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Cancer Detection Programs Every Woman Counts (can detect)

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Cancer Detection Programs Every Woman Counts (can detect)

     can detect

    Cancer Detection Programs: Every Woman Counts 1

    This section includes information about Cancer Detection Programs: Every Woman Counts (CDP: EWC). This program provides selected benefits to uninsured and underinsured women whose household income is at or below 200 percent of the Federal poverty level. The goal of the program is to reduce breast and cervical cancer mortality rates in this population of California women. In addition to offering screening and diagnostic services, the program is designed to facilitate regular rescreening of women with normal or benign breast and/or cervical conditions and to provide follow-up services for women with possible diagnoses of breast and/or cervical cancer, including referral for treatment when necessary.

Cancer Detection The Cancer Detection Section (CDS) is part of the California

    Section (CDS) Department of Public Health, Chronic Disease and Injury Control

     Division. CDS manages the multi-faceted Cancer Detection

     Programs: Every Woman Counts.

Cancer Detection Programs: Components of CDP: EWC include the following:

    Every Woman Counts

    (CDP: EWC)

     Health education and outreach activities

     Clinical services

     Quality assurance and improvement through professional

    education and evaluation of clinical data

     Patient care coordination to ensure women are screened

    regularly and that follow-up occurs when needed

     The program is funded by both Federal and State dollars. Federal

     funds are received from the Centers for Disease Control and

     Prevention. State funds are received from two tobacco taxes.

     Breast and cervical cancer early detection and screening services are

     provided in all counties of the State.

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CDP: EWC and CDP: EWC and Medi-Cal are separate programs; however,

    Medi-Cal Work Together CDP: EWC relies on the Medi-Cal billing process to process both

     hard copy and electronic claims.

    Regional Contractors The Regional Contractors are local representatives of CDP: EWC.

     The Regional Contractors are public and private agencies that ensure

     low-income women receive breast and cervical cancer screening

     services. The Regional Contractors are responsible for recruitment,

     training, and maintenance of the CDP: EWC provider network and

     providing tailored health education for eligible recipients.

    Clinical Standards CDP: EWC services are performed in accordance with CDS clinical

     standards, which are available through 10 Regional Contractors

     statewide and online at www.medi-cal.ca.gov.

    Activities Regional Contractors conduct the following activities:

     Recruit and train CDP: EWC primary care providers (PCPs)

     Support CDP: EWC providers to participate in breast and/or

    cervical health service delivery networks

     Conduct local targeted outreach and education for low-income,

    high-risk women

     Address gaps in the delivery of these services

     Coordinate professional education about breast and/or cervical

    cancer screening and related subjects

     Provide technical assistance for development of patient

    tracking and follow-up systems that facilitate annual

    rescreening and timely referrals for women with

    abnormal findings

     Provide technical assistance and training in entering recipient

    information, eligibility, and data into the CDP: EWC data entry

    application known as DETEC (DETecting Early Cancer)

     Provide technical assistance and training with data entry to

    meet the Core Program Performance Indicators (CPPI)

    measuring quality outcomes

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    Provider Participation All PCPs must contact the Regional Contractor in their area for Requirements information and orientation before rendering CDP: EWC

    services. Prior to providing services, all new PCPs must receive

    training about program standards and requirements, submission of

    hard copy or electronic claims, and submission of outcome data via

    DETEC. New PCPs are eligible to render services only after the

    effective date of enrollment, as stated in the CDP: EWC welcome

    letter. PCPs must adhere to all requirements contained in the Primary

    Care Provider Enrollment Agreement (PCPEA), CDS clinical

    standards and data submission requirements.

     A Primary Care Provider must:

     Be a Medi-Cal provider in good standing and licensed in the

     State of California.

     Enroll in the program through a Regional Contractor.

     Complete and sign a Primary Care Provider Enrollment

    Agreement.

     Have Internet access.

    Internet Access Required PCPs must have Internet access to obtain the 14-character recipient

     identification number that is required for hard copy or electronic claim

     submission, and for completing DETEC online enrollment and data

     forms. See “Online Recipient Information Form” in this section for

     further instructions.

