Comprehensive Medical and Dental Program

Reinsurance

Statement/Purpose

DCS Comprehensive Health Plan (DCS CHP) pursues revenue available from the AHCCCS stop-loss program known as reinsurance.

Definitions

Reinsurance: Reinsurance is a stop-loss program provided by AHCCCS to DCS CHP for the partial reimbursement of covered medical services for the Contract Year. The reinsurance Contract Year is the year beginning on October 1 and ending on September 30. Reinsurance is paid for services incurred for a member beyond an annual deductible level.

Policy

DCS CHP participates in the AHCCCS Reinsurance Program and receives reinsurance benefits for partial reimbursement of covered medical services incurred for a member beyond an annual deductible level.

DCS CHP complies with the eligibility requirements, determination of benefits, and deductible rates set forth in the AHCCCS Reinsurance Policy Manual, the AHCCCS Medical Policy Manual (AMPM), and the IGA between DCS CHP and AHCCCS.

Procedure

Regular Reinsurance

Regular reinsurance covers partial reimbursement of covered inpatient hospital services. Inpatient hospitalization encounters are used to determine reinsurance benefits. DCS CHP has a $150,000 deductible for regular reinsurance and a 75% reimbursement of the remaining balance. This pertains to inpatient claims only. Inpatient services are those services provided in acute care hospitals (provider type 02), specialty per diem hospital (provider type C4), and accredited psychiatric hospitals (provider type 71) only. Same-day admit-and-discharge services do not qualify for reinsurance. Regular reinsurance does not cover services provided by any other inpatient provider type, including but not limited to RTCs and subacute facilities. Refer to the AHCCCS Reinsurance Policy Manual for additional details.

Nursing Facility (NF) services provided within 30 days following an acute hospital stay are eligible for reinsurance coverage. The total number of NF days eligible for reinsurance shall not exceed 90 days per Contract year regardless of whether there is one or multiple post-hospitalization nursing facility admissions.

Services provided at mental health residential treatment centers and subacute facilities are not eligible for reinsurance reimbursement

Catastrophic Reinsurance

The Catastrophic Reinsurance program encompasses members receiving certain biologics/high cost specialty drugs as well as those members who are diagnosed with certain conditions.

The following catastrophic diseases/treatments have no deductible and an percent reimbursement of AHCCCS allowed amount or DCS CHP paid claims:

• Gaucher’s Disease:85%

• Hemophilia: 85%

• Non-DDA VP responding Von Willebrand’s Disease: 85%

• Biologic/High Cost Specialty Drugs: 85%

• Behavioral Health: 75% (applies only to members enrolled in ALTCS prior to 10/01/2007 for services approved prior to that date)

• State Only Terminations: 100%

[See AHCCCS Reinsurance Processing Manual for details on conditions and biologics/high cost specialty drugs covered].

Gene therapies are evaluated on a case-by-case basis for members with hemophilia, von Willebrand’s, Gaucher’s and all other disease states.

Requests for reinsurance and supporting clinical documentation is submitted within 30 days of the initial diagnosis, enrollment with DCS CHP or, for continuation of previously approved catastrophic reinsurance, within 30 days of the start of the new contract year.

Transplant Services and Immunosuppressant Medication

DCS CHP covers medically necessary transplant services and related immunosuppressant medications in accordance with Federal and State law and regulations. Services include pre-transplant inpatient or outpatient evaluation, donor search, organ/tissue harvesting or procurement, preparation and transplantation services, and convalescent care. [See AMPM 310-DD and the Specialty Contract for Transplantation Services for a complete list of the AHCCCS covered transplants].

DCS CHP, through the Early and Periodic Screening Diagnostic and Treatment (EPSDT) Program for individuals under age 21, covers all non-experimental transplants necessary to correct or ameliorate defects, illnesses and physical conditions whether or not the transplant is covered by the AHCCCS State Plan.

All transplants require prior authorization. DCS CHP and its contracted MCO are responsible for care coordination, and reimbursement for all components covered under the transplant contract.

DCS CHP and its contracted MCO conduct timely and complete evaluations to determine whether a particular transplant is medically necessary, considered the standard of care and is not considered experimental.

DCS CHP notifies AHCCCS Medical Management within 30 days of the first component of the transplant utilizing the Request for Transplant Reinsurance Form. In general, the components are defined as follows:

• Outpatient transplant evaluation,

• Donor search and/or harvesting of the donor cells for stem cell transplants,

• Preparation and transplant,

• Post-transplant care (Days 1–30 and Days 31–60).

Reporting

The DCS Finance Unit generates a monthly Potential Reinsurance Cases Report from the DCS Health Information System and updates a monthly reinsurance tracking spreadsheet with new paid claim information. Cases are checked against subsequent AHCCCS Remittance Advice Reports to determine if the potential cases meet the applicable deducible amount, catastrophic disease criteria, or transplant criteria. If the applicable deductible/criteria is met but the member does not appear on the AHCCCS report within 30 days, DCS CHP reviews the status of the related encounters.

Audit and Reporting

The AHCCCS reinsurance remittance is audited against the DCS CHP expected reinsurance recovery and discrepancies are reviewed. If DCS CHP is overpaid on either an open or closed case, DCS CHP notifies the Reinsurance Program Compliance Auditor Supervisor at AHCCCS within 30 days.

DCS CHP and its contracted MCO provides information on transplant or Catastrophic receipts to AHCCCS, as required, for qualifying recipients eligible for reinsurance reimbursements. A transplant may qualify for outlier coverage when a specified contractual deductible is met or exceeded. Before processing, the outlier invoice is reviewed. Only transplant related services are included in the outlier calculations. DCS CHP submits the following information with the outlier request to AHCCCS Reinsurance Unit for review:

• Outlier Worksheet (Supplied by AHCCCS);

• All completed stage invoices;

• Proof of payment to the facility;

• List of all non-covered/denied charges by transplant stage.