Current through Register Vol. 51, No. 19, September 20, 2024
A. The
Program reimburses a facility fee when the free-standing Medicare certified
ambulatory surgery center provides a covered surgical procedure, in accordance
with 42 CFR § 416.166 to an eligible Medicaid recipient.
Reimbursement for the facility fee includes, but is not limited to the
following:
(1) Nursing, technician, and
related services;
(2) Use of the
facility;
(3) Drugs, biologicals,
surgical dressings, supplies, splints, casts, and appliances, and any equipment
directly related to the provision of surgical procedures;
(4) Administrative costs;
(5) Materials including supplies and
equipment for the administration and monitoring of anesthesia;
(6) Radiology services for which separate
payment is not allowed and other diagnostic tests or interpretive services that
are integral to a surgical procedure;
(7) Supervision of the services of a nurse
anesthetist by the operating surgeon;
(8) Ancillary items and services that are
integral to a covered surgical procedure as defined in
42 CFR § 416.166; and
(9) Any laboratory testing performed under a
Clinical Laboratory Improvement Amendment of 1988 (CLIA) certificate of waiver.
B. Reimbursement
Methodology:
(1) Reimbursement fees equal 80
percent of the current Medicare-approved ASC facility fee for services
furnished to Medicaid recipients in connection with covered surgical
procedures.
(2) If one covered
surgical procedure is furnished to a recipient, payment is at the Maryland
Medicaid Program payment amount which is 80 percent of the current Medicare
approved facility fee for that procedure.
(3) If more than one covered surgical
procedure is provided to a recipient in a single operative session, payment is
made at 100 percent of the Maryland Medicaid Program payment amount for the
procedure with the highest reimbursement rate. Other covered surgical
procedures furnished during the same session are reimbursed at 50 percent of
the Maryland Medicaid Program payment amount for each procedure.
(4) When a covered surgical procedure is
terminated before the completion due to extenuating circumstances or
circumstances that threaten the well-being of the patient, the Medicaid Program
payment amount is based on one of the following:
(a) If the covered procedure for which the
anesthesia is planned is discontinued after the induction of anesthesia or
after the procedure is started, the reimbursement amount is 80 percent of the
current Medicare approved facility fee; or
(b) If the patient is prepared for surgery
and the surgery is then cancelled before the induction of anesthesia,
reimbursement shall be 50 percent of Maryland Medicaid payment amount.
C. Dental
services rendered in an ASC on or after December 1, 2014, shall be reimbursed
as follows:
(1) For covered dental services
that have a reimbursement amount of $1,000 through $2,999.99, the ASC facility
fee will be $600;
(2) For covered
dental services that have a reimbursement amount of $3,000 through $4,999.99,
the ASC facility fee will be $1,250;
(3) For covered dental services that have a
reimbursement amount of $5,000 through $7,999.99, the ASC facility fee will be
$2,500; and
(4) For covered dental
services that have a reimbursement amount of $8,000 and over, the ASC facility
fee will be $3,000.
D.
The provider shall submit a request for payment as set forth in COMAR
10.09.36.04A.
E. The Program reserves the right
to return to the provider, before payment, all invoices not properly completed,
including but not limited to, diagnostic and procedure codes and description of
services provided.
F. The Program
shall authorize payment on Medicare claims only if:
(1) The provider accepts Medicare
assignment;
(2) Medicare makes
direct payment to the provider; and
(3) Medicare has determined that the services
are medically justified, excludes dental services.
G. The Department shall make supplemental
payment on Medicare cross-over claims subject to the following provisions:
(1) Deductible is paid in full;
(2) Coinsurance shall be paid lesser of:
(a) 100 percent of the coinsurance amount; or
(b) The balance remaining after
the Medicare payment is subtracted from the Medicaid rate; and
(3) Services not covered by
Medicare, but considered medically necessary by the Program, according to the
limitations of Regulation .04C of this chapter.
H. The provider may not bill the Program for:
(1) Completion of forms and
reports;
(2) Broken or missed
appointments;
(3) Professional
services rendered by mail or telephone; or
(4) Providing a copy of a recipient's medical
record when requested by another licensed provider on behalf of the recipient.
I. The Program shall
make no direct payment to a recipient.
J. The Program shall make no separate direct
payment to any person employed by or under contract to any free-standing
Medicare-certified ambulatory surgical center facility for services covered
under this regulation.
K. Billing
time limitations for claims submitted pursuant to this chapter are set forth in
COMAR 10.09.36.06A.
