Current through Register Vol. 35, No. 6, March 26, 2024
MAD covers outpatient services which are medically necessary
for prevention, diagnosis or rehabilitation as indicated by the condition of an
eligible recipient. Services must be furnished within the scope and practice of
a professional provider as defined by state laws and regulations.
A.
Outpatient covered services:
Covered hospital outpatient care includes the use of minor surgery or cast
rooms, intravenous infusions, catheter changes, first aid care of injuries,
laboratory and radiology services, and diagnostic and therapeutic radiation,
including radioactive isotopes. A partial hospitalization program in a general
hospital psychiatric unit is considered under outpatient services. See 8.321.5
NMAC, Outpatient Psychiatric Services and Partial
Hospitalization.
B.
Outpatient noncovered services: MAD does notcover the following
specific outpatient benefits:
(1) outpatient
hospital services not considered medically necessary for the condition of the
eligible recipient;
(2) outpatient
hospital services that require prior approval for which the approval was not
requested except in cases with extenuating circumstances as granted by MAD or
its designee;
(3) outpatient
hospital services furnished to an individual who was not eligible for MAD
services on the date of service;
(4) experimental or investigational
procedures, technologies or therapies and the services related to them,
including hospitalization, anesthesiology, laboratory tests, and imaging
services; see 8.325.6 NMAC, Experimental or Investigational Procedures
or Therapies;
(5) drugs
classified as "ineffective" by the federal food and drug
administration;
(6) laboratory
specimen handling or mailing charges; and
(7) formal educational or vocational services
which relate to traditional academic subjects or training for employment.
C.
MCO payment
rates: If a provider and an MCO are unable to agree to terms or fail to
execute an agreement for any reason, the MCO shall be obliged to pay, and the
provider shall accept, 100 percent of the "applicable reimbursement rate" based
on the provider type for services rendered under both emergency and
non-emergency situations. The "applicable reimbursement rate" is defined as the
rate paid by HSD to the provider participating in medicaid or other medical
assistance programs administered by HSD and excludes disproportionate share
hospital and medical education payments.
D.
Prior authorization: Certain
procedures or services performed in outpatient settings can require prior
approval from MAD or its designee. Outpatient physical, occupational, and
speech therapies services require prior authorization.
E.
Reimbursement for outpatient
services: Effective November 1, 2010, outpatient hospital services are
reimbursed using outpatient prospective payment system (OPPS) rates. The OPPS
rules for payment for packaged services, separately reimbursed services are
based on the medicare ambulatory payment classification (APC) methodology.
(1) Reimbursement for laboratory services,
radiology services, and drug items will not exceed maximum levels established
by MAD. Hospitals must identify drugs items purchased at 340B prices.
(2) Services or supplies furnished by a
provider under contract or through referral must meet the contract services
requirements and be reimbursed based on approved methods. See 8.302.2 NMAC,
Billing For Medicaid Services.
(3) For critical access hospital providers,
the MAD outpatient prospective payment system (OPPS) fee-for-service rate will
be set based on the provider's reported cost to charge ratio reported in the
provider's most recently filed cost report prior to February 1, 2012.
(4) For services not reimbursed using the
outpatient prospective payment system (OPPS) methodology or fee schedule,
reimbursement for a MAD fee-for-service provider will be made using the
medicare allowable cost method, reducing medicare allowable costs by three
percent. An interim rate of payment is established by MAD. A rate of payment
for providers not subject to the cost settlement process is also established by
MAD to equal or closely approximate the final payment rates that apply under
the cost settlement TEFRA principals. If the provider is not cost settled, the
reimbursement rate will be at the provider's cost to charge ratio reported in
the provider's most recently filed cost report prior to February 1, 2012.
Otherwise, rates are established after considering available cost to charge
ratios, payment levels made by other payers, and MAD payment levels for
services of similar cost, complexity and
duration.
