Current through Register Vol. 50, No. 9, September 20, 2024
A.
Effective for dates of service on or after October 15, 2007, the reimbursement
for selected physician services shall be 90 percent of the 2007 Louisiana
Medicare Region 99 allowable or billed charges, whichever is the lesser amount,
unless otherwise stipulated.
1. If there is
no equivalent Medicare fee, the Medicaid fee shall be set based on the Medicare
fee for a similar service. In the absence of any applicable Medicare fee, the
fee shall be set at the Medicaid fee for a similar service or the Medicaid fee
for other states.
2. If
establishing a Medicaid fee based on Medicare rates results in a fee that is
reasonably expected to be insufficient to ensure that the service is available
to beneficiaries, an alternate methodology shall be used. The fee shall be set
at the Medicaid fee for a similar service or the Medicaid fee for other
states.
B. Effective for
dates of service on or after January 1, 2008, the reimbursement for selected
physician services shall be 90 percent of the 2008 Louisiana Medicare Region 99
allowable or billed charges, whichever is the lesser amount, unless otherwise
stipulated.
1. The reimbursement shall
remain the same for those services that are currently being reimbursed at a
rate that is between 90 percent and 120 percent of the 2008 Louisiana Medicare
Region 99 allowable.
2. For those
services that are currently reimbursed at a rate above 120 percent of the 2008
Louisiana Medicare Region 99 allowable, effective for dates of service on or
after January 1, 2008, the reimbursement for these services shall be reduced to
120 percent of the 2008 Louisiana Medicare Region 99
allowable.
C. Effective
for dates of service on or after August 4, 2009, the reimbursement for all
physician services rendered to recipients 16 years of age or older shall be
reduced to 80 percent of the 2009 Louisiana Medicare Region 99 allowable or
billed charges, whichever is the lesser amount.
1. For those services that are currently
reimbursed at a rate below 80 percent of the Louisiana Medicare Region 99
allowable, effective for dates of service on or after August 4, 2009, the
reimbursement for these services shall be increased to 80 percent of the
Louisiana Medicare Region 99 allowable or billed charges, whichever is the
lesser amount.
2. The following
physician services are excluded from the rate adjustment:
a. preventive medicine evaluation and
management;
b.
immunizations;
c. family planning
services; and
d. select orthopedic
reparative services.
3.
Effective for dates of service on or after November 20, 2009, the following
physician services are excluded from the rate adjustment:
a. prenatal evaluation and management;
and
b. delivery
services.
D.
Effective for dates of service on or after January 22, 2010, physician services
rendered to recipients 16 years of age or older shall be reduced to 75 percent
of the 2009 Louisiana Medicare Region 99 allowable or billed charges, whichever
is the lesser amount.
1. The following
physician services rendered to recipients 16 years of age or older shall be
reimbursed at 80 percent of the 2009 Louisiana Medicare Region 99 allowable or
billed charges, whichever is the lesser amount:
a. prenatal evaluation and management
services;
b. preventive medicine
evaluation and management services; and
c.
obstetrical delivery services.
E. Effective for dates of service on or after
January 22, 2010, physician services rendered to recipients 16 years of age or
older shall be reduced to 75 percent of the 2009 Louisiana Medicare Region 99
allowable or billed charges, whichever is the lesser amount.
F. Effective for dates of service on or after
January 22, 2010, all physician-administered drugs shall be reimbursed at 90
percent of the 2009 Louisiana Medicare average sales price (ASP) allowable or
billed charges, whichever is the lesser amount.
G. Effective for dates of service on or after
January 22, 2010, all physician services that are currently reimbursed below
the reimbursement rates in
§15113 D-F shall be increased to the
rates in §15113
D-F.
H. Effective for dates of
service on or after December 1, 2010, reimbursement shall be 90 percent of the
2009 Louisiana Medicare Region 99 allowable for the following obstetric
services when rendered to recipients 16 years of age and older:
1. vaginal-only delivery (with or without
postpartum care);
2. vaginal
delivery after previous cesarean (VBAC) delivery; and
3. cesarean delivery following attempted
vaginal delivery after previous cesarean delivery. The reimbursement for a
cesarean delivery remains at 80 percent of the 2009 Louisiana Medicare Region
99 allowable when the service is rendered to recipients 16 years of age and
older.