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    Regional Contractors Regional Contractors determine who may be enrolled as a PCP Enroll PCPs based on the need to complete service networks in a geographic area

    or improve access to care for targeted populations.

    PCP Categories CDP: EWC-enrolled PCPs fall into two categories:

     Those who may only be paid for breast cancer screening

    services. These PCPs may bill the program for

    procedure codes marked with a diamond () in the list under

    the “Approved Procedures” heading of this section.

     Those who may be paid for both breast and cervical cancer

    screening services. These PCPs may bill the program

    for procedure codes marked with a square () in the list under

    the “Approved Procedures” heading of this section.

    NPI Billing Requirement PCPs are required to use only a National Provider Identification (NPI)

    number to bill for services covered by CDP: EWC.

    When a PCP acquires an NPI, the Medi-Cal Provider ID number

    (legacy number) is end-dated and all client records associated with

    that Provider ID are transferred to the new NPI. Therefore, any claims

    submitted under the legacy number will be denied.

    Referral Providers Referral providers are those who receive referrals from PCPs to

     render any screening or diagnostic services. Referral providers must

     be Medi-Cal providers in good standing and licensed in the State of

     California. Referral providers do not enroll in CDP: EWC or sign a

     provider agreement. Examples of referral providers

     include the following:

     Anesthesiologists

     Laboratories

     Mammographers

     Pathologists

     Radiologists

     Surgeons

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    Claimable Procedures Referral providers may bill CDP: EWC for all procedure codes marked for Referral Providers with a dot (;) in the list under the “Approved Procedures” heading

     located in this section.

Referral Providers In order to bill, CDP: EWC referral providers must have the recipient’s

    Rely on PCPs 14-character ID number provided by the PCP. Claims submitted

     without the recipient’s ID number will be denied.

     After the PCP verifies the recipient’s eligibility for and enrolls her in

     CDP: EWC, the PCP must communicate the recipient ID number to

     the referral provider. The referral provider may then submit a claim for

     payment, according to CDP: EWC guidelines.

     Referral providers must report their screening and diagnostic findings

     to the PCP, who is responsible for submitting data and outcomes to

     CDP: EWC and for coordinating further care or follow-up.

Payments from Referral and Primary Care providers must not attempt to obtain

    Recipient Disallowed payment from recipients for co-payments or the balance of costs

     of breast and/or cervical cancer screening or diagnostic services.

     Payment received by providers from CDP: EWC in accordance with

     the Medi-Cal fee structure, constitutes payment in full.

    LA County Waiver Providers who render services for the following special programs may Program, RHC and bill only with a CDP: EWC provider number and must submit claims FQHC Guidelines according to CDP: EWC guidelines:

     LA County Waiver Program

     Rural Health Clinics (RHCs)

     Federally Qualified Health Centers (FQHCs)

    All other requirements in this section apply to these special program

    providers. Questions may be directed to the Telephone Service

    Center (TSC) at 1-800-541-5555.

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    Assessment of Tobacco Use PCPs are required to assess every woman screened through and Referral for Smoking CDP: EWC and refer those who do use tobacco to a cessation Cessation program. Screening for tobacco use is to be completed by the PCP at

    time of enrollment or recertification and recorded on the Recipient

    Eligibility Form. The provider must keep a copy of the recipient-signed

    form on file.

     Assessment is encouraged to be performed at every office visit and is

    not a separately reimbursable procedure. Tobacco assessments and

    cessation referrals must be documented and maintained in the

    recipient’s medical record.

Tobacco Cessation Referral The California Smoker’s Helpline provides many valuable resources

    Resource Suggestions for users of tobacco products and health care providers. The helpline

    can be accessed online at www.californiasmokershelpline.org or by

    calling 1-800-NO-BUTTS (1-800-662-8887).

     The California Tobacco Control Program provides information about a

    variety of topics, including help with quitting and local tobacco control

    efforts. Information can be found on the California Department of

    Public Health website www.cdph.ca.gov in the “Programs” section.

     The Center for Tobacco Cessation provides training and technical

    assistance to organizations statewide to increase their capacity in

    tobacco cessation. Information is available at the website

    www.centerforcessation.org.

