2018Maximum Affordable Payment Schedule (MAPS)

for Medical and Medical-Related Services

Discussion Paper

Background

Pursuant to statute, Texas Labor Code §352.054, “Rates for Medical Services”, and rule, Texas Administrative Code (TAC) Title 40, Part 20, §852.1, “Alternative Purchasing Methods – Rates for Medical Services”, the Texas Workforce Commission (TWC) is required to annually reevaluate rates for medical services. Rates must be based on Medicare and Medicate schedules for current procedural terminology (CPT). Where Medicare and Medicaid rates are not applicable, rates that represent best value must be established based on factors that include reasonable and customary industry standards for each specific service. The TAC also requires the Commission to establish rates at a level adequate to ensure availability of qualified providers, and in adequate numbers to provide assessment and treatment, and within a geographic distribution that mirrors customer distribution. Adopted rates are reflected in theagency’s Maximum Affordable Payment Schedule (MAPS).

In 1999, the Sunset Commission reviewed the legacy Texas Rehabilitation Commission and Texas Commission for the Blind and called for an examination of cost- and resource-based rates for medical services. Before the Sunset Commission review, the agencies had a Medical Consultation Committee consisting of approximately20 medical professionals of different specialties. Thecommittee created the rate schedule for the agencies annually and adjustedrates accordingly. Since 2000, rates have been reviewed based on Medicare and Medicaid,withadopted rates based on those fee schedules.TWC’s Vocational Rehabilitation (VR) currently uses 2012 Medicare rates.

Medicare establishes rates for most of the medical services offered by VR from a fee schedule that is reviewed annuallyby the U.S. Centers for Medicare & Medicaid andthat contains fees for most services listed in the American Medical Association (AMA) CPT coding book. Other rate sources, such as Medicaid and workers compensation, do not price as many of the codes thatVR commonly uses, and are not always reviewed on a yearly basis. To ensure the use of current rates for the broadest range of medical services offered by VR, the decision was made to use Medicare rates for all medical services for which fees are available.

Medicare does not price dental services solegacy DARSadopted Medicaid rates for dental services. Because Medicaid dental fees apply only to services for children, the state dental consultant advised VR to add a 20 percent premium to ensure adequate provider availability and access to services for adult customers.

Issues

Rate revisions were last adoptedby legacy DARS in 2012. An annual review of the MAPS rates was conducted in each of the subsequent years except 2016, during which time programs were being prepared for transfer to TWC or HHSC. Revisions were not adopted in 2013-2015 due to concerns that reductions would adversely impact the availability of providers in certain specializations and/or geographic areas. In addition, in FY 2015, HHSC was preparing to assume the annual rate review process on behalf of DARS, but ultimately did not assume those duties for the VR program due to legislative action resulting in the transfer of the program to TWC. Given the time elapsed since the last revision,the Maximum Affordable Payment Schedule needs to be updated to ensure alignment with current Medicare rates and to help sustain availability of providers.

To conduct the annual review of rates, staff reviews data for the most recent completed state fiscal year using the current MAPS rate and compares it with the proposed rates, which in this instance is the 2017 Medicare Fee Schedule. The data reviewed for the prior fiscal year includes all MAPS codes that were active in ReHabWorks andall purchases made using aMAPS code. The Division for Operational Insight (DOI) assists with pulling the data for review and analyzes thepotential budget impact of proposed rates. Data received from DOIis then separated into groups of rates for similar services to identify potential areas of significant budgetary impact or impact on the availability of providers. Staff then completes the analysis and develops recommendations for consideration. Following is a summary of the analysis and recommendations:

Approximately 97 percent of the proposed MAPS rates for Fiscal Year 2018(FY’18) are based on Medicare or Medicaid rates, with the remaining 3 percent established using alternative methodologies. Whenit isnecessary to establish rates for services not identified by an industry standard (such as the AMACPT) or cost-based rate schedules (such as Medicare and Medicaid), the rates are developedby reviewing services in other agencies and through consultation with the appropriate medical director or medical consultant for the agency.

A comparison of all active TWC system MAPS codes with the proposed rates indicates that:

  • 31 percent of procedure rates will go down;
  • 58 percent of procedure rates will go up; and
  • 11 percent of procedure rates will not change.

Based on applying the proposed rates, it is estimated that at current usage, TWC expenditures for medical and medical-related customer services will decrease by approximately $400,000.

Decision Points

For the FY’18MAPS rate schedule, staff seeks guidance on adoption ofthe followingrate schedules and methodologies.It is expected that implementing these schedulesand methodologies will result in changes to most of the existing rates for medical and medical-related services and will ensure provider availability as required by the TAC:

  • Adopt the 2017 Medicare Fee Schedule. Continue to use Region 18 (Harris County) Physician Fee Schedule for procedures listed in the 2017AMA CPT for the entire state Region 18 has more VR customers and providers than any other Texas Medicare region.
  • Adopt the Medicare 2017 Durable Medical Equipment Texas fee schedule for eye-related medical equipment, including eyeglasses,as well as orthoticsandprosthetics and other medical equipment coded from the AMA’s Healthcare Common Procedure Coding System.
  • Continue to implement the Medicare Part B fee schedule for injectable drugs and equipment.
  • Continue to use the Medicare Clinical Laboratory/Pathology rates for Texas at 120 percent of the listed rate to ensure adequate provider availability.
  • Continue to use Medicaid dental service rates for Texas at 120 percent of the listed rate to ensure adequate provider availability.
  • Continue existing rates and rate-setting methodologies for all unspecified procedures and servicesnot listed in the Medicare or Medicaid rate schedules. These services have been reviewed and rates established in consultation with the appropriate medical director or medical consultant; payment will be authorized in accordance with established procedures. Examples of these services include:

procedural codes unique to TWC customers;

new codes for which a rate has not yet been established;

established codes that do not have a published rate;and

miscellaneous AMA CPT codes (codes ending in 99 and other nonspecific procedures).

These recommended methodologies will result in changes to most of the existing rates for medical and medical-related services because of changes in the corresponding cost-based schedules.

Pursuant to Texas Labor Code §352.054, if the Commission approves staff recommendations regarding the above schedules and methodologies, the Commission must provide notice to interested persons and allow submission of comments prior to final adoption. Following the comment period, Commission approval will be requested to adopt the new rates and incorporate them into the agency’s MAPS schedule.

DP - 2018 Maximum Affordable Payment Schedule (MAPS) for Medical and Medical-Related Services (1.25.18)

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