Current through Register Vol. 41, No. 3, September 23, 2024
A.
Reimbursement for the services covered under FAMIS MOMS 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/speech-language therapy services, hospice
services, school-based health services, 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
therapy provided by home health providers and outpatient rehabilitation
facilities and for home health skilled nursing visits. Prior authorization is
required after five visits for outpatient mental health visits in the first
year of service and prior authorization is required for the following
nonemergency outpatient procedures: Magnetic Resonance Imaging, Computer Axial
Tomography scans, or Positron Emission Tomography scans.
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 non-institutionalized FAMIS MOMS individuals 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 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: § 32.1-325 of the Code of
Virginia; 42 USC § 1396 et seq.
