Service

Medicaid reimburses outpatient services and emergency room services.  These include, but are not limited to:

·         Physician, Advanced Practitioner of Nursing, Physician Assistant, urgent care sites and OP hospital clinic visits;

·         Therapeutic injections*

·         Prescription drugs*;

·         Family planning services and supplies;

·         Routine antepartum/postpartum visits;

·         Clinic visits, chemotherapy and/or radiotherapy for cancer treatment;

·         PT, OT, and Speech Therapy;

·         Lab, radiology and diagnostic services;

·         OP surgery; and

·         EPSDT services.

(*within limitations)

Nevada Medicaid reimburses for services provided in a freestanding ambulatory surgical center (ASC).  Some ASC services require QIO authorization.

Outpatient services are reimbursed according to the Medicaid Fee Schedule.

Routine antepartum/

postpartum visits are included in the global antepartum obstetrical rate and are billed using the state devised CPT code 59420.

Medically necessary services include preventive health services, well-child services, acute care, perinatal care, family planning, diagnostic laboratory and radiological services, emergency medical services, transportation services, preventive and restorative dental services, mental health and pharmaceutical services.

RHCs are reimbursed according to the simple average of cost settlement 1999 and 2000 cost per visit to establish base prospective payment system (PPS) rate effective 1/1/01.  In each subsequent fiscal year, an inflation index is applied to the PPS rate. There are special provisions for changes in scope of service.

Medically necessary services include preventive health services, well-child services, acute care, perinatal care, family planning, diagnostic laboratory and radiological services, emergency medical services, transportation services, mental health, preventive and restorative dental services* for children and pharmaceutical services.

FQHCs are reimbursed according to the simple average of cost settlement 1999 and 2000 cost per visit to establish base prospective payment system (PPS) rate effective 1/1/01.  In each subsequent fiscal year, an inflation index is applied to the PPS rate.  There are special provisions for changes in scope of service.

Nevada Medicaid authorizes payment for laboratory services provided to all eligible recipients. 

Clinical laboratory services include CPT codes 36400 –36425, 80000 – 87999, 88150, 88155, 89005 – 89999, 99000 – 99002.

Laboratory tests which are not Medicaid benefits include:

·         Post mortem exams listed under the Anatomic Pathology section of the CPT manual;

·         Fertility codes under the Other Procedures section of the CPT. The codes are 89250, 89300, 89310, 89320, 89325, 89329 and 89330.  Exception:  Medicaid will only pay for code 89310 after a vasectomy.

Medicaid reimburses for radiology services considered medically necessary for the diagnosis and treatment of a specific illness, symptom, complaint or injury, or to improve the functioning of a malformed body member

Outpatient clinical laboratory services are restricted to one single source laboratory contractor within the geographical areas of Clark County, Washoe County, Carson City and Douglas Counties, with certain exceptions.  Anatomical pathology, with the exception of pap smears, hospital inpatient lab services, and surgical pathology are not included under contract services. The remainder of rural Nevada is not affected except for tests referred out.  All referred tests must be sent to the single source laboratory.

A licensed physician or other licensed person working within the scope of their practice must request radiology services (e.g. Advanced Nurse Practitioner, Physician Assistant.

Laboratory and radiology services are reimbursed the lower of billed charges or the fixed fee as shown in the Medicaid Fee Schedule.  These fees are based on Relative Value Units (RVUs).

Nevada Medicaid covers medically necessary services provided in nursing facilities (NF) for those acute care program members who need nursing care 24 hours a day, but who do not require hospital care under the daily direction of a physician.  Covered services include:

·         Nursing services;

·         Basic patient care;

·         Dietary services;

·         Administrative physician visits;

·         Non-customized durable medical equipment;

·         Rehabilitation therapies prescribed as a maintenance regimen;

·         Over-the-counter medications;

·         Social, recreational and spiritual activities; and

·         Other services as necessary.

Nursing homes are reimbursed a per diem rate, which is individually determined for each facility. 

Nevada Medicaid covers physician services for all members within certain limits based on member age and eligibility.  Physician services include medical assessment, treatment and surgical services performed in the office, clinic, hospital, home, nursing facility or other location by a licensed doctor of medicine or osteopathy.

Physicians are paid the lower of billed charges OR the fixed fee established in the Medicaid Fee Schedule.  These rates are calculated using Relative Value Units (RVUs).

Covers preventive care including immunizations, annual physical exams.  Coverage includes referrals for developmental disabilities as well as vision, hearing, dental and behavioral health care.