    Breast and Cervical Cancer PCPs working in connection with CDP: EWC are authorized to enroll Treatment Program (BCCTP) CDP: EWC eligible individuals in the Breast and Cervical Cancer

    Treatment Program (BCCTP). The BCCTP has two programs for

     which individuals may be eligible. The federal BCCTP provides

     full-scope Medi-Cal to eligible women who meet all the federal criteria.

    The State-funded BCCTP only provides cancer treatment and related

    services to any individual, including men, who does not meet the

    federal criteria. BCCTP enrollment information is available from

    BCCTP eligibility specialists at 1-800-824-0088. BCCTP guidelines

    also are available on the Medi-Cal website at www.medi-cal.ca.gov.

    Referral to BCCTP BCCTP offers treatment through the Medi-Cal program for individuals

    with breast and/or cervical cancer who meet eligibility criteria. Entry

    into BCCTP through CDP: EWC is restricted to women who meet all

    CDP: EWC eligibility guidelines. Family PACT (Planning, Access,

    Care and Treatment) Program providers may also enroll patients into

    BCCTP.

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    Diagnoses Obtained Women who are already in CDP: EWC and are diagnosed with Through CDP: EWC breast cancer (including in situ) and/or cervical cancer, cervical

    intraepithelial neoplasia II (CIN II) or CIN III can be referred into

    BCCTP. Providers should fill in the box on the DETEC Screening

     Cycle Data form that states, “Patient enrolled in BCCTP. Check

    ONLY if you have completed the BCCTP enrollment process.”

    Providers should go to the BCCTP website and follow the program

    enrollment procedures. If the patient has a breast or cervical cancer

    that is not on the drop down menu of qualifying diagnoses for BCCTP

    enrollment, the provider should call BCCTP and request to speak with

    a manager for further instructions.

Diagnoses Obtained Only individuals who meet CDP: EWC program eligibility

    Outside CDP: EWC criteria can be referred to BCCTP through CDP: EWC PCPs.

     The provider must confirm that the patient meets all CDP: EWC

     eligibility criteria, and that the patient has presented documentation of

     breast cancer (including in situ) and/or cervical cancer, CIN II or

    CIN III. The provider must be able to present this documentation

    upon request. In addition, the patient completes the Recipient

    Eligibility Form on paper, and the provider completes the eligibility

    form verifying current financial and demographic information.

     Providers then complete the DETEC Enroll Recipient form online and

    select the field labeled, “The purpose of this enrollment is to only refer

    the recipient to BCCTP for Breast [or Cervical] Cancer treatment,”

    indicating the patient is being referred to BCCTP. PCPs must enter

    the qualifying diagnosis and submit the CDP: EWC enrollment data.

    If the patient has a breast or cervical cancer that is not on the

    drop-down menu of qualifying diagnoses for BCCTP enrollment, the

    provider should call BCCTP and request to speak with a manager for

    further instructions. No other data is required. The provider must

    keep recipient-signed documentation of the Recipient Eligibility Form

    on file. Providers then are to follow BCCTP enrollment procedures.

    For information about billing an office visit for the verification of a

    cancer diagnosis, or for more BCCTP information, contact the

    Eligibility Specialist at 1-800-824-0088. Additional information can be

    found at www.medi-cal.ca.gov.

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CDP: EWC Additional If a provider determines more testing is needed for a woman

    Testing to Confirm from outside CDP: EWC before confirming a cancer diagnosis, Diagnosis the provider may perform testing under CDP: EWC as long as

     the testing is a program covered service. The provider must

     understand that once billing occurs in CDP: EWC, the same data

     requirements apply as if the woman were screened within CDP: EWC.

     This means complete screening cycle data must be submitted using

     the online DETEC Screening Cycle Data forms.

    Provider Data-Reporting Funding for the CDP: EWC Program is dependent on data reported Requirements by providers. Providers must maintain complete, accurate and timely

     recipient data using the appropriate DETEC online forms. Several

     guidelines for data maintenance include:

     Each recipient has a 365-day certification period when she is

    eligible to receive services.

     DETEC will guide PCPs in how to submit screening procedures

    and dates.

     DETEC will allow changes to data already submitted.

