Service

The following services are covered by Medicaid:

·         Outpatient services incident to the services of physicians and dentists in treating their patients;

·         Physician and dentist professional component;

·         Outpatient diagnostic services;

·         Outpatient therapy services;

·         Outpatient speech pathology services;

·         Outpatient therapeutic and rehabilitative services including use of hospital facilities, clinic and ER services, and services of hospital personnel;

·         Medical supplies, drugs and biologicals used by physicians or hospital personnel in treatment.

There is a limit of 24 ambulatory medical visits per fiscal year (July 1 through June 30).  This includes any combination of physicians, optometrists, chiropractors, podiatrists, clinics, and hospital outpatient facilities (except ER).  Visits are not counted toward the limit in the following circumstances:

·         Individuals under age 21, including Health Check (EPSDT);

·         Visits billed to both Medicare and Medicaid;

·         Participants in the Community Alternatives Program;

·         Visits made to a hospital ICF, SNF, ICF/MR, as well as adult care home patients, or patients in their homes.

Specified diagnoses: acute sickle cell disease, hemophilia, end stage lung disease, unstable diabetes, chemotherapy or radiation therapy for malignancy, or any life-threatening illness or terminal state of any illness.  This also includes adults receiving mental health services.

Outpatient hospital services are reimbursed a ratio of cost to charge (RCC) basis.  DMA assigns an RCC yearly to each facility.  Covered hospital outpatient services (with the exception of lab) are paid at 80% of the hospital’s RCC.

Some outpatient hospital services are subject to a $3.00 copayment. 

Physician and physician-directed services are covered.  These services may be provided in a clinic setting, a SNF, other medical facility or a patient’s home.

Services may be provided by physicians, PAs, NPs or nurse midwives.

RHCs are paid on a prospective per visit basis for core services.  These per visit rates are established based on reasonable costs incurred in a specific base year and increased each fiscal year by the percentage increase in the Medicare Economic Index for primary care services and adjusted to take into account any increase (decrease) in the scope of services furnished during that fiscal year.  These prospective rates are subject to cost settlement.

Covered non-core services are paid on a FFS basis according to the Medicaid Fee Schedule, and are subject to annual cost settlement.

Physician and physician-directed services are covered.  These services may be provided in a clinic setting, a SNF, other medical facility or a patient’s home.

Services may be provided by physicians, PAs, NPs or nurse midwives.

FQHCs are paid on a prospective per visit basis for core services.  These per visit rates are established based on reasonable costs incurred in a specific base year and increased each fiscal year by the percentage increase in the Medicare Economic Index for primary care services and adjusted to take into account any increase (decrease) in the scope of services furnished during that fiscal year.  These prospective rates are not subject to cost settlement.

Covered non-core services are paid on a FFS basis according to the Medicaid Fee Schedule, and are subject to annual cost settlement.

Laboratory and radiology services are covered when ordered by a physician.

Outpatient laboratory services and independent lab services do not count toward the 24-visit limit.

Lab and x-ray services that are performed as part of routine physicals (except Health Check/EPSDT) are not covered.

Radiology/X-ray procedures count towards the 24-visit limit except radiation therapy for cancer and same day referrals from a physician.

Lab and x-ray services do not require Carolina ACCESS authorization numbers.  These services are managed by virtue of the fact that the PCP or a specialist who has a referral from the PCP have determined that the test(s) are medically necessary.

Fees for independent laboratory services as well as outpatient hospital facilities, physicians and any other providers supplying outpatient lab services are the lower of the submitted charge or the appropriate fee from the fee schedules in effect on July 1, 1990.  Annual fees are increased each January 1 based on the forecast of the GNP implicit price deflator, but not exceed the percentage increase granted by the NC State Legislature and not to exceed the Medicare maximum fees.

Radiology services are reimbursed according to the Medicaid Fee Schedule.

Facility services for qualified individuals are covered.  These include:

·         Semi-private room;

·         Therapeutic leave days (60 days per calendar year);

·         OTC drugs;

·         Personal hygiene items and services;

·         Personal laundry services;

·         Medically necessary vaccines and tests;

·         Antiseptics, dressings and medications;

·         Durable medical equipment;

·         Physical, speech and occupational therapy;

·         Other items as necessary.

Prior approval for the appropriate level of care is required.

Nursing home residents are not subject to copayments for physician visits, etc.

Physician visits for nursing home residents do not count toward the 24-visit limit.

Certified nursing facilities are reimbursed on a prospective basis (except state-operated facilities, which are reimbursed their reasonable and allowable costs).

Prospective rates are determined annually for each facility (effective October 1 of each year).  Each prospective rate is comprised of a direct patient care rate and an indirect rate.  Rates are derived from cost reports for a base year period selected by the state.

