LARC Learning Community Presentation – Billing and Reimbursement: Challenges and Strategies

Thank you, and for our next speaker, I’m pleased to welcome Robin Summers. Robin Summers is a senior policy director at NFPRHA, the National Family Planning & Reproductive Health Association Summers leads NFPRHA’s Medicaid work focusing on ensuring access to high quality family planning services, Medicaid eligibility and enrollment, Affordable Care Act implementation and helping family planning providers and administrators as well as state Medicaid officials improve their Medicaid family planning expansion programs Summers has been with NFPRHA since 2005. She earned her Juris Doctor from Rutgers School of Law – Camden, and has a BA in history from Truman State University. I’m pleased to welcome you, Robin Thanks so much for having me today. I want to tell you a little bit briefly about NFPRHA We’re a national membership organization that represents that broad spectrum of family planning administrators and clinicians serving poor and low-income nationwide. If you’re not a member of NFPRHA already, certainly I encourage you to check us out When it comes to billing and reimbursement for LARC, there are a number of challenges in providing LARC postpartum and beyond, as you well know. Today, I’m gonna focus on two key areas: coverage and cost, to talk about some of the issues our providers are seeing and some of the potential solutions being used to address, workaround, and overcome these challenges Given NFPRHA’s membership, ongoing, we’re coming at this from the perspective of our providers, but I hope that the ideas will be illustrative for you in terms of the challenges being faced by the providers serving patients through your program. As you know, the ACA requires most private insurance plans to cover LARC methods without cost-sharing. This includes all new individual and employer insurance plans, which are required to cover all FDA-approved methods of contraception, sterilization, and counseling without cost-sharing as part of the ACA’s Women’s Preventative Health Services Benefit No cost-sharing means basically what it says Patients should not have to have any out of pocket costs including payment of deductibles, fees, or other charges for coverage of contraceptive methods including LARC. Patients cannot be asked to pay up front and then be reimbursed Currently, there are three different LARC methods that are the FDA’s list of approved methods: the implantable rod, IUD copper, and IUD with progestin The ACA requires coverage of brand-name contraceptives that do not have generic equivalents, so therefore, all IUDs that do not have generic equivalents must be covered. In addition to services relating to inserting a LARC, services related to follow up and management of side effects, counseling for continued adherence, and device removal should also be covered without cost sharing The law only applies to new plans. Older plans are what are known as grandfathered, meaning that if they existed on or before the ACA was signed into law in March of 2010, then they are grandfathered in and they stay that way unless and until they change significantly Now, we get asked this a lot. What does that mean? It means that they either cannot significantly cut benefits, increase cost-sharing, or change premium contributions by more than 5 percent The number of grandfathered plans is going down quite a bit. About 26 percent of plans were grandfathered in 2014, and that’s down from 36 percent in 2013 It should also be noted that some religious employers do not have to comply with the contraceptive coverage requirement. Churches and houses of worship are exempt. Religious nonprofits have an accommodation, allowing them to opt out. In those situations, coverage responsibility shifts to the insurance plan itself or the third-party administrator that’s running the plan. There’s litigation ongoing with this, and stay tuned for more changes. It’s been a bit of a moving target in the last few years As has been the Supreme Court’s decision in the Hobby Lobby case last year, which basically meant that certain for-profit corporations do not have to comply with the requirement as well. There’s regulations ongoing that are trying to clarify exactly what that definition includes. What does it mean to be a for-profit corporation? And the accommodation that had originally only applied to religious nonprofits has been proposed to be expanded to include and define these groups. That process is also ongoing LARC coverage in Medicaid varies, as you know, by state and within states depending on the exact type of coverage a person is enrolled in. It’s gotten more complicated today than it was a few years ago. Family planning has long been covered in traditional Medicaid and I put sort of “traditional” with air quotes, without cost-sharing. But states have had flexibility about exactly what is covered Most states cover LARC. They don’t necessarily cover all types. Most states cover a broad range of contraceptive methods, but they don’t

necessarily cover everything There have also been planning expansions in 28 states and these are an expansion of Medicaid eligibility to cover family planning services and supplies for populations that are not otherwise eligible for Medicaid. Those programs often offer access to a broader range of methods and more expansive services. Since 2005, states have had the authority to enroll Medicaid enrollees in what are called Alternative Benefit Plans with some exceptions. Benefit packages in these ABP plans mirror the benefits in certain specified private health plans Now, why does any of that matter? Well, this matters in particular post ACA because ABP plans are the designated benefit packages for most people eligible for Medicaid expansion under the Affordable Care Act. Under the ACA, ABP plans, therefore, get what are known as the Essential Health Benefits. Essential Health Benefits includes the Women’s Preventative Services Benefit. So that means that ABP plans have to cover all FDA-approved contraceptive methods including related follow up, side effect management, and important lead device removal So, for millions of newly eligible low-income women who enrolled through a Medicaid expansion in a