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Massachusetts Health Centers – Insurance and Other Clarification MemoTable of ContentsDental Only Patients . 2Health Safety Net . 2CHIP . 3MassHealth Limited . 3CarePlus . 3Qualified Health Plans purchased through the Health Connector (including ConnectorCare). 3Healthy Start Women . 3Children’s Medical Security Plan (CMSP) . 3Managed Care . 3Senior Care Options (SCOs) . 4Program of All-inclusive Care for the Elderly (PACE) . 5Primary Care Payment Reform (PCPRi) . 5Reclassification of the Self-Pay Portion of Third Party Charges . 6Self-pay Sliding Discounts . 7Boston Public Health Commission . 7ACA Funds . 7Community Health Workers . 7Counting Nurse Triage Visits . 8UPDATED Memo to Massachusetts Health CenterUniform Data System – January 2018Page 1

To Massachusetts Health Centers:Below outlines the UDS reporting instructions for the above categories:Dental Only PatientsFor individuals who do not utilize medical services at your health center (e.g., dental-only patients orbehavioral health patients), your health center is expected to track and report their MEDICAL insuranceon Table 4 lines 7-11. These individuals may not have insurance for dental services but they may haveinsurance for primary care and other medical/behavioral health services. Table 4 lines 7-12 recordsPrincipal Third Party Medical Insurance Source. A patient seen in the dental clinic with Medicaid, Private,or Other Public dental insurance who did not use medical services may be presumed to have the samekind of medical insurance. If a patient does not have dental insurance, you may not assume that they areuninsured for medical care, and the health center must obtain this information from the patient.Health Safety NetThe Health Safety Net is categorized as a state or local safety net program. These are programs which payfor a wide range of clinical services for uninsured patients, generally those under some income limit setby the program. They may pay based on a negotiated fee-for-service, or fee-per-visit. They may also pay“cents on the dollar” based on a cost report, in which case they are generally referred to as an“uncompensated care” program. Most are generally “capped” at a maximum total amount, and paymentsare often paid in a different fiscal year. The following are how your data should be reported across tables4, 9d, and 9e.Tables AffectedTable 4Table 9DTable 9EUPDATED Memo to Massachusetts Health CenterUniform Data System – January 2018Treatment While patients may need to qualify foreligibility, these programs are not consideredto be public insurance. Patients served are to be counted on Line 7 asuninsured. The health center’s usual charges for eachservice are to be considered charges directlyto the patient (reported on Line 13, ColumnA). If the patient pays any co-payment, it isreported in Column B. If they are responsible for a co-payment butdo not pay it, it remains a receivable until it iscollected or is written off as a bad-debt inColumn F. All the rest of the charge (or all of the charge ifthere is no required co-payment) is reportedas a sliding discount in Column E.A. The total amount received during the calendaryear from the State or local indigent careprogram is reported on Line 6a.Page 2