Covered services are:

·         Diagnosis and consultation;

·         Therapy; and

·         Surgery.

Abortions are permitted to save the life of the mother, and the case of rape or incest. 

Medically necessary hysterectomies are permitted but require documentation and approval.

Services and supplies incident to physician services are covered.

There is a limit of 24 ambulatory medical visits per fiscal year (July 1 through June 30).  This includes any combination of physicians, optometrists, chiropractors, podiatrists, clinics, and hospital outpatient facilities (except ER).  Visits are not counted toward the limit in the following circumstances:

·         Individuals under age 21, including Health Check (EPSDT);

·         Visits billed to both Medicare and Medicaid;

·         Participants in the Community Alternatives Program;

·         Visits made to a hospital ICF, SNF, ICF/MR, as well as rest home patients, or patients in their homes; and

·         Pregnancy related services.

Specified diagnoses: acute sickle cell disease, hemophilia, end stage lung disease, unstable diabetes, chemotherapy or radiation therapy for malignancy, or any life-threatening illness or terminal state of any illness.

Physician services are reimbursed according the NC Medicaid Fee Schedule.  These fees are currently 95% of the Medicare Fee Schedule RBRVS.  Exceptions to this are the various Medical Faculty Practice Plans of the University of North Carolina at Chapel Hill and East Carolina University, which are reimbursed at cost and cost settled at year-end.

There is a $3.00 copayment per physician visit.

The program is called “Health Check” and provides preventive care to children and teens from birth to age 21.

A complete Health Check screening consists of the following age-appropriate components required to be done at each visit, unless otherwise noted:

·         Comprehensive unclothed physical exam;

·         Comprehensive health history;

·         Nutritional assessment;

·         Anticipatory guidance/health education;

·         Measurements, blood pressure, vital signs;

·         Developmental screening, including mental, emotional and behavioral;

·         Immunizations;

·         Vision and hearing screenings;

·         Laboratory procedures: hemoglobin/hematocrit, urinalysis, sickle cell, tuberculin skin test and lead screening.

The Health Check program was integrated with the Carolina ACCESS managed care program in 1999.

The Health Check Automated Information and Notification System (AINS) is a computerized system that identifies and tracks Medicaid-eligible children (birth through age 20) to determine whether they are receiving regular Health Check screenings, immunizations and referrals for special healthcare problems.  The system also notifies parents of Medicaid-eligible children of scheduled Health Check appointments, missed appointments, immunizations due and available programs.

Health Check services must be billed on the CMS-1500 claim form.  Lab work done in conjunction with Health Check can be billed on the UB-92 claim form.

These services are reimbursed according to the Medicaid Fee Schedule.

Family planning services covered under Medicaid include the following:

·         Consultation (including counseling and patient education), examination and treatment prescribed by a physician or nurse practitioner and furnished by or under his/her supervision;

·         Laboratory examinations and tests;

·         Medically-approved methods, procedures, pharmaceutical supplies and devices to prevent conception through chemical, mechanical or other means;

·         National family planning methods;

·         Voluntary sterilization in accordance with the procedures outlined under “Sterilizations” in Chapter Five of the Provider Manual.

Certified Planned Parenthood Centers are reimbursed for family planning services, which consist of counseling services and patient education, examination and treatment by medical professionals in accordance with applicable state requirements, laboratory examination and tests, medically approved methods, procedures, pharmaceutical supplies, and devices to prevent contraception.

Family planning services do not require Carolina ACCESS PCP referral.

These services are reimbursed according to the Medicaid Fee Schedule.

There is no copayment for family planning services.

Services must be provided under the direction of a physician or dentist.

There is a limit of 24 ambulatory medical visits per fiscal year (July 1 through June 30).  This includes any combination of physicians, optometrists, chiropractors, podiatrists, clinics, and hospital outpatient facilities (except ER).  Visits are not counted toward the limit in the following circumstances:

·         Individuals under age 21, including Health Check (EPSDT);

·         Visits billed to both Medicare and Medicaid;

·         Participants in the Community Alternatives Program;

·         Visits made to a hospital ICF, SNF, ICF/MR, as well as rest home patients, or patients in their homes.

Specified diagnoses: acute sickle cell disease, hemophilia, end stage lung disease, unstable diabetes, chemotherapy or radiation therapy for malignancy, or any life-threatening illness or terminal state of any illness.

Payments are made to health departments for a clinic services on a negotiated fee basis, not to exceed reasonable costs.

For services that are provided through the memorandum of understanding between the DMA and the Division of Public Health, a supplemental payment (cost settlement) is made annually.

Services billed by health departments for physicians, nurse midwives and nurse practitioners who are not salaried employees of a health department are paid according to the Medicaid fee schedule.

NOTE: Free-standing Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) are discussed in earlier sections of this matrix. 

FDA-approved legend drugs and insulin are covered.

