Services covered:

·         Medically necessary medical care and procedures ordered by a physician or dentist;

·         Family planning, abortion and hysterectomies, subject to certain limitations;

·         EPSDT services;

·         Dental services.

Hospital outpatient services are limited to one visit per day to the same outpatient clinic.

Outpatient clinics are paid at a reasonable rate to be determined by the reasonable cost of such services, not to exceed 116% of the combined average fee of the general practitioner and specialist for an office visit according to the fee schedule for practitioners of the healing arts.

The payment rate for ancillary or special services (except for clinical diagnostic laboratory services subject to the Medicare Fee Schedule) provided at an outpatient clinic visit is based on the ratio of cost to charge (RCC).  RCC factored special services are developed from the annual hospital audited fiscal year end reports.

Some services are on fixed fees.

Connecticut does not have RHCs.

The following services may be covered:

·         Professional services;

·         Supplies and pharmaceuticals incidental to professional services;

·         Pharmaceuticals provided by an FQHC in compliance with pharmacy guidelines;

·         Obstetrical and perinatal care;

·         Clinic visits;

·         FQHC professional services provided to FQHC patients if covering inpatient hospital visits;

·         Mental health visits provided in compliance with mental health guidelines; and

·         Dental services.

There is an encounter-specific reimbursement rate for all “FQHC covered services”.  The encounter rate reimburses 100% of reasonable costs.

Initial FFS reimbursement to FQHCs is made per the terms of reimbursement for the performing provider. 

Additional reimbursement may be provided based on the provider’s encounter rate as established through the FQHC cost report.

Coverage is provided for medically necessary clinical laboratory services, for which the laboratory holds certification according to the provisions of CLIA.

The Department pays for medically appropriate and medically necessary radiology or ultrasound center services ordered by a licensed physician or other practitioner.

Payment for lab and radiology services is made at the lowest of:

·         The provider’s usual and customary charge to the general public;

·         The lowest Medicare rate;

·         The amount in the applicable fee schedule as published by the Department;

·         The amount billed by the provider; or

·         The lowest price charged or accepted for the same or substantially similar goods or services by the provider from any person or entity.

Covered nursing home services include but are not limited to:

·         Nursing services;

·         Special care services, including activity therapy, recreation, social services and religious services;

·         Supportive services, including dietary, housekeeping, maintenance, institutional laundry and personal laundry services;

·         Transportation services; and

·         Personal comfort items, medical supplies and special care supplies.

These facilities are paid facility-specific per diem rates.

Covered services include:

·         Services provided in the physician’s office, a hospital, a client’s home, a long-term care facility or other medical care facility;

·         Medical and surgical supplies used by the provider in the course of treatment;

·         Injectable drugs, within limitations;

·         Second surgical opinion;

·         Family planning services; and

·         EPSDT services.

Prior authorization is required for certain services, including electrolysis epilation, physical therapy services that exceed certain visit limitations, reconstructive surgery, plastic surgery and transplant procedures.

Payment for physician services is made at the lowest of:

·         The provider’s usual and customary charge to the general public;

·         The lowest Medicare rate;

·         The amount in the applicable fee schedule as published by the Department;

·         The amount billed by the provider; or

·         The lowest price charged or accepted for the same or substantially similar goods or services by the provider from any person or entity.

Dental services covered:

·         Diagnostic services, including home visits, x-rays and oral exams;

·         Preventive services, including prophylaxis, fluoride treatment for children under 21, space maintainers, night guards and sealants; and

·         Restorative services, including fillings, crowns, endodontics, prosthodontics, dental surgery, extractions, and orthodontics (under EPSDT program).

Many dental have limitations, including prior authorization.

Dental services not covered include:

·         Fixed bridges;

·         Periodontia;

·         Implants;

·         Transplants;

·         Cosmetic dentistry;

·         Vestibulopasty;

·         Unilateral removable appliances;

·         Partial dentures under certain circumstances; and

·         Certain surgical procedures.

Payment is made at the lower of:

·         The usual and customary charge to the public;

·         The fee as contained in the dental fee schedule published by the Department; or

·         The amount billed by the provider.

The Commissioner of Social Services establishes the fee contained in the Dental Fee Schedule.  The fees are based on moderate and reasonable rates prevailing in the respective communities where the service is rendered.

Dental hygienists are covered at 90% of dental fees.

Program consists of a comprehensive health screening of Medicaid recipients under the age of 21.  The screening includes, but is not limited to the following:

·         A review of the recipient’s health history;

·         An assessment of growth and development;

·         Identification of potential physical or developmental problems;

·         Preventive health education;

·         Referral assistance to providers.

Under EPSDT, Connecticut Medicaid covers necessary health care, diagnostic services, treatment and other measures to correct or ameliorate defects, physical and mental illnesses, and conditions discovered during the screening services.

Services may be provided by physicians, outpatient hospital facilities, HMOs, visiting nurse associations, clinics operated under a physician’s supervision, local public health agencies, RHCs, Indian health agencies and community health centers.