I. Effective for
dates of service on or after July 1, 2012, reimbursement shall be as follows
for the designated physician services:
1.
reimbursement for professional services procedure (consult) codes 99241-99245
and 99251-99255 shall be discontinued;
2.
cesarean delivery fees (procedure codes 59514-59515) shall be
reduced to equal corresponding vaginal delivery fees (procedure codes
59409-59410); and
3. reimbursement
for all other professional services procedure codes shall be reduced by 3.4
percent of the rates on file as of June 30, 2012.
J. Effective for dates of service on or after
January 1, 2013 through December 31, 2014, certain physician services shall be
reimbursed at payment rates consistent with the methodology that applies to
such services and physicians under part B of title XVIII of the Social Security
Act (Medicare).
1. The following physician
service codes, when covered by the Medicaid Program, shall be reimbursed at an
increased rate:
a. evaluation and management
codes 99201 through 99499; or
b.
their successor codes as specified by the U.S. Department of Health and Human
Services.
2. Qualifying
Criteria. Reimbursement shall be limited to specified services furnished by or
under the personal supervision of a physician, either a doctor of osteopathy or
a medical doctor, who attests to a specialty or subspecialty designation in
family medicine, general internal medicine or pediatrics, and who also attests
to meeting one or more of the following criteria:
a. certification as a specialist or
subspecialist in family medicine, general internal medicine or pediatric
medicine by the American Board of Medical Specialists (ABMS), the American
Board of Physician Specialties (ABPS), or the American Osteopathic Association
(AOA); or
b. specified evaluation
and management and vaccine services that equal at least 60 percent of total
Medicaid codes paid during the most recently completed calendar year, or for
newly eligible physicians the prior month.
3. Payment Methodology. For primary care
services provided in calendar years 2013 and 2014, the reimbursement shall be
the lesser of the:
a. Medicare Part B fee
schedule rate in calendar years 2013 or 2014 that is applicable to the place of
service and reflects the mean value over all parishes (counties) of the rate
for each of the specified or, if greater, the payment rates that would be
applicable in those years using the calendar year 2009 Medicare physician fee
schedule conversion factor multiplied by the calendar year 2013 and 2014
relative value units in accordance with
42 CFR
447.405. If there is no applicable rate
established by Medicare, the reimbursement shall be the rate specified in a fee
schedule established and announced by the Centers for Medicare and Medicaid
Services (CMS); or
b. provider's
actual billed charge for the service.
4. The department shall make payment to the
provider for the difference between the Medicaid rate and the increased rate,
if any.
K. Effective for
dates of service on or after February 1, 2013, the reimbursement for certain
physician services shall be reduced by 1 percent of the rate in effect on
January 31, 2013.
L. The
reimbursement for newly payable services not covered by Medicare, when there is
no established rate set by Medicare, shall be based on review of statewide
billed charges for that service in comparison with set charges of a similar
service.
1. If there is no similar procedure
or service, the reimbursement shall be based upon a consultant physicians'
review and recommendations.
2. For
procedures which do not have established Medicare fees, the Department of
Health and Hospitals, or its designee, shall make determinations based upon a
review of statewide billed charges for that service in comparison with set
charges for similar services.
3.
Reimbursement shall be the lesser of the billed charges or the Medicaid fee on
file.
M. Effective for
dates of service on or after June 20, 2015, the reimbursement for the
physician-administered drug, 17 Hydroxyprogesterone (17P), shall increase to
$69 per dose.
N. Effective for
dates of service on or after February 1, 2018, physicians, who qualify under
the provisions of
§15110 for services rendered in
affiliation with a state-owned or operated entity that has been designated as
an essential provider, shall receive enhanced reimbursement rates up to the
community rate level for qualifying services as determined in
§15110 C
O. Administration of treatments related to a
declared public health emergency shall be reimbursed at up to 100 percent of
the Louisiana Region 99 Medicare rate for the duration deemed necessary by the
Medicaid Program to ensure access.
AUTHORITY
NOTE: Promulgated in accordance with
R.S.
36:254 and Title XIX of the Social Security
Act.