Manufacturers must have signed a rebate agreement with DMA in order for their drugs to be covered.

Each compounded prescription must contain at least one legend drug in order to be reimbursed by Medicaid.

The following are not covered:

• Over the counter drugs;
• DESI drugs;
• Medical supplies or devices: needles, syringes, catheters, IV sets, TED hose, etc.;
• Diaphragms;
• Routine immunizations, flu vaccine, DPT immunization, etc.;
• Fertility and impotence drugs;
• Drugs used for cosmetic indications; and
• DME.

Prescription drugs are limited to 6 prescriptions per month, with the following exceptions:

·         Individuals under age 21, including Health Check (EPSDT);

·         Participants in the Community Alternatives Program; and

·         Specified diagnoses.  These are acute sickle cell disease, hemophilia, end stage lung disease, unstable diabetes, chemotherapy or radiation therapy for malignancy, or any life-threatening illness or terminal state of any illness.

A prescription for a drug designated by a brand or trade name is considered an order for drug by its generic name, except when the prescriber personally indicates on the prescription order, “dispense as written.”

Reimbursement for prescription drugs is determined using the cost per unit times the quantity dispensed, plus the dispensing fee.  Reimbursement is limited to the applicable price in effect on the date of service, not on the date of payment.

The cost of the drugs is calculated from the lower of the cost on file from First DataBank using the AWP less 10%, the MAC price if applicable, or the actual acquisition cost reported by the pharmacy.

The dispensing fee is $5.60.

There is a copayment of $1.00 per prescription.

Case management services are provided to the following Medicaid populations:

·         Adults and children at risk of abuse, neglect or exploitation (according to established criteria); these are individuals who are mentally ill, emotionally disturbed, substance abusers or have developmental disabilities.

·         Individuals infected with HIV/AIDS.

For services provided to adults and children at risk of abuse, neglect or exploitation, providers must have a Master of Social Work degree or a Bachelor of Social Work degree, or be a social worker who meets the state requirements for Social Worker II classification.  Individuals receiving these services cannot be institutionalized or be receiving services through home and community-based waiver programs.

Individuals with HIV/AIDS may not be institutionalized or be receiving services through home and community-based waiver programs.

Case management services do not require Carolina ACCESS PCP referral.

Reimbursement for case management providers is the same per unit rate (one unit = 15 minutes) for all providers and is determined annually by DMA.

Ambulance services must be medically necessary and are subject to limitations.  Such transportation is not considered medically necessary when other means of transportation can be safely used (includes air ambulance).

Non-ambulance transportation to medical appointments is covered for recipients who have no other means of transportation.

Non-emergency medically necessary transportation for recipients in nursing homes or domiciliary care facilities is covered if care cannot be provided in the facility.

Non-emergency medically necessary state-to-state transportation (ground or air) is covered for out-of-state services or to return to NC.

Medicaid recipients must apply for non-emergency transportation services through the Department of Social Services.

Referral by a Carolina ACCESS PCP is not required for transportation services.

For state-to-state transportation, DMA’s fiscal agent (EDS) must give prior approval.

Reimbursement for ambulance service is based on the level of service rendered, not the type of vehicle used.  These services are billed using HCPCS codes and are reimbursed according to the Medicaid Fee Schedule.

Non-emergency transportation is reimbursed based on the level of care rendered and according to the fee schedule.

Nurse Midwives may provide services to pregnant women and newborns throughout the maternity cycle that includes labor, birth and the postpartum period.

Nurse Practitioners may provide primary care, including services in homes, ambulatory care facilities, long-term care facilities, and other health care institutions.

Nurse Midwife services must be performed under the supervision of a physician licensed to practice obstetrics.

Nurse Practitioner services must be performed under supervision of a licensed physician or, in the case if independent NPs, in collaboration with a licensed physician.

Nurse midwives practicing in accordance with state law are reimbursed according to the Medicaid Fee Schedule.

Independent Nurse practitioners are reimbursed according to Medicaid fee schedule.

NC’s program is called “Baby Love.”

Maternity Care Coordinators (located in all 100 county health departments and most community health centers) provide case management services and assist women in obtaining medical care and an array of social support services such as transportation, housing, job training and day care.

The benefit package of covered services has also been enriched by the inclusion of childbirth and parenting classes, in-home skilled nursing care for high-risk pregnancies, nutrition counseling, psychosocial counseling and postpartum/newborn home visits. 

The program is jointly administered by DMA and the Division of Public Health, Women’s and Children’s Section.

Pregnant women can receive comprehensive care from the beginning of pregnancy through the end of the month in which the 60^th postpartum day occurs.

Reimbursement for case management providers is the same per unit rate (one unit =15 minutes) for all providers and is determined annually by DMA.

See above “Baby Love” Program.