CHIPIt is currently unrealistic for health centers to differentiate between SCHIP and MassHealth. Thus, allindividuals covered by MassHealth and SCHIP should be reported on line 8a of Table 4, lines 13a and 13bcolumn A for capitation and managed care fee for service, respectively, and lines 1, 2a, 2b on Table 9D. Ifat some point it differentiating between MassHealth and SCHIP becomes more straightforward, healthcenters will be expected to report SCHIP on line 8b on Table 4.MassHealth LimitedReport as uninsured on Table 4 line 7.If you are able to distinguish these charges and collections from regular Medicaid, report on Table 9D line7. If you are not able to distinguish, report on line 1 of Table 9D.CarePlusReport all CarePlus as Medicaid on line 8a in Table 4.Qualified Health Plans purchased through the Health Connector (including ConnectorCare)The UDS does not distinguish between Gold, Silver or Bronze plans. As the manual states, all of thesesubsidized plans are reported as Private Insurance on Table 4 Line 11. Charges and revenues are reportedon Table 9D Line 10 (unless the plan is a managed care plan then it is reported on 11a or 11b for capitatedand FFS plans, respectively). It is important that grantees reassign the patient portion of third partycharges to self-pay Table 9D Line 13 to reflect co-pays and deductibles.Healthy Start WomenReport as uninsured on Table 4 (line 7) and on Table 9D other public (line 7).Children’s Medical Security Plan (CMSP)CMSP is not considered SCHIP by the Bureau of Primary Health Care as it is funded solely with State dollarsand does not receive the federal match. It has limited coverage – outpatient only – and children whorequire inpatient services are linked into/’covered’ through the Health Safety Net Trust Fund.CMSP is to be reported on line 10a of Table 4. On Table 9D, you should report the revenue, cash, etc. onlines 7, 8a and 8b (other public).As of July 1, 2017, changes were implemented to CMSP’s billing process (elimination of UniCare as theadministrator); however, they do not effect UDS categorization of CMSP. It is a state Medicaid programbut does not receive any federal reimbursement.Managed CareA. Neighborhood Health Plan – most (if not all) of NHP is managed care. For UDS purposes, NHP hasthree categories – commercial (private), and Medicaid. You need to track these managed careenrollees and their corresponding charges and member months separately.B. Network Health – the same as NHP, you must track the enrollees by the type of coverage andcategoryC. HealthNet – the same as NHP, you must track the enrollees by the type of coverage and category.UPDATED Memo to Massachusetts Health CenterUniform Data System – January 2018Page 3

D. BMC’s HealthNet – for those health centers that continue to participate in Boston MedicalCenter’s HealthNet network whereby individuals are given a ‘card’ that gives them access to allservices within the medical center. Technically, these individuals are not “insured” however, aftera lengthy discussion with Art Stickgold, we agreed that these individuals should be reported online 10A of Table 4.E. CeltiCare – as CeltiCare’s market penetration increases you need to pay attention to thecategories that are offered by CeltiCare and report member months accordingly on lines 13a and13b. You need to track CeltiCare managed care enrollees and their corresponding charges andmember months separately by category.F. Fallon Community Health Plan – the same as NHP, you must track the enrollees by the type ofcoverage and category.See the Table below for details/summary:Commercial includingbut not limited to NHP,Network Health,HealthNet, (possiblyCeltiCare). Includes allQHPs purchasedthrough the Connector.Medicaid Managed Careincluding but not limitedto NHP, Network Health,HealthNet, CeltiCare,CarePlus plansIndemnity Medicaid(straight fee-for-service,non-managed care)SCHIPIncluding but not limitedto NHP, Network Health,HealthNetThe ‘original’ BMCHealthNetTable 4 – MedicalInsurance SourceLine 11Table 4 – ManagedCare UtilizationLine 13a column D forcapitation; line 13bcolumn D for fee forservice (ffs)Table 9DLine 8aLine 13a column A forcapitation; line 13bcolumn A for ffsLines 2a for capitation,line 2b for managed careffs, line 1 for straight ffsLine 8aNot applicableLine 1Line 8aLine 13a column A forcapitation; line 13bcolumn A for ffsLines 2a for capitation,line 2b for managed careffs, line 1 for straight ffsLine 10ALine 13a column C forcapitation; line 13bcolumn C for ffsLines 8a for capitation,line 8b for managed careffs, line 7 for straight ffsLines 11a for capitation,line 11b for managedcare ffs, line 10 forstraight ffsSenior Care Options (SCOs)On Table 4 the patient would be reported as a Medicare patient (line 9). On Table 9D the collection wouldbe from both Medicare and Medicaid. There should be some rational division of the charges which shouldbe Medicare up to the amount that Medicare pays and then all the rest would go up to Medicaid. Thiswould apply for straight fee-for-service (line 4 and lines 1 for Medicare and Medicaid, respectively),managed care capitation (lines 5a and 2a for Medicare and Medicaid, respectively) and managed care feefor-service (lines 5b and 2b for Medicare and Medicaid, respectively).UPDATED Memo to Massachusetts Health CenterUniform Data System – January 2018Page 4