     PCPs may update screening and follow-up forms for an

    additional 365 days after the recipient’s eligibility has expired.

     PCPs must ensure that all recipient screening, diagnostic, and

    treatment data have been entered through DETEC.

    Recipient Eligibility Criteria The following information describes recipient eligibility criteria.

    Age Women 25 years of age and older may be eligible for cervical cancer

    screening consisting of a pelvic examination, a screening Pap test and

    the necessary follow-up cervical diagnostic services.

     Women 40 years of age and older may be eligible for breast cancer

    screening consisting of a Clinical Breast Exam (CBE) and

    mammogram, as well as necessary follow-up breast diagnostic

    services.

    Note: Only certain providers are eligible to render cervical cancer

    screening and diagnostic services. See “Provider Participation

    Requirements” on a preceding page of this section.

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    Income To qualify for breast and cervical cancer screening services, recipients must have a household income at or below 200 percent of the federal poverty level. “Household income” includes incomes of all family members (the applicant, spouse and children) living together. When adults other than spouses reside together, each person shall be considered a separate family.

    The Federal Poverty Level Income Guidelines are used to determine financial eligibility for CDP: EWC. “Gross income” refers to income

    before taxes and other deductions. This chart is updated annually.

    FEDERAL POVERTY INCOME GUIDELINES

    200 Percent of Poverty by Family Size

    Effective April 1, 2011 through March 31, 2012

    Family Members Monthly Gross Annual Gross

    Living in Household Household Income Household Income

    1 $1,815 $21,780

    2 $2,452 $29,420

    3 $3,089 $37,060

    4 $3,725 $44,700

    5 $4,362 $52,340

    6 $4,999 $59,980

    7 $5,635 $67,620

    8 $6,272 $75,260

    For each additional $637 $7,640 member, add

“Gross Household Income” means the monthly sum of income (before

    taxes and other deductions) received by an individual from the sources identified by the U.S. Census Bureau. Monthly gross income for migrant farm workers and other seasonally employed persons may be computed by averaging total gross income received during the previous 12 months. U.S. Census Bureau sources of income are:

     Money wages or salary

     Net income from non-farm self-employment

     Net income from farm self-employment

     Social Security

     Dividends, interest (on savings or bonds), income from estates

    or trusts, net rental income or royalties

     Public assistance or welfare payments

     Pension and annuities

     Unemployment compensation/disability insurance

     Workers’ compensation

     Child support

     Veterans’ pension

     Alimony

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    Health Insurance For a woman to be eligible for CDP: EWC, her PCP must certify that

     she is uninsured or underinsured, based on the woman’s self-report.

    Recipients may be certified as underinsured for CDP: EWC if all three

    of the following conditions are met:

     No Medicare Part B coverage

     Either no Medi-Cal coverage or limited scope Medi-Cal such as:

    ; Medi-Cal for pregnancy or emergency service only, or

    ; Medi-Cal with unmet Share of Cost (SOC) obligations

     Either no other public or private insurance coverage or other

    limited health insurance, such as:

    ; Other health insurance co-payments or deductible

    obligations that cannot be met

    ; Other health insurance benefit restrictions, public or private,

    which exclude services available through CDP: EWC

Residency Eligible women must have a California address.

    Eligibility Period A recipient is eligible for CDP: EWC for one year, starting on the date

     when the DETEC Recipient Information form is completed and

     submitted. This eligibility period does not change if the recipient

     transfers to another PCP. The eligibility period is for the recipient, not

     the provider. Re-enrollment or recertification can only occur annually,

     when a recipient’s one-year recipient eligibility period ends.

     Example:

     A recipient sees PCP provider A on February 1. Provider A

     establishes the patient’s eligibility on this date by entering

     information into the DETEC form. The recipient’s eligibility period

     spans from this date, February 1, to the following January 31 (one

     year).

     Then, the recipient visits provider B in June, four months after seeing

     provider A. Provider B finds the recipient in the CDP: EWC

     application using the recipient’s last name and date of birth. Provider

     B creates a new recipient record by updating the Recipient

     Information in DETEC. The recipient remains eligible only until

     January 31, as previously established. Each provider maintains

     separate records, but the recipient’s dates of eligibility are not

     affected.

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