state will receive coverage of all LARC methods, no matter how the state defines its family planning benefit for the rest of the Medicaid program. The other key place that we see differences in this since all – since family planning is a required service under Medicaid traditionally, is in contraceptive counseling. Traditionally, Medicaid has not covered counseling for contraceptives, but the Women’s Program and Services Benefit does cover that. So that’s a change So somebody walking in with a Medicaid card doesn’t necessarily tell you exactly what’s covered. You have to know the specifics of their Medicaid coverage to know what’s covered Also, an increasing number of states including Idaho, West Virginia, and Kentucky also enrolled groups of individuals apart from the Medicaid expansion population into ABP plans. So anyone who is enrolled in a plan in those states would also get the Women’s Preventative Services Benefit So what LARC methods are covered and how it also varies by managed care plans. Today, there are nearly three-quarters of Medicaid beneficiaries receive services through some type of managed care arrangement. There’s some special considerations regarding managed care, notably that something called the Freedom of Choice Provision, which is that Medicaid enrollees are entitled to seek coverage of family planning services from any Medicaid-participating provider, regardless of whether they’re technically in a managed care plan network. It’s a really important provision Those providers that provide services to those patients also have to get paid either by the state or the managed care plan, and the state sets that requirement. The idea of all of this and all of this complication about exactly what is covered and how it’s covered and what plan you’re in, all of these things have really complicated the situation for providers So obviously that’s a huge challenge, but apart from that, just even knowing what’s covered, the fundamental challenge we’re seeing right now for providers is that a number of payers are not, in fact, covering all FDA-approved methods even when they’re supposed to. In the private insurance context, although plans are allowed to use what are called reasonable medical management techniques to control cost and promote efficient delivery of care, exactly what that includes or excludes is really poorly defined We know for sure that plans can choose to not cover without cost-sharing services and contraceptives provided at out-of-network providers and pharmacies. Now, a minute ago I said Medicaid managed care has to cover services provided out-of-network. That does not apply to private insurance outside of Medicaid. But even if the plan chooses not to cover a method that’s provided as an out-of-network provider, the plans do have to cover out-of-network without cost sharing if there is no one in-network who can perform the service. That is certainly the case that we’re seeing in a number of states Brand-name drugs that have a generic equivalent don’t have to be covered as long as the generic equivalent is covered without cost-sharing Plans do have to cover brand-name drugs that don’t have a generic equivalent and to date, there are no generic equivalents for LARC methods that have been approved by the FDA In addition, for methods for which there is both brand name and a generic, if the provider determines that the generic is not medically-appropriate for their patients, the plan does have to have a waiver process that allows the brand to be covered without cost-sharing The information about these waiver processes vary dramatically from plan to plan. So providers really are sort of left with the responsibility of trying to find out from every plan what

exactly their process is and how that works It’s better to get that information up front, but it’s added certainly some levels of complication both for providers and for patients But there’s a number of other forms of medical management such as Step Therapy, which is the idea of requiring a trial. Say, you have to have two failures on an oral contraceptive before you are allowed to have an IUD or other LARC. There’s also quantity limits. In the LARC context, you can only have one LARC every three years even if your previous LARC was expelled or you had some other complication and had to have it removed Then there’s also prior authorization. We believe that none of these kinds of things should actually be allowed since women are supposed to have access to all methods under the ACA, and these techniques can serve as fairly large barriers to accessing care, but we’ve seen them in some insurance plans. The bottom line here is that LARCs are covered, but we’re finding a lot of loopholes. We keep pushing the federal government for clearer prohibition on what should not be included as reasonable medical management. In the meantime, advocates are pushing new laws at the state level and fighting this plan by plan So how does this relate to postpartum LARC? Well, it makes it all the more challenging by complicating reimbursement. Even if your state has addressed Medicaid reimbursement for postpartum LARC, there are other factors in play that are impacting providers’ ability to get paid and, therefore, provide care So what should providers do if their insured patient is having trouble getting LARC coverage without cost-sharing? These tips are applicable to all settings, including hospitals. First and foremost, the National Women’s Law Center has something called the Cover Her Hotline and they have the website, e-mail address, and phone number available. They’re really trying to sort of navigate this plan by plan and help providers and patients push back They’re sort of the first best place to get information and to get help Secondly, make sure that providers are using the appropriate codes for preventative health services. Services are only covered without cost-sharing for patients when they’re appropriately coded. Insurance claims may allow access to an off-formulary method if it’s medically indicated, as I mentioned earlier, in this waiver process. But it’s really important, as I said, for providers to talk with the insurance companies and get the information about what exactly that waiver process entails It will make