Kansas Department of Social and Rehabilitation
Integrated Service Delivery - Candy Shively, Deputy Secretary (785)
From: Bobbi Mariani RE: Tuberculosis Coverage
The purpose of this memo is to communicate policy and procedure changes in the Tuberculosis Coverage program, a state funded medical assistance program. These changes are being made as a result of a new inter agency agreement between SRS and the Kansas Department of Health and Environment designed to provide for treatment of tubercular patients in a cost effective manner. All changes are effective upon receipt of this memo.
Background - As is the case with other infectious diseases, preferred treatment recommendations for patients with tuberculosis have evolved over time. For many years, the state relied on special hospitals established specifically for the treatment of tubercular patients, commonly referred to as sanitariums. Improved medical treatment and a reduction in the number of TB patients ultimately led to the closure of the state TB hospitals in the mid -1970's. New laws were enacted at that time to care for those with TB. Those laws required the Kansas Department of Health and Environment (KDHE) to select and provide treatment of patients as a public health protection. The laws also directed SRS to maintain coverage for inpatient care when needed, creating the state TB medical assistance program. These laws are still in effect today.
At that time, most typical forms of TB cost very little to treat on an outpatient basis with hospitalization being an alternative only in severe cases or when a patient would not cooperate with outpatient treatment. The introduction of drug resistant and multi-drug resistant strands of the disease have increased the complexity of treatment as well as the cost of providing the treatment. In addition, scientific and medical advancements have resulted in many new treatment options. Although ultimate treatment for some infected individuals may still involve inpatient care, quite often a less expensive form of treatment is available.
Under the current TB program, the limited scope of coverage prevented payment of these alternate treatments. Because funds were not available for more cost effective treatment options, people were sometimes treated in more costly inpatient settings. The program changes outlined in this memo will now provide funding for other methods of treatment.
EES has operated the eligibility portion of the state TB program for many years, with payment of medical claims made through the MMIS. Health Care Policy-Medical Policy staff have been responsible for establishing the scope of benefits provided to these beneficiaries. Coverage has been available to any state resident in need of TB treatment, including Medicaid- ineligible immigrants. These basic eligibility policies are not being changed at this time.
Coordination of Care - As the public health agency, KDHE’s Tuberculosis Control and Prevention Program has responsibility for monitoring the TB population. Staff with this program not only collect statistical information but also provide case management for all active tuberculosis patients. Most importantly, they are responsible for monitoring all identified TB cases in the state and ensuring the patient complies with the prescribed treatment regimen. This is done by public health nurses through the local health departments. Individualized case plans are developed to ensure the goals of best practice care and cost effective care are met.
The modified TB Coverage group will rely upon the case plan developed by KDHE in determining eligibility, payment of services and provider of services.
Eligibility - The basic eligibility criteria for
an individual in this group remain the same. In order to
be eligible under this
group the individual must meet the following requirements:
Eligibility will be processed using an MS program. A TB Special Medical Indicator (PICK code) must be used for the appropriate months.
Eligibility is authorized for a period of time consistent with the approximate length of reatment. Informal eligibility reviews must be completed every 6 months.
Prior Authorization - The major change to the eligibility process involves a new prior authorization process. Only individuals authorized by KDHE to receive TB services are eligible under this coverage group. State law mandates all confirmed or suspected cases of TB must be reported to KDHE. The prior authorization process will enable KDHE to establish the case plan prior to payment of any other services.
The KDHE authorization will be documented on the revised ES-3100.3. KDHE will determine if the individual would have otherwise been in need of inpatient care prior to approving care. Applications and other requests for coverage under this group without KDHE’s approval shall be denied. In some cases, a copy of the case plan may be requested from KDHE.
If staff become aware of a consumer with a TB diagnosis or if a request for TB coverage is made directly to the eligibility worker, they are to be referred to the TB nurse at the local health department or directly to KDHE program staff.
Case processing - Cases will no longer be processed and maintained in local SRS offices. A specialized eligibility worker has been appointed at the HealthWave Clearinghouse. The TB Eligibility Specialist, will be responsible for processing all TB applications. Any applications or requests for TB coverage shall be referred to the TB specialist.
NOTE: Except for persons eligible only for limited medical coverage under a restricted benefit plan (e.g. Medically Needy with unmet Spenddown, LMB only, ADAP), there is no need to establish a TB case for a person who is Medicaid eligible.
Scope of Medical Services - In addition to inpatient hospital services, additional services maybe covered if approved by KDHE and HCP-MP staff. These vary in scope depending upon the medical need of the individual but may include nursing facility or assisted living care, medical monitoring, etc.
NOTE: When a TB patient is approved for NF care, there is no need to change to LTC budgeting, complete LOTC or request a LOC score. Any payment made to an NF in this situation is separate and apart from standard LTC Medicaid processes.
Providers and Payment of Services - KDHE will attempt to use active Medicaid providers where possible and assist interested providers in enrolling with Medicaid. However, alternate providers may be used in some situations.
Payments for alternative services provided under this group will generally be made outside of the MMIS. Inpatient claims may be direct billed to the MMIS. KDHE and HCP-MP staff will assist providers in filing claims when necessary. Payments for all services will eventually be tied back to a beneficiary and present on the MMIS.
Payment rates may be negotiated depending on the patients level of need, availability of services in the area and other factors. Negotiation is the responsibility of KDHE staff, but rates will be approved by HCP-MP staff.
Thelma Bowhay, RN, HCP-MP TB Program Manager (785) 296-3981: service and benefit questions.
Diane Dreyer, HealthWave Clearinghouse TB Eligibility Specialist (785) 431-7127: client specific status questions
KDHE Contacts: Phil Griffin, TB Control and Prevention Director