STAR and SMAC

Hello,

I am Nevada’s representative to the State Advocates for Reimbursement (STAR) and State Medicare Administrative Contractor (SMAC) Network.  Because I am part of a community based program that serves clients who have all types of insurance coverage I am happy to take on these issues.

I will post updates and concerns on the NSHA website if SLPs and Audiologists will view the information. 

Each Network meets via phone once a month.  There is also an ongoing email dialogue with members asking and answering questions.  The Network also meets at various national conferences.  I attended the ASHA Health Care/Business Conference in Seattle in May where the STAR and SMAC networks had a combined meeting.  ASHA has been very supportive of these Networks and will often bring in experts to update us on the issues.  They also ask for our feedback.

There are many critical issues playing out.  I will briefly cover them in this report and if you want more detail please email me at DianeRoss@TheContinuum-Reno.com.  Also if you have questions or concerns regarding reimbursement, coding, etc., I will do my best to help you find the answers.

STAR

ASHA has formed an Ad Hoc committee to look at Medicaid issues.  The Center for Medicare and Medicaid (CMS) assist the states in reimbursing each Medicaid program.  Each state must follow certain rules in order to receive reimbursement but each state also has the ability to have their own rules as well which includes reimbursement rates and criteria for what types of therapy services are covered. Each state must have a Medicaid Service Plan that defines policy, coverage and limitations. It is important that the reader understand that speech therapy services are not mandated by CMS and Nevada has the option to not provide these services.   Given the economic situation/crises in Nevada, this is important information.  Medicaid has already decreased our reimbursement rates and can do it again.  Because Medicaid also reimburses for medically necessary therapies delivered in the school environment, these concerns impact almost all of us.  Were you aware that while Nevada mandated the private insurance sector, starting in 2011, to cover the diagnosis of Autism, Medicaid was exempted?  So if you record that the child is being treated for speech and language problems related to Autism, your therapy program will not be covered.

SMAC

The Medicare Therapy Caps have been in effect for many years.  A number of committees have been looking at alternatives to this terrible policy. Three alternatives have been suggested.  ASHA has been actively participating.  At the last SMAC call, a request that we provide feedback over which of the alternatives would be most beneficial to Medicare recipients.  If you are interested in learning more about these choices, email me and I will provide you with the information.

Do you know the difference between “habilitative” and “rehabilitative” therapy?  Habilitation was included in the reform bill but has not been defined.  Many insurance providers will not cover any therapy services unless there is evidence of an “accident, injury or illness”, thus excluding children who have been diagnosed with “developmental disabilities”.

ASHA is actively working on helping to define “habilitation”. 

And finally a word about Health Care Reform and how it might impact our profession.  Although the jury is still out on how successful this reform will be, there are some positive changes that will impact our ability to provide services.  Stay tuned.

Diane Ross


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