La. Admin. Code tit. 50 § XI-16703

Current through Register Vol. 50, No. 11, November 20, 2024

Section XI-16703 - Alternate Payment Methodology

A. Effective for dates of service on or after October 20, 2007, the Medicaid Program establishes an alternate payment methodology for adjunct services provided by rural health clinics (RHCs) when these professional services are rendered during evening, weekend or holiday hours. This alternate payment methodology is in addition to the Prospective Payment System methodology established for RHC services.

1. A payment for adjunct services is not allowed when the encounter is for dental services only.

B. The reimbursement for adjunct services is a flat fee, based on the Current Procedural Terminology (CPT) procedure code, in addition to the reimbursement for the associated office encounter.

C. Reimbursement is limited to services rendered between the hours of 5 p.m. and 8 a.m. Monday through Friday, on weekends and State legal holidays. Documentation relative to this reimbursement must include the time that the services were rendered.

D. Effective for dates of service on or after January 1, 2019, RHCs shall be reimbursed a separate payment outside of the prospective payment system (PPS) rate for the following services:

1. Long-Acting Reversible Contraceptives (LARCs)

a. Reimbursement for LARCs shall be at the lesser of, the rate on file or the actual acquisition cost for entities participating in the 340B program. Rural health clinics eligible for 340B pricing must bill Medicaid at their 340B actual acquisition cost for reimbursement.

2. Mammogram Screening and Diagnosis

a. Reimbursement for mammogram screening and diagnostics shall be a flat fee on file based on Medicaid covered current procedural terminology (CPT) code(s), in addition to the PPS rate for the associated encounter/office visit.

E. Effective for dates of service on or after April 1, 2019, the Medicaid Program shall establish an alternative payment methodology for behavioral health services provided in RHCs by one of the following practitioners:

1. physicians with a psychiatric specialty

2. nurse practitioners or clinical nurse specialists with a psychiatric specialty

3. licensed clinical social workers; or

4. clinical psychologists

F. The reimbursement for behavioral health services will equal the all-inclusive encounter PPS rate on file for fee for service on the date of service. This reimbursement will be in addition to any all-inclusive PPS rate on the same date for a medical/dental visit.

G. Dental services shall be reimbursed at the all-inclusive PPS rate on file for fee for service on the date of service. This reimbursement will be in addition to any all-inclusive PPS rate made on the same date for a medical/behavioral health visit.

H. During the Coronavirus Disease 2019 (COVID-19) public health emergency, Louisiana Medicaid will establish an alternative payment methodology (APM) for RHC providers to be reimbursed at the standard vaccine administration payment rates listed on the COVID-19 vaccine and treatment fee schedule outside of the facility's current all-inclusive prospective payment system rate on file. This APM will only be allowed when the COVID-19 vaccine is administered without the performance of an evaluation and management procedure on the same date of service.

I. Effective for dates of service or after January 1, 2022, the Medicaid Program shall reimburse for community health worker services through a separate payment outside the PPS rate.

La. Admin. Code tit. 50, § XI-16703

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 34:1036 (June 2008), Amended by the Department of Health, Bureau of Health Services Financing, LR 441903 (10/1/2018), Amended LR 442168 (12/1/2018), AmendedLR 45435 (3/1/2019), Amended LR 46185 (2/1/2020), Amended LR 471528 (10/1/2021), Amended LR 471875 (12/1/2021).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.