Major Changes in Medicaid

The Florida Medicaid program is making some big changes.

In May, Medicaid changed the fee schedules for Licensed Midwives and Birth Centers. Medicaid eliminated almost every code for Birth Centers and added one, leaving them with a total of two billable codes. Midwives also lost many of their billable codes and were left with limited services which they can now be paid for.

At the same time, Medicaid has been transitioning to Managed Care programs statewide. They are changing the name of their program entirely to the “Statewide Medicaid Managed Care Managed Medical Assistance Program.” Region by region, most individuals enrolled in Medicaid are being switched to HMOs. This transition should have caused no great upheavals. Providers were assured that they should continue providing all of the services which were previously authorized, because the new plans MUST pay the previously authorized services for up to 60 days. Better yet, for the first 30 days, providers were expecting to be paid at the rate they were previously receiving.

Express Claims contacted the MMAs before the change took place to ensure that their clients would be paid, even though their contracts were through the Birth Centers. The representatives from the HMOs all said this would be fine, no problem at all! Unfortunately, that has not been the case. Currently, a great number of claims are being denied for Birth Centers and Licensed Midwives. Medicaid is still paying properly, but the MMAs are not–and the majority of Florida Medicaid subscribers are now considered managed care. The HMOs are not recognizing the codes that are being billed, because they are not on the Birth Center fee schedule, but they ARE on the Licensed Midwife schedule. These fees should be covered, but the HMOs do not have the LMs connected to the BCs at this point.

As of September 5, Express Claims was told by Wellcare (the HMO holding the majority of Medicaid’s MMAs in Florida) that as long as the LMs became linked to the BCs, the issue would be solved. A massive email was sent to the director at Wellcare and we hope to hear of some progress very soon.

Another major issue is in the billing of 59430TH code for postpartum care. Medicaid wants 59430TH to be billed alongside 59410 for vaginal delivery. Medicaid adopted this code in 2003, but the MMAs have been rejecting this code. They don’t seem to recognize the Medicaid coding rules. We believe that these insurance companies should know how Medicaid processes codes if they are going to be processing these codes, as well. This is another issue that Express Claims is taking great measures to resolve.

For some providers, the recent changes in Medicaid’s fee schedules and managed care, as well as the rejection of code 59430TH, means very little money coming in. These are serious issues that Express Claims is working diligently to fix. When claims are denied, they are not set aside. They are brought to the forefront and we are working from every angle to get payments for providers. Medicaid and the HMOs need to get organized and set their systems up to properly pay Birth Centers and midwives. We hope that with our persistent phone calls and e-mails, Express Claims can help get this resolved… Soon!

For more helpful information: Medicaid Managed Care Update-AHCA

To view which codes Medicaid is currently accepting:  Updated Fee Schedules