Current through September 17, 2024
NMAP reimburses IHS facilities for inpatient and outpatient
services at the Medicare/Medicaid rates established by the federal Department
of Health and Human Services (HHS).
Rate changes are effective the first day of the month
following the Department's receipt of the Medicare Interim Rate Notice. Because
specific Medicare/Medicaid rates are used and there is 100 percent federal
match of these costs, NMAP will not make an end-of-year settlement for Indian
Health Service facilities.
003.01
General Requirements
11-003.01A Eligibility:
Medically necessary services will be made available to any Indian, as that term
is defined herein, who is also determined to be eligible for Medicaid in
accordance with Title 477 of the Nebraska Administrative Code.
11-003.01B Services Provided for Clients
Enrolled in the Nebraska Medicaid Managed Care Program: See 471 NAC
1-002.01.
11-003.01C HEALTH CHECK
(EPSDT) Treatment Services: See 471 NAC Chapter 33.
11-003.01D Copayments / Cost Sharing:
American Indians or Alaskan Natives who are eligible for, and have received,
Medicaid covered services from an IHS or Tribal (638) facility shall be exempt
from all copayment and cost sharing obligations.
003.02 Covered Services
11-003.02A Scope of an Encounter An encounter
includes:
1. A practitioner visit which may be
a:
a. Physician, doctor of osteopathy,
physician assistant, nurse practitioner, or certified nurse midwife;
b. Dentist;
c. Optometrist;
d. Podiatrist;
e. Chiropractor;
f. Speech, audiology, physical or
occupational therapist;
g. Mental
health provider such as a psychologist, psychiatrist, licensed mental health
practitioner, certified drug and alcohol counselor, or a certified nurse
practitioner providing psychotherapy or substance abuse counseling or other
treatment with family and group therapy; or,
h. Pharmacist.
2. Diagnostic services such as:
a. Radiology;
b. Laboratory;
c. Psychological testing; or,
d. Assessment (mental health)
3. Supplies used in conjunction
with a visit such as dressings, sutures, etc.;
4. Medications used in conjunction with a
visit such as an antibiotic injection; and,
5. Prescribed drugs dispensed as a part of
the encounter.
11-003.02B Encounters: Visits with more than
one health professional, and multiple visits with the same health professional,
that take place during the same day within the IHS or Tribal (638) facility
constitute a single encounter.
11-003.02B1
Exceptions:
a. When the patient is seen in
the clinic, or by a heath professional, more than once in a 24-hour period for
distinctly different diagnosis. Documentation must include unrelated diagnosis
codes;
b. When the patient must
return to the clinic for an emergency or urgent care situation subsequent to
the first encounter that requires additional diagnosis or treatment;
c. When a patient requires a pharmacy
encounter in addition to a medical health professional or mental health
encounter on the same day. Medicaid covers only one pharmacy encounter per day;
or,
d. When the patient is seen in
the clinic by a clinical social worker or psychologist for a mental health
encounter in addition to a medical health professional encounter on the same
day.
003.03 Non-Encounter Services
Services rendered outside the office setting, office
services that do not meet the criteria for the encounter, non-IHS Facility
services, pharmacy services that are not provided by a designated tribal
pharmacy or pharmacist, or services provided to non-American Indian or
non-Alaskan Native clients. Examples of non-encounter services include, but are
not limited to: Inpatient hospital visits, home and nursing facility visits,
home health visit, durable medical equipment, ambulance, brief visit with nurse
for blood pressure check, telehealth or telephone
consultations.
