospital Did not sign a Contract. Stanford Hospital and Healthcare added Heart (HRT), Double Lung (DLL) and Single Lung (SLT) Transplants to their Contract. The Transplant Per diem Rate for 11+/61+ has changed to $2083.00/day. 16

Pending Transplant Contract Changes Banner University Medical Center Phoenix Banner Phoenix has been certified for Heart Transplants. We are currently negotiating rates and should have a signed contract soon. Addition of Car-T Drug Tecartus to Specialty Contract o Tecartus will be added effective 10/01/2020 as soon as contracts are negotiated and signed. o Tecartus will be Reinsured similar to Kymriah and Yescarta. 17

Miscellaneous Issue Reinsurance Payment Cycle Abend Issue. o Batch Replacement (VR) and Void (VD) encounters are causing the Reinsurance Payment Cycle to Abend (crash). o The Reinsurance Cycle and Encounter Cycle . o It appears to occur when most of the case total value is recouped. o The abend causes your remits to be off due to the fact that we have to correct the problem manually. o The Reinsurance and Encounter IT Staff are working on troubleshooting this issue. 18

Recaps Why didn t This CRN Associate to my case? o Is it a covered service in the RI325? o If it s an IP stay, is it an interim bill? o Is it an acute care facility PT02? Interim bills will not associate to RI Cases. o Only Provider Type C4 and PT71 interim bills will associate to cases. o Did the stay cross contract years? There is no Reinsurance for IP Stays which cross Contract Years. 19

Recaps Mayo s 61-100 Component Mayo requested this for the continuity of care for their Bone Marrow recipients It reimburses OP and Form A only The stage is paid at the AHCCCS fee for service rate for all transplant related OP and Form A claims within the 61- 100 days 20

Reminders Out of State Transplants o Please note: AHCCCS Medical Director MUST approve all out-of-state transplants or transplants that occur at out-of-state contracted hospitals for non-contracted types o The Letter of Agreement (LOA) must be received and reviewed by AHCCCS Rates and Reimbursement Manager before the case can be created in PMMIS. 21

More Reminders Do not forget to monitor your cases over $1,000,000.00 so you can request to receive enhanced reinsurance. Do not forget to request your catastrophic cases timely, (ie, HEM, VON, GCC, BIO) 22

Reminders - Continued There is no Transplant Reinsurance for Kidney Transplants as they are capitated. All providers must be registered. Notwithstanding the denial of reinsurance by AHCCCS, the Contractor is responsible for payment of claims for all services approved by the Contractor. 23

Health Plans AHCCCS Hospitals 24

Questions? 25

Thank You. 26