ACT Health Insurance News

North Carolina’s Division of Medical Assistance, responsible for Medicaid coverage, has issued a statement to ACT that they will pay for psychiatric services of our psychiatry providers in nursing facilities. In some cases, payment will be made through Unmet Medical Needs Funding. Payment for psychology services is dependent on the availability of Direct Supervision by a Physician and is subject to Prior Approval. Because Medicare, the major insurance type for your residents, has a rule disallowing same specialty/ similar diagnosis/ same day treatment and Medicare considers Psychiatry and Psychology “same specialty”, ACT must stagger the scheduling of our psychiatry providers and psychology providers and cannot create the “Direct Supervision” requirement that Medicaid requires. Thus, ACT cannot bill Medicaid as a primary/ only insurance source for Psychology services. Additionally, Medicaid as an only source of insurance has informed ACT that they will not pay for any mental health services in the rest home setting, unless of a one time emergency nature.

We apologize for these inconveniences. If you feel these regulations have created an access to care issue for your residents, we urge you to contact the Division of Medical Assistance, CIGNA Medicare, Center for Medicaid and Medicare Services and your local state representatives. As a taxpayer, your voice is heard.

North Carolina’s Medicare + Choice is expanding to offer 33 new health plans based on a Preferred Provider Organization (PPO) model in January of 2003. This change provides Medicare covered individuals greater access and more choices in health care as well as access to affordable prescription drugs. A Preferred Provider Organization allows Medicare covered individuals to choose any healthcare provider they want to, but pays more of the healthcare cost if the covered individual chooses a doctor who is enrolled with Medicare + Choice. ACT is taking steps to enroll all providers with the Medicare + Choice program.

What is happening to Mental Health Centers??

This question has been echoing throughout the North Carolina community this year. Mental health centers have been closing or merging with other mental health centers and contracting out services. Patients referred to their local Mental Health Centers have been on waiting lists for up to 4 months in order to get care.

Mental Health Centers are facing great challenges due to the North Carolina Secretary of State’s mandate that they become Local Management Entity’s by the Year 2004. What does this mean? Mental Health Centers are gradually changing their focus from direct provision of services to overall management of service availability and service provision on the county level. As a provider to long-term care facilities across North Carolina, ACT, Inc. would like to be a part of the solution for Mental Health Centers. A more in-depth look at these changes will be taken in our November – December issue.

HIPAA

What is a Hipaa?

Simplified, the Health Insurance Portability and Accountability Act of 1996 is a law created for the purpose of improving health insurance accessibility for people changing employers and for creating administrative simplification to entice providers into electronically transmitting health related data in a protected environment. Further goals within this law are: