The HBAI Services Benefit

1. What are some examples of the types of barriers to self-management that HBAI can address?

HBAI services can be offered to address any psychosocial barrier that affects an individual’s ability to effectively manage a chronic disease. It could be emotional, e.g., the person feeling overwhelmed, anxious, or depressed, which is interfering with taking the appropriate steps to effectively manage his/her condition. It could be related to a lack of knowledge about diet and exercise, or it could be a financial issue, such as not having enough income to pay for basic needs, such as food, medicines, or rent. These expanded services will help health care providers meet the required clinical practice activities whether they are seeking payment as a Patient Centered Medical Home (PCMH) or under the new Medicare Payment Reform (Medicare Access and CHIP Reauthorization Act—MACRA) rules.

2. Can HBAI be offered to overcome psychosocial barriers that are related to diabetes management?

If issues are related to management of diabetes only, the HBAI codes would be inappropriate. However, if there are comorbidities, HBAI could be provided as a strategy for continuation of care to address issues related to the comorbid condition(s). For example, if the individual has diabetes and asthma, you could offer DSMT and then add a CDSME workshop with additional components via HBAI to address the psychosocial barriers that are preventing management of the asthma, e.g., environmental factors in the home that are triggering asthma. This wholeperson approach should be very appealing to potential health care partners because multiple medical conditions are more difficult to manage and are associated with increased costs. Health plans and health care providers, as well as state Medicaid agencies, are looking for ways to address these issues.

3. Can we offer chronic care management in conjunction with HBAI?

Chronic care management (CCM) is an established Medicare benefit for individuals with two or more chronic conditions. Although it is a Medicare benefit, State Medicaid Agencies and Medicaid managed care organizations (MCOs) have the option of providing CCM as part of an enhanced benefit package. This benefit can be offered in conjunction with the CDSME HBAI service to help participants improve management of their medical conditions. An individual can receive CCM for 12 months initially. At the completion of the twelve months, there should be a reassessment to determine if the chronic care management services are still needed. While direct supervision is required for HBAI, general supervision can be provided for CCM, which means that there is more flexibility in terms of how and when the service is provided to support self-management goals. (Please see Question 3, page 4, under the “Supervision” section.) If you combine HBAI and chronic care management, the projected costs and revenue can be combined in determining your break-even point.

Marketing and Partnerships

1. What approach should we take as we talk to health care providers about partnering with us to offer HBAI services via the Stanford Chronic Disease Self-Management Program (CDSMP) for their patients?

It would be important to talk about complex patients with psychosocial issues impacting their disease outcomes and how this service can help. Physician practices don’t have the time to address these issues. They only have a few minutes with each patient; the HBAI service can make their job easier and help their patients. You should point out that it is a covered benefit under Medicare and Medicare Advantage and highlight your success in offering the program. Providers are concerned about patients with multiple medical conditions and psychosocial barriers that can impede positive health outcomes. Because they are not equipped to address the types of issues that these patients present, they should be interested in hearing how you can help improve health outcomes for this population.

Under new MACRA rules, which are in effect for all Medicare providers nationwide, practices are required to expand care coordination activities or reduce their already low reimbursement. They are moving toward being paid based on outcomes, and the Stanford CDSMP can help them improve outcomes and enhance their reimbursement under MACRA.

Practices know that they need to do something different and will need to figure out how. If they add services that they offer themselves, they will incur more costs, or they can work with you to get the work done. Showing them how you can help meet these requirements and remain cost neutral so that they don’t lose their reimbursement is a win/win.

2. What do we need to be prepared to discuss as we engage health care partners?

First of all, you should be sure that they understand the HBAI service and what specific benefits it has for them. Then, they will want to know what the initial intake process is, how services occur, and where services are provided. Also, they will want to know what you want them to do, e.g., will they help deliver CDSMP, bill, or provide some other service? If they will be billing, they will want to know how the revenue will be accounted. You would discuss the reimbursement amount, the staff required, the population that you want to serve, etc. If you come to them with a self-contained program with all personnel, then it is just a matter of discussing how you can implement the service under their Medicare provider number. If you need to use their staff to support the program, that is a different discussion.

3. How can I get our local outpatient providers to see the benefit of HBAI and work with us?

The new MACRA rules require that all ambulatory care centers move to a pay-for-performance model. Because HBAI addresses barriers to self-management, the service can help improve outcomes, so there should be a lot of interest. You can find out which patients the practice is most concerned about—which ones are high risk and high cost—and target those for HBAI. You can help them improve their outcomes, and the service is reimbursable.

4. What suggestions do you have for working with our Veterans Administration (VA) to offer HBAI?

There would be an opportunity through the VA Choice program. A veteran must have access to every covered benefit within 30 days or 40 miles of their home. HBAI is a covered benefit, and if the service is needed, the VA has 30 days/40 miles to provide it. If not, veterans can use their Choice benefit to receive the service. So, signing up with the VA to offer HBAI would be a good approach.

5. We are thinking about partnering with our State Department of Health as the Medicare provider. Is that a reasonable path?

Yes. Some State Departments of Health are Medicare providers and already have a number. In that case, they might be interested in partnering with you to offer HBAI as a public health intervention to improve health outcomes in the state. Another option might be the State Department of Mental Health, particularly if the state is interested in addressing co-occurring mental disorders and chronic physical health problems.

6. We are partnering with a skilled nursing facility (SNF) and are looking into offering CDSMP HBAI services as part of the discharge plan to help patients return safely to their homes. Is this allowable?

Generally, you cannot bill for the service while someone in a SNF, as the billing includes all services for an inpatient facility—it is all inclusive. Once the person is discharged, then you can offer HBAI as an outpatient service under Medicare Part B. If a hospital is under bundled payment, you can jointly market the program with the SNF as a way to reduce costs by helping the patient to leave the SNF sooner. You can offer it as an ongoing program to target hospitals that are in the 90 day bundled payment arrangement.

7. We plan offer CDSMP for the prison systems. Will we be able to bill Medicare via the HBAI benefit once we start offering the service?

Usually, prisons contract with a vendor that provides the medical care. The vendor generally has an option to outsource services that it doesn’t offer, and there is a rate associated with that service. You could explore subcontracting with the vendor for HBAI.

Supervision

1. Can a nurse practitioner provide the clinical oversight for HBAI?

Yes, a nurse practitioner, a physician, or a psychologist can provide the supervision when billing Original Medicare. Most Medicare Advantage plans will also cover HBAI when supervision is provided by a licensed clinical social worker, depending on the plan and the social work licensure law in that particular state.

2. How does the Nurse Practitioner (NP) model work for HBAI, compared to the model that uses a psychologist?

For the NP-led model, all services must be individual encounters, and the clinician bills are not based on time. The interventions can be offered before and after CDSMP sessions and during breaks. For the psychologist, there are both individual and group codes based on time.

3. Please explain the difference between general and direct supervision, and what type of supervision is required for Medicare reimbursement of HBAI services?

“Direct supervision” means that the clinician is in the building while the service is provided. ”General supervision” means that the service is provided under the overall direction of the clinician, but the presence of the clinician in the building is not required while the service is provided.

CMS requires direct supervision for a HBAI claim to be paid by Medicare. However, if the service is offered in a rural area where telehealth is approved, general supervision is acceptable. The clinician can be accessed via a secure skype-like connection or telephonically. Bundled payment organizations can provide telehealth anywhere. For instance, if you are working with a hospital that refers patients to you under bundled payment, you could provide general supervision for HBAI and bill it under Medicare. Also, telehealth is allowed without restriction for the next generation accountable care organizations (ACOs).

4. We don’t have a psychologist on staff, and we don’t have enough services yet to hire one. What suggestions do you have for finding a clinician?

You could contract with a psychologist for the hours that are needed to provide HBAI services or partner with an organization that has a psychologist on staff, such as your State Department of Mental Health, a specialty clinic, or possibly the Veterans Administration. Supervision can also be provided by a Nurse Practitioner (NP), and your local health department or another partner might already have an NP on staff that can provide the supervision. Most Medicare Advantage plans allow use of a licensed clinical social worker, depending on the licensure laws in the particular state, so that is an option that you should also explore.

5. We are in a rural area, and there are shortages of clinical psychologists. What options do we have?

First, you should consider telehealth. The telehealth regulations cover HBAI as a telehealth service. Therefore, the psychologist that provides the supervision can be in a metropolitan area, linking to your program via telehealth, and it’s billable. In addition to reimbursement, there is an additional technology fee that you can collect to cover the cost of the connection.

You should also consider enrolling as a provider in Medicare Advantage plans if they are available in your area because most allow supervision by a licensed clinical social worker, depending on the licensure laws in the particular state.

Billing

1. Do Medicare Advantage Plans have to cover HBAI?

Yes, HBAI is a service covered by Medicare, and Medicare Advantage plans must cover all the services that Original Medicare covers.

2. We are working with a clinic that has the Provider Transaction Access Number (PTAN) and National Provider Identifier (NPI) number to bill Medicare. Is it necessary for the psychologist to also have an NPI number?

Yes, both the organization and the clinician who provides HBAI must have an NPI number, and both numbers must be on the claim. These numbers allow the Centers for Medicare & Medicaid Services (CMS) to track where services are provided and who is providing them.

3. How do you get a National Provider Identifier (NPI) number, and how long does it take?

The application is made online, and you should hear back within 48 hours.

4. We want to target dual eligibles for HBAI, but our Medicaid State Plan doesn’t cover the service. Does Medicaid have to cover the co-insurance?

Medicaid is mandated to cover the coinsurance, even if the Medicaid State Plan doesn’t cover the service. CMS sent a letter to all Medicaid directors to clarify this. If participants have Medicaid only, the state has the option to deny the service; but if participants are dual eligibles, Medicaid must pay the coinsurance.

5. If someone is getting care coordination through the Medicaid Health Home program, would billing HBAI be double dipping?

No, it would not be double dipping, and it is permissible for someone to receive both. The Health Home is a Medicaid benefit, while HBAI is a Medicare benefit; these are two distinct services. Each state develops their own proposed Health Home model for care coordination, while HBAI services are designed to help overcome perceived barriers to self-management of a chronic disease. One is for coordination, and the other is for service delivery. Medicaid is required to pay the coinsurance for dual eligible who receive HBAI, regardless of whether or not the state Medicaid program covers HBAI as a benefit.

Telehealth

1. What is needed for a telehealth connection?

All you need for telehealth is a two-way audio-visual connection that is secure and HIPAA compliant. For example, Go to Meeting has HIPAA compliant telehealth service as an add-on to the Go to Meeting subscription.

We tested a telehealth model for CDSMP. While people in a rural area are participating in each of the six CDSMP sessions, the licensed person is available and intermittently observing through the telehealth connection. The clinician doesn’t have to interact with participants during the sessions but must be available in case something occurs that requires intervention.

2. If HBAI is offered via telehealth, can the assessment be provided remotely too?

Yes. If the service is provided in a rural area, the entire procedure can occur via a secure, HIPAA compliant telehealth connection.

3. How do I know if an area qualifies to offer telehealth?

Telehealth has to be offered in a designated rural area; the designation is developed by United States Department of Agriculture (USDA). The U.S. Health Resources & Services Administration (HRSA) has a look-up tool to determine if the location meets the requirement. There are some waivers to allow expansion of telehealth. For example, anyone who is in bundled payment can receive all services via telehealth during their bundled payment episode of care without geographic restriction.

This project was supported, in part by grant number 90CS0058-01-00, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.