a big difference in terms of helping patients get access When providers actually talk to payers, they should really be talking to the medical director with any concerns. This is an area where state agencies can play a really important role in working to ensure that Medicaid managed care plans are not creating medical management barriers and working with state insurance commissioners to improve private plan coverage and eliminate loopholes I also said I would talk about cost, and this is obviously the other really big issue in terms of providers’ ability to provide LARCs The cost to stock methods, cost to provide them how cost impacts access, getting reimbursed appropriately. All of these things play into cost, and this applies to all LARC methods including postpartum insertion The first issue of cost in family planning provider realm depends on how it is covered by the payer, as a medical benefit or as a pharmacy benefit. It’s a little different for hospitals, but some of the issues are possibly adaptable. These distinctions vary by state and plan, as with everything else, and come with their own pros and cons that can impact the patient’s access and providers’ bottom line Functionally, LARCs are covered as a medical benefit. Then it’s the buy and bill method where the provider buys the device directly from a manufacturer or designated pharmacy or specialty distributor and then they bill the patient’s insurance carrier for the device and insertion procedure. If it’s a pharmacy benefit, there’s less up front cost because the provider is not actually stocking the methods in advance. The pharmacy or specialty distributor bills the patient’s insurance carrier directly for the device and then the provider bills the patient’s insurance carrier for the related procedures and services But I think a lot of folks think that the medical benefit method is arguably better in terms of patient access and especially when we’re trying to get same-day placement But the cost of stocking the device is increasingly prohibitive for our members, safety net providers that serve predominantly low income and, therefore, still uninsured patients. So maximizing the revenue for the devices that can be paid for is critical The number of strategies that we’re encouraging folks to explore to reduce the stocking burden such as volume discounts, 90-day net trons, the use of 340B and other payment options State agencies can encourage providers to explore these options and improve systems to maximize provider options One thing also I’ll note is that even though it’s more common for the implant to be considered

a pharmacy benefit than for IUDs, it can make up front stocking challenging since devices typically have to be tied to specific patients It could take up to seven days to receive a device via the various specialty pharmacy programs. So it’s something to keep in mind as your programs are sort of setting the parameters for how things are covered through your programs So I talked about medical management earlier, but it comes into play here as well when we’re talking about some of these reimbursement challenges. Another example particularly in the LARC context of how medical management is a barrier, we’ve heard of an insurance plan where the patient must get a referral from the primary care provider. Now, this is in the private insurance context because such referrals are not allowed in Medicaid But if the family planning provider places the IUD without a referral, the patient is then responsible for half the device fee and half of the insertion fee That particular provider says that sometimes they spend time to assist the patient directly in getting their referral, but it’s not always possible. Even when it is, it’s a cost in terms of staff time and resources. Another big issue here is timely payments. Cash flow is a real concern if the cost to acquire the device is not received in a timely manner Ensuring that payer sources including state payer sources are paying in a timely manner is hugely, hugely important to facilitating the insertion of LARCs. It’s very especially important I think for postpartum LARC insertion In the postpartum realm, there’s special considerations for the provision of LARCs. Along with a lack of provider training and difficulty with stocking issues within the hospital setting, the key reimbursement challenge, as you know, is often the use of a global fee for birth and a lack of FFS payment for LARC devices or insertion in addition to birth costs A lot of work has been focused around getting this fixed in Medicaid. As of December of 2014, there’s at least 11 state Medicaid programs that have published final or proposed guidance regarding reimbursement for postpartum LARC We need to continue this work not only to get more states to adopt it, but to have them require it of their managed care plans. Private insurers also need to be urged to insure appropriate payment outside of global or bundled fees That’s an increasing challenge in this day and age when bundled payments are being promoted as a means of service delivery and payment reform Additionally, the coverage and other cost issue I talked about earlier have an impact on providers’ ability to provide postpartum LARC. Minimizing barriers posed by medical management, payment methodologies, and proper oversight of Medicaid managed care plans are all really important to improving postpartum LARC access Finally, I’d say that a key consideration is not just to focus on adequate payments for the device itself, which is something we care about a lot, but also for the things that go with it. LARC aren’t just about the device cost. They’re about the insertion, removal, reinsertion when warranted, counseling, any complications. The list goes on. So making sure that all of those ancillary things are covered along with good reimbursement costs for the device itself are sometimes a better strategy than going to a state and saying – or going to a plan and saying, “I want more money for X device.” So it’s something to consider moving forward So I talked about a few different strategies and one of my colleagues, Amanda Kelinson is on the phone, and I want to ask her to talk briefly about a project that she’s been working on that will likely be of interest