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Program HH (HIV/AIDS) Covered Services

Revised: 04-17-2017

Recipients may be eligible for Program HH only or with other Minnesota Health Care Programs (MHCP), such as Medical Assistance (MA).

Program HH only eligible recipients may have a combination of benefits:

Benefit and eligibility type

Dental

Mental Health

Nutrition

Case Mgmt

Drug

MTMS

Basic (DN)

X

X

X

X

X

Drug and insurance assistance, plus basic (HI)

X

X

X

X

X

X

Dental Benefit

The Program HH dental benefit covers routine diagnostic, preventive, and corrective dental procedures as specified in the MHCP Provider Manual’s Dental Services section. In addition, the following guidelines apply to nonroutine Program HH dental benefit services.

Diagnostic

  • • Comprehensive exam (once every three years)
  • • Periodic exam (once every six months)
  • • Periapical x-rays
  • • Full mouth series (once every four years)
  • • Panoramic x-ray (once every three years; once every two years for patients who cannot cooperate for intra-oral film due to a developmental disability or medical condition that does not allow for intra-oral film placement)
  • Preventive

  • • Prophylaxis (once every six months; for recipients with pervious history of documented periodontal therapy, may be alternated with a periodontal maintenance appointment)
  • • Fluoride varnish (once per year)
  • • Sealants (recipients through age 20, only first and second permanent molars)
  • Restorative

  • Posterior fillings (paid at the amalgam rate regardless of the material used)
  • • Anterior fillings
  • • Crowns
  • • Pontics
  • • Endodontics (anterior and premolars endodontics only; authorization is required for molars)
  • Periodontics

  • • Scaling and root planing (once every three years; authorization required)
  • • Full mouth debridement (once every five years)
  • • Periodontal maintenance (once per six months, but not within three months of a prophylaxis)
  • MHCP will deny claims for any combination of the following performed on the same date:

  • • Adult prophylaxis
  • • Full mouth debridement
  • • Periodontal scaling and root planing (four or more teeth per quadrant)
  • • Periodontal scaling and root planing (one to three teeth per quadrant)
  • MHCP allows multiple quadrants for periodontal scaling and root planing (four or more teeth per quadrant and one to three teeth per quadrant) on the same day.

    Prosthodontics

  • • Removable appliances (once per arch every three years; partial dentures must meet utilization criteria and be prior authorized)
  • • Reline, rebase and repair of removable appliance (may not exceed the cost of new appliance)
  • Oral Surgery

  • • Extractions (non-impacted or third molars)
  • • Biopsies
  • • Incise and drain
  • • Splinting (for repositioning a traumatized tooth or stabilizing an alveolar fracture)
  • Authorization is required for the following:

  • • Extractions for impacted teeth or third molars
  • • Tooth transplantation
  • • Placement of device to facilitate eruption of impacted tooth
  • • Surgical repositioning of teeth
  • • Transseptal fiberotomy
  • • Radical resection of maxilla or mandible
  • • Bone replacement graft for ridge preservation – per site
  • Orthodontics

    Orthodontic treatment is limited to children through age 20 years, must meet the specifications of utilization criteria, and must be prior authorized.

    Temporomandibular Joint (TMJ) Disorder

    TMJ disorder treatment must meet utilization criteria and be prior authorized for the following:

  • • Occlusal orthotic appliance
  • • Unspecified TMD therapy, by report
  • • All TMJ splints
  • Pain Relief

  • • General anesthesia (for children through age 20 years)
  • • Palliative treatment
  • • Sedative fillings
  • • Nitrous oxide
  • Dental Billing

    Refer to the General Billing Guidelines in the Dental Services (Overview) section for complete billing information.

    Review denied claims for recipients with Program HH because services may be reimbursed differently under Program HH. Refer to the services listed above in this section and those that require authorization in the Program HH Dental Authorization Requirement Chart for specific coverage details.

    Providers must contact Program HH to have denied claims reviewed for reimbursement.