Please get in touch with the SCOs with which you have a contract and determine the gross ratio ofMedicaid and Medicare – a gross ratio Medicare to Medicaid is acceptable, or outpatient allocation ofMedicare to Medicaid would work as well. Use this on Table 9D and allocate between Medicare andMedicaid proportionally.NOTE: Commonwealth Care Alliance (CCA) and Senior Whole Health are both SCOs, and therefore shouldbe categorized as above. However, CCA and United serve dual eligibles under age 65 in the One CareProgram, which could be counted as Medicare managed care since it is for duals. As a reminder, One Careis for disabled adults between 21 and 64 who are dually eligible due to their disability status. SCOs areonly for 65 persons who are eligible for MassHealth, and are therefore dually eligible too.Program of All-inclusive Care for the Elderly (PACE)Report all clinicians associated with the PACE program on lines 1-11 of Table 5 and line 1 of Table 8A.Count medical visits provided by these clinicians if they meet the UDS criteria (i.e., face to face,documented in the patient’s chart, independent clinical judgment is rendered, provided by a licensedclinicians). You may include nursing FTEs on line 11 but do not include nursing visits on line 11. Reportcharges for these visits and collections (take some reasonable portion of PMPM) on Table 9D – you willneed to determine the split between Medicare and Medicaid. NOTE: What we are trying to determine isthe reasonable part of your PACE reimbursement that is due to outpatient care. It is acceptable for youto work ‘backwards’ by determining the medical costs and using this amount as the payments on Table9D column B (with corresponding gross charges in column A).For ancillary and wrap services, including the personnel providing these services, report them on line 29aof Table 5, the costs for them on line 12 of Table 8A, and the income received for the portion of the nonclinician-provided services goes on line 10 of Table 9E.For the ancillary and wrap services, PACE programs are shown as an expense on line 12 Table 8a. You donot include any visits from the PACE program on Table 5. Staff for the PACE program should be countedon line 29a of Table 5. The income is shown on table 9E line 10.If patients enrolled in PACE come into the health center and see a physician who is part of your 330 staffwith legitimate medical visits (face to face, documented in the patient’s chart at the health center,independent clinical judgment, etc.), then the physicians and mid-levels providing this care at the healthcenter would be counted on lines 1-11 of Table 5 along with the medical visits in column b and the patienton line 15 column c. Do not include nursing visits that are incidental to custodial care (so, do not includethese visits on line 11 of Table 5, but include the FTEs). Count all the medical visits Count all FTEsIf Medicare pays you for the visits (in which the PACE enrollee saw a 330 clinician) above the PACE PMPM,then you would show the charges and collections for that visit on Table 9D. If Medicare does not reimburseyou for this 330 visit, then you would show a reasonable medical PMPM on Table 9D line 4a and reducethe amount on Table 8a.Primary Care Payment Reform (PCPRi)Primary Care Payment Reform initiative (PCPRi) was an alternative payment methodology that worked toimprove access to primary care, enhance patient experience, quality, and efficiency through careUPDATED Memo to Massachusetts Health CenterUniform Data System – January 2018Page 5

management and coordination. PCPRi combined a shared savings/risk arrangement with qualityincentives.In this model, participants contract with MassHealth, and committed to delivering primary care consistentwith the Commonwealth’s definition of a patient-centered medical home with a focus on behavioralhealth integration. As a result, participants were provided a managed care capitated amount per patientper month to provide the full breadth of primary care and behavioral health services. Services not coveredunder the capitated payment were paid on a managed care FFS basis. The following is how patientscovered by PCPRi should be captured on the UDS.Tables AffectedTable 4Table 9DTreatment People covered by this plan are considered asMedicaid Managed Care and are insured ontable 4 It is considered to be managed care and allmember months should be counted andincluded as a capitated Medicaid program The health center’s usual charges for eachservice for those covered by this plan are to beconsidered Medicaid Managed Care Capitatedcharges (Column A). The capitated payments from MassHealthshould be reported as revenues in Column B. The difference between the Charges and thecapitated payment should be considered asthe allowance. The health center’s usual charges for servicesnot covered under the capitated paymentshould be considered as Managed Care Fee forService. Payments and allowances related tothese charges should be handled as you wouldnormally handle these on the UDS. Any retroactive payments (Wrap-aroundpayments) related to charges that are coveredunder the cap or not should be handled as youwould normally handle these on the UDS.NOTE: PCPRi ended on December 31, 2016.Reclassification of the Self-Pay Portion of Third Party ChargesThose of you who underwent a system conversion to NextGen have experienced some difficultyidentifying and moving the charges associated with copayments and deductibles to line 13 column A ofTable 9D.Per Art Stickgold regarding NextGen, if issues still persist:Run a listing of all adjustments and find the adjustments that state transfer copayment, deductible, andresponsibility. The worst case is that you have a code that has a code that says self-pay (as opposed toUPDATED Memo to Massachusetts Health CenterUniform Data System – January 2018Page 6

from Medicare to self-pay). If this is the case, then they have to run a report by payor class. What chargeswere Medicare, Medicaid, down to self-pay.Self-pay Sliding DiscountsOn Table 9D, line 13, column e, report only slides for individuals who are low income (200% FPL).a. Report gross charges for all individuals on line 13 column Ab. Report cash received for patients on line 13 column Bc. Report cash from HSN on line 6a T9EThe ‘extra slides’ (i.e., slides for individuals above 200% FPL) are not reported anywhere on the UDS.Patient Centered Medical Home - A number of health plans in Massachusetts are providing PMPM dollarsfor the health centers to pilot PCMH.d. Should these be counted as MM on Table 4? Noe. The income from this PMPM should be by payor on T9D column B. The payment shouldbe listed in column C3.Boston Public Health CommissionThere has been some inconsistency regarding the categorization of the funds received from the BostonPublic Health Commission. The funds are public. Therefore, funds received from the Boston Public HealthCommission should be reported on line 7 (local government) of Table 9E.ACA FundsACA funds received from MassHealth that are not paid on a FFS basis and/or are not tied to direct patientservices should be reported on Table 9e line 6: State Government Grants and Contracts (specify: ), noton Table 9d. Please use the specify box and indicate that a portion of the total on this line is from thissource.Community Health WorkersCommunity Health Workers can perform many functions at a health center and thus can be classifiedacross many lines on Table 5 in the Enabling Services section. Per the instructions, care should be takento distribute an individual staff members time across 1 or more columns reflecting what functions theyprovide at the health center. The manual specifically states that:Community Health Workers (Line 27c) are lay members of communities who work in associationwith the local health care system in both urban and rural environments and usually shareethnicity, language, socioeconomic status, and life experiences with the community membersthey serve. Staff may be called community health workers, community health advisors, lay healthadvocates, promotoras, community health representatives, peer health promoters, or peer healtheducators.Specific consideration should be made to ensuring that CHWs who provide Case Management orPatient/Community Health Education services are categorized on these lines so that their visits can beappropriately reported.UPDATED Memo to Massachusetts Health CenterUniform Data System – January 2018Page 7

Counting Nurse Triage VisitsNurse triage visits are one of the most common visits reported on the UDS on Table 5, line 11 and as longas patients who are seen by the nurse during a triage encounter are not referred to and seen by anothermedical provider on the same day, they can typically be counted on the line 11 on Table 5 as a nurse visit.Whether you bill for these services or not does not have a bearing on whether they should or should notbe counted on your UDS Report.UPDATED Memo to Massachusetts Health CenterUniform Data System – January 2018Page 8