Payment for EPSDT services is made at the lowest of:

·         The provider’s usual and customary charge to the general public;

·         The amount in the applicable fee schedule as published by the Department;

·         The amount billed by the provider; or

·         The lowest price charged or accepted for the same or substantially similar goods or services by the provider from any person or entity.

Family Planning Services include any medically necessary approved diagnostic procedures, treatment, counseling, drugs, supplies or devices which are prescribed or furnished by a provider to individuals of child-bearing age for the purpose of enabling such individuals to freely determine the number and spacing of their children.

Informed consent is required for sterilization procedures.

Payment is made in accordance with the payment policy established for each provider group.

Clinic services means preventive, diagnostic, therapeutic, rehabilitative or palliative items or services that:

·         Are provided to outpatients;

·         Are provided by a facility that is not part of a hospital but is organized and operated to provide medical care to outpatients;

·         Are furnished by or under the direction of a physician or dentist; and

·         Are performed at the clinic, a satellite site, school or community center.

Medical clinic services include:

·         Physician’s care

·         Pediatric services;

·         Respiratory therapy;

·         Ambulatory surgery;

·         Family planning services;

·         Dialysis treatment;

·         Health screening services for the elderly; and

·         Abortion services.

Includes medical clinics, family planning clinics, ambulatory surgery centers and other free-standing clinics.

Reimbursement of a visit to a clinic patient is limited to one per day for the same clinic provider to the same patient involving the same treatment modality, illness or injury regardless of the location at which the service is furnished, except as otherwise defined.

Payment is made at the lower of:

·         The usual and customary charge to the public;

·         The Medicare rate;

·         The fee as contained in the individual clinics’ fee schedule as published by the Department; or

·         The amount billed.

The fee established for a clinic visit is “all-inclusive”, except as authorized by the Department in writing, and represents the maximum amount payable for any recipient for all sources of care at the clinic for that visit.

The rate for one-day ambulatory surgical centers includes:

·         Preoperative examination;

·         Operating and recovery room services; and

·         All required drugs and medicine.

The Department will pay for drugs that are prescribed by a licensed authorized practitioner as a result of accepted methods of diagnosis and treatment (within certain limitations).

The Department will not reimburse for an original prescription or refill that exceeds the supply requirement for a period of 30 days not to exceed 240 units except under certain circumstances.

Certain drugs require prior authorization.

Prescriptions (brand names) are generally reimbursed at the lowest of the following:

·         The Department’s Estimated Acquisition Cost (EAC) plus the applicable dispensing fee; or

·         The provider’s usual and customary charge to the general public; or

·         The amount billed by the provider.

Estimated Acquisition Cost is the Department’s best estimate of the price generally and currently paid by providers for a drug marketed or sold by a particular manufacturer or labeler in the package size most frequently purchased by providers.

Generic drugs are reimbursed based on Maximum Allowable Cost (MAC), which is equal to Average Wholesale Price (AWP) minus 4%.

Case management services are covered for the following special populations:

·         Chronically mentally ill; and

·         Developmentally disabled.

These services are reimbursed at per diem rates.  Only state-funded providers are eligible for reimbursement.

Payment for transportation may be made for eligible recipients under the Medicaid program when needed to obtain necessary medical services covered by Medicaid, and when it is not available from volunteer organizations, other agencies, personal resources, or is not included in the medical provider’s Medicaid rate.

Transportation may be paid only for trips to/from a medical provider for the purpose of obtaining medical services covered by Medicaid.  If the medical service is paid for by a source other than the Department, they may pay for the transportation as long as the medical service is necessary and is covered by Medicaid.  DSS pays directly for emergency and non-emergency ambulance services.  Non-emergency medical transportation is contracted to 2 regional brokers.

For all transportation, payments shall be made at the lower of:

·         The usual and customary charge to the public, if applicable;

·         The Medicare rate, if one exists;

·         The fee, as published by the Department in its fee schedule; or

·         The amount requested or billed.

Medicaid covers the following services provided by Nurse Practitioners:

·         Medically necessary and medically appropriate professional services;

·         Services provided in the NP’s office, client’s home, hospital, long term care facility or other medical facility;

·         Family planning services;

·         Medical and surgical supplies used by the provider in the course of treatment;

·         Injectable drugs administered by the NP; and

·         EPSDT services.

Nurse Midwife services are covered as above (except injectable drugs).  These services are limited to the care and management of healthy mothers and newborns, only throughout the maternity cycle, and well-woman gynecological care, including family planning services.

Payment for NP’s and NM’s is the lowest of:

·         The provider’s usual and customary charge to the general public;

·         The lowest Medicare rate;

·         The amount in the applicable fee schedule as published by the Department;

·         The amount billed by the provider; or

·         The lowest price charged or accepted for the same or substantially similar goods or services by the provided from any person or entity.

NP’s and NM’s are reimbursed 90% of physician rates.

There is no special program in Connecticut.

No separate category of covered services.  Included in obstetrical services.

Included in global obstetrical fee.