    Dental Authorization Requirements

    If a recipient is eligible for both MA and Program HH, follow MHCP Authorization requirements and submit the authorization to the medical review agent. The medical review agent must receive all required documentation to complete its review. Refer to MHCP fee-for-service (FFS) Dental Authorization charts for procedure-specific documentation requirements:

  • Children and Pregnant Women Authorization Chart
  • Limited Benefits Non-Pregnant Adults Authorization Chart
  • If the recipient has Program HH only or the dental benefit is limited, refer to the Program HH Dental Authorization Requirement Chart and submit appropriate documentation to the medical review agent.

    Mental Health Benefit

    Program HH recipients have access to limited mental health services. The Program HH mental health benefit covers the following limited outpatient services:

  • Diagnostic Assessment (90791 only)
  • Psychotherapy (90875 and 90876 are not covered)
  • The Program HH mental health benefit does not cover medications, but several mental health medications are included on the Program HH limited drug formulary. Refer to Program HH drug formulary to see a list of covered medications.

    Nutrition Benefit

    MHCP covers enteral nutritional products when recommended by a registered dietician for up to $100 per calendar month for recipients approved for the nutrition benefit.

    To receive the Program HH nutrition benefit, recipients must first meet with an MHCP-enrolled registered dietician to determine the medical necessity to receive nutritional supplements.

    Registered Dietician Responsibilities

    An MHCP-enrolled registered dietician must identify and document the medical necessity for nutritional supplements using the Nutritional Supplemental Authorization Request (DHS-5849) (PDF) form. The dietician completes the recipient and dietician information sections every six months and faxes the form to the dispensing provider. The recipient may also take the form to give to the dispensing provider.

    If the recipient is eligible for MA in addition to the Program HH coverage, submit claims for dietician services to MHCP according to Licensed Dieticians and Licensed Nutritionists guidelines. If the recipient is eligible for only Program HH, the recipient or recipient’s private insurance (if any) may be responsible for the dietician services. The recipient may choose a dietician from the Ryan White funded dieticians if Medicaid, Medicare or other insurance do not cover the dietician service.

    Dispensing Provider Responsibilities

    An MHCP-enrolled medical supplier or pharmacy must request authorization for the Program HH nutritional products from the customer care specialist. The medical supplier or pharmacy completes the dispensing provider information section of the Nutritional Supplement Authorization Request form and faxes it to 651-431-7414 (do not submit these requests to the medical review agent).

    After processing, Program HH will fax the approved or denied authorization request to the medical supplier or pharmacy. MHCP will issue a follow-up letter to the dispensing provider in the MN–ITS mailbox and send a letter to the recipient.

    Billing

    To receive Program HH payment for the nutritional products, the dispensing provider must submit the claim(s) as follows:

  • • Bill using the 837P format
  • • Enter the approved authorization number (from the approval notice from the customer care specialist)
  • • Enter the registered dietician’s NPI as the ordering provider
  • • Enter the appropriate diagnosis code(s) that matches the authorization form
  • Drug Benefit

    The Program HH drug benefit, or AIDS Drug Assistance Program (ADAP), covers the copay for drugs from the Program HH ADAP formulary for eligible recipients with insurance coverage, and may cover the full cost for the uninsured eligible recipients. If a drug name appears on the ADAP formulary, but the NDC does not appear in NDC Search or your claim for that drug is denied as noncovered, call Customer Care at 651-431-2398 to add the specific NDC.

    Insurance Benefit

    The Program HH insurance benefit pays an eligible recipient’s medical insurance premium. To qualify, the recipient must not have access to employer-sponsored insurance or if the recipient has employer-sponsored insurance, he or she is responsible for paying more than 50 percent of the monthly premium. Medical insurance premiums include, but are not limited to, the following:

  • • Qualified health plans obtained through MNsure
  • • Insurance obtained through the open market
  • • Recipient portion of employer sponsored insurance (ESI) (if the employee pays more than 50 percent of the premium)
  • Case Management

    Program HH funds several clinic and community-based organizations that link Program HH recipients to a variety of services, such as access to health care coverage, legal services, etc. Case management services are available from agencies specifically trained in HIV Case Management Standards (PDF). Recipients living with HIV/AIDS who need a case manager may contact Minnesota AIDS Line at 800-248-2437 to find agencies that provide case management.

