Current through Register Vol. 41, No. 3, September 23, 2024
A.
Reimbursement for the services covered under FAMIS fee-for-service and MCHIPs
shall be as specified in this section.
B. Reimbursement for physician services,
surgical services, clinic services, prescription drugs, laboratory and
radiological services, outpatient mental health services, early intervention
services, emergency services, home health services, immunizations, mammograms,
medical transportation, organ transplants, skilled nursing services, well baby
and well child care, vision services, durable medical equipment, disposable
medical supplies, dental services, case management services, physical therapy,
occupational therapy, or speech-language therapy services, hospice services,
school-based health services, behavioral therapy services including applied
behavior analysis, and certain community-based mental health services shall be
based on the Title XIX rates.
C.
Reimbursement to MCHIPs shall be determined on the basis of the estimated cost
of providing the MCHIP benefit package and services to an actuarially
equivalent population. MCHIP rates will be determined annually and published 30
days prior to the effective date.
D. Exceptions.
1. Prior authorization is required after five
visits in a fiscal year for physical therapy, occupational therapy, and
speech-language therapy provided by home health providers and outpatient
rehabilitation facilities and for home health skilled nursing visits. Prior
authorization is required for the following nonemergency outpatient procedures:
Magnetic Resonance Imaging, including Magnetic Resonance Angiography (MRA),
Computerized Axial Tomography (CAT) scans, including Computed Tomography
Angiography (CTA), or Positron Emission Tomography (PET) scans performed for
the purpose of diagnosing a disease process or physical injury. Prior
authorization for dental services will be based on the Title XIX prior
authorization requirements for dental services.
2. Reimbursement for inpatient hospital
services will be based on the Title XIX rates in effect for each hospital.
Reimbursement shall not include payments for disproportionate share or graduate
medical education payments made to hospitals. Payments made shall be final and
there shall be no retrospective cost settlements.
3. Reimbursement for outpatient hospital
services shall be based on the Title XIX rates in effect for each hospital.
Payments made will be final and there will be no retrospective cost
settlements.
4. Reimbursement for
inpatient mental health services other than by free standing psychiatric
hospitals will be based on the Title XIX rates in effect for each hospital.
Reimbursement will not include payments for disproportionate share or graduate
medical education payments made to hospitals. Payments made will be final and
there will be no retrospective cost settlements.
5. Reimbursement for outpatient
rehabilitation services will be based on the Title XIX rates in effect for each
rehabilitation agency. Payments made will be final and there will be no
retrospective cost settlements.
6.
Reimbursement for outpatient substance abuse treatment services will be based
on rates determined by DMAS for children ages six through 18 years. Payments
made will be final and there will be no retrospective cost
settlements.
7. Reimbursement for
prescription drugs will be based on the Title XIX rates in effect.
Reimbursements for Title XXI do not receive drug rebates as under Title
XIX.
8. Reimbursement for covered
prescription drugs for noninstitutionalized FAMIS recipients receiving the
fee-for-service benefits will be subject to review and prior authorization when
their current number of prescriptions exceeds nine unique prescriptions within
180 calendar days, and as may be further defined by the agency's guidance
documents for pharmacy utilization review and the prior authorization program.
The prior authorization process shall be applied consistent with the process
set forth in
12VAC30-50-210
A 7.
Statutory Authority: §
32.1-351 of the Code of Virginia; 42 USC §
1396 et
seq.