to you. A lot of what I talked about comes from that work. Amanda? Thanks Robin, and thanks to ASTHO for letting me join you briefly today. I was excited to get this opportunity. It was so timely because of a new product that is on the horizon for NFPRHA and our colleagues at ACOG, the National Health Law Program, the National Women’s Law Center, and the University of California at San Francisco’s Bixby center. Our colleagues and I are working on a project because we witnessed the challenges that providers have faced related to offering LARC methods because of the significantly higher costs of these methods compared to other contraceptive methods As such, the group has created a guide that aims to explain the landscape of LARC insurance coverage and served as a resource for providers navigating stocking, reimbursement, and other scenarios that create barriers to the provision of these methods. This guide is intended to help alleviate the financial challenges so that providers are better able to offer a full range of contraceptive methods and minimize some of the out-of-pocket costs or delays in care to their patients This guide is certainly not intended to endorse LARC methods over other types of contraceptives, though we just want to highlight that contraceptive care should always be patient-centered and

responsive to individuals’ preferences, means, and values. Again, we’re just trying to eliminate some of the barriers to this particular method So while not focused specifically on inpatient settings, we are confident that the resources included in the document will be of use to you folks on the call today. Specifically, will include resources like coverage guidelines that Robin discussed today, stocking devices, obtaining reimbursements, and troubleshooting the special circumstances that come along with things like failed insertions or expulsions So we’re anticipating the guide will be released in the coming weeks, and we look forward to sharing it with ASTO so that all of you on the call today can have access to it and an additional added benefit to those of you coming to the NFPRHA National Conference is that you’ll get a copy of it in your tote bag So if you have questions, please reach to NFPRHA. We look forward to sharing this resource for you Thanks Amanda. So with that, this is contact information for the policy communication side of the NFPRHA team including my e-mail address and our phone number and website. So, thanks again for having me, and I’m happy to answer any questions Thank you so much, Robin and Amanda, for your presentation. While we’re waiting for some of those chat questions to come in via our chat pod, I’d like to point everyone to we have a poll just previously about what coverage or cost challenges are providers in your states facing that might impact their ability to provide LARCs postpartum. While the answers were pretty even across the board, the most response were the coverage and cost challenges are mostly around the use of the global fee for births in private or public insurance That came in at 33 percent. However, we did get responses of understanding what is and what is not covered by insurance, payers, and plans; Medicaid management loopholes; docking costs, and an inability to offer same-day placement because of payer billing restrictions So we’re listening to those and hopefully we’ll be able to address some of those via technical assistance moving forward, but we do have a chat question and that is to both Robin and Amanda. What guidance can you provide about making the business case for postpartum LARC? We’ve heard this come up many times about either for state legislators and getting state fees or some sort of other making the case, either within the hospital. What kind of guidance do you have or does NFPRHA have for our leaning community? Well, I’m happy to start. This is Robin. I think one of the biggest things that we talk about a lot is really understand the sort of value proposition of LARC, being able to explain why the state or the plan should spend more money to benefit them to benefit your patients. It goes beyond just public health You have to actually show them the financial side. The good news is there’s also a huge emphasis going on right now on quality in plans and not just paying for care, but paying for quality care. That’s something that I think all of the evidence around LARC, particularly postpartum, I think can really be helpful So making sure that you’re sort of prepared up front to make your case with facts and figures and data and dollar signs, I think is really beneficial. Amanda, I don’t know if you have anything to add to that? Yeah, I would agree and second your comments, Robin, and just share an anecdote. I was visiting with somebody from a managed care plan the other day, and I asked this person, “What should I say in response to a managed care plan who may not see the benefits of inserting a long-acting reversible contraceptive if somebody is turning on and off the plan?” Their response was that insurance is inherently a risk-based model, and they’re willing to take that risk to pay for a significantly more expensive method because I think we all know on the call that birth spacing is important to achieving healthy pregnancies The closer that you have those pregnancies together, the likelihood of having a complicated pregnancy, and therefore, increased spending related to inpatient stays for those pregnancies and births. The risk is increased. I think appealing to that logic with insurance or coverage more generally is an important factor when making this argument

Yeah, and I think that’s a really great point, and it sort of reminds me to say that just because you’re prepared data and you have your facts and figures doesn’t mean that the same argument is gonna work with different providers – excuse me, different payers. Every payer has sort of their interest and their own focus and what matters to them. So understanding what the payer is after and how you can help them achieve their goals I think is really key Thank you so much Robin and Amanda. We really appreciate your comment and we’re looking forward to getting additional materials and having you join us on future calls. Thank you Thank you [End of Audio]