    Medication Therapy Management Services

    Medication Therapy Services (MTMS) are covered for Program HH recipients with Basic (DN) or Basic Plus Drug (HI) coverage. Provider eligibility and privacy space requirement will be the same as the MHCP fee-for-service (FFS) MTMS requirements. This service is being provided to help Program HH recipients understand the importance of their drug regiment, issues with compliance, possible side effects and follow up support.

    Eligible Program HH recipients may receive MTMS if they are currently taking or have been prescribed but have not yet started a medication regiment of any HIV/AIDS antiretroviral medication(s).

    Covered Services

    MTMS for Program HH includes the following:

  • • Obtaining necessary assessments of the recipient’s health status
  • • Monitoring and evaluating the recipient’s response to the drug therapy, including safety and effectiveness
  • • Performing a comprehensive medication review to identify, resolve, and prevent medication-related problems, including adverse drug events
  • • Providing verbal education and training designed to enhance the recipient’s understanding and appropriate use of the medications
  • • Providing information, support services and resources designed to enhance the recipient’s adherence with the recipient’s therapeutic regimens
  • • Formulating a medication treatment and compliance plan
  • • Documenting the care delivered and communicating essential information to the recipient’s other primary care providers
  • Program HH recipients may receive up to 12 MTMS encounters per year. Providers may request authorization for additional encounters.

    An encounter can include the following:

  • • Face-to-face encounter, in an area that meets all privacy space requirements and may be provided in:
  • • Ambulatory care outpatient settings
  • • Clinics
  • • Pharmacies
  • • Telephone encounter, when the call is:
  • • Initiated by the pharmacist
  • • Directed to the recipient home phone number on file; the recipient’s file or record must be available for immediate viewing by the pharmacist throughout the telephone conversation (Program HH will not pay for file or record retrieval time)
  • • Provided in an area that is enclosed enough to prevent other employees or the public from overhearing the conversation
  • • Documented and kept on file, explaining the need for the telephone contact rather than a face-to-face contact
  • • Provided in conjunction with at least one face-to-face encounter per year
  • • Interactive video (ITV) encounter (review MTMS Delivered via Interactive Video)
  • • Home visit, when the face-to-face encounter is:
  • • Provided in the recipient’s home
  • • Medically necessary
  • • Documented with a valid explanation for the reason other MTMS venues were not be in the recipient’s best interest
  • Billing

  • • Submit claims using MN–ITS 837P
  • • Enter the pharmacist’s NPI number as the treating/rendering provider
  • • Enter the pharmacy, clinic or hospital MHCP provider NPI number as the pay-to provider
  • • Use the appropriate MTMS codes (see table below)
  • • Use modifier GT for ITV encounters
  • • Use modifier U4 for telephone encounters
  • • Use place of service 12 for home visit face-to-face encounters
  • MTMS codes

    Code

    Description

    Unit

    Benefit Limit

    Rate

    99605

    A first encounter performed face-to-face

    15 min

    1 per 365 days

    $52

    99606

    Subsequent follow-up with same recipient

    15 min

    Up to 11 per 365 days

    $34

    99607

    Additional increments for 99605 or 99606

    15 min

    Up to 4 per date of service

    $24

    Authorization

    If a recipient requires more than the annual 12 MTMS encounters, complete the Program HH MTMS Authorization Request (DHS-6246) (PDF) form and fax it to Customer Care at 651-431-7414 (do not fax to medical review agent).

    Additional Resources

  • HIV/AIDS program (Disabilities) page
  • HIV/AIDS page
  • Legal References

  • Ryan White HIV/AIDS Treatment Extension Act of 2009 (Public Law 111-87, October 30, 2009)
  • Minnesota Statutes 256.9365 Purchase of Continuation Coverage for AIDS Patients.
  • Minnesota Statutes 256.01, subds. 18, 19, 20 State authority for HIV/AIDS
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