Children born to Medicaid-eligible pregnant women are eligible for Medicaid for the first year of life regardless of changes in income level of the family.  These children are automatically eligible for Healthy Kids as long as they remain with the mother and continue to reside in Nevada.

Healthy Kids services are currently reimbursed according to the Medicaid Fee Schedule using the appropriate local state devised procedure codes (S-Codes).

Family planning services include:

·         Pap smears;

·         Colposcopy;

·         Cervical biopsy pelvic examination;

·         Laboratory analysis;

·         Pregnancy testing and counseling;

·         Fitting of diaphragm and cervical cap;

·         Insertion of Norplant implant and IUDs;

·         Removal of IUDs;

·         Treatment of genital warts and dysplasia;

·         Hematocrit/hemoglobin;

·         Contraceptive supplies (pills, condoms, contraceptive injections, diaphragms, sponge, film, vaginal suppositories, cervical cap);

·         Gonorrhea culture; and

·         Testing for syphilis, HIV, chlamydia, and other STDs.

Medicaid also covers family planning services for men.

Nevada covers abortion care under the Hyde Amendment.  Public funds may not be used to pay for an abortion unless the procedure is necessary to preserve the mother’s life or the pregnancy is the result of rape or incest and the woman signs a notarized affidavit or witnessed declaration attesting to this fact.

Family planning services do not require a PCP referral, however, an OB/Gyn may not be a PCP.

Family planning services are part of the capitation rate paid to MCOs. HIV/STD testing, counseling, and treatment are also capitated. Medication for HIV/AIDS is carved out and billed directly to the State.

Under FFS, these services are reimbursed according to the Medicaid Fee Schedule.

There are no specific requirements for clinic services.   Information regarding covered services and other information is captured under other headings, such as physician services, RHC and FQHC.

Nevada Medicaid reimburses pharmacies for prescriptions dispensed to each Medicaid recipient, with a maximum of a 34-day supply.  Maintenance medications have a maximum of 100-day supply.

Covered drugs include:

·         Legend pharmaceuticals manufactured by companies participating in the federal Medicaid Drug Rebate Program, not on the excluded formulary list;

·         Pharmaceuticals prescribed for a medically accepted indication;;

·         Family planning items such as diaphragms, condoms, foams and jellies.

·         See attached list for drugs with special requirements or which require PA

The state legislature approves rate increases for dispensing fees.

Nevada Medicaid will not reimburse for the following drugs (with certain exceptions):

·         Pharmaceuticals considered experimental as to substance or diagnosis for which prescribed;

·         Pharmaceuticals manufactured by companies not participating in the Medicaid Drug Rebate Program unless rated “1-A” by the FDA;;

·         Yohimbine; and

·         Drug Efficacy Study and Implementation (DESI) list “less than effective drugs”.

·         Agents used for weight loss

·         Agents when used to promote fertility; and

·         Agents used for cosmetic purposes or hair growth.

Legend drugs are reimbursed to the lowest of:

·         Maximum Allowable Cost (MAC) plus the professional/dispensing fee;

·         Estimated Acquisition Cost (EAC) plus the professional/dispensing fee; OR

·         The pharmacy’s usual charge to the general public.

The Maximum Allowable Cost (MAC) is the cost established by the Centers for Medicare and Medicaid Services (CMS) for multiple source drugs that meet certain criteria.

Estimated Acquisition Cost (EAC) is defined by Nevada Medicaid as Average Wholesale Price (AWP) less 15%. 

Currently, the professional/dispensing fee is $4.76 per prescription.

Providers who have entered into aPPO/ HMO agreements agree to accept payment for less than the amount of billed charges and accept this payment as payment in full.  Medicaid can make payments only where there is recipient legal obligation to pay, such as a co-pay and/or deductible.

Targeted case management is available for the following populations:

·         Severe Emotionally Disturbed (SED) Children;

·         Seriously Mentally Ill (SMI) persons;

·         Developmentally Delayed Infants and Children;

·         Mentally Retarded;

·         Juveniles on Probation (JPS);

·         Child Protective Services (CPS); and

·         Blind and Visually Impaired Persons.

These services are reimbursed the lower of billed charges OR the fixed fee established in the Medicaid Fee Schedule.

Medicaid covers medically necessary emergency transportation such as ambulance and air ambulance services.  Emergency services do not require authorization. 

Medically necessary, non-emergency services require authorization.  Examples of non-emergency services not requiring authorization are:

·         an ambulance service that begins and ends out-of-state;

·         the transport of a hospital inpatient to a lower level of care, .e.g, a nursing facility;

·         transfer from acute general hospital to acute psychiatric hospital; and

·         return from the emergency room to a nursing facility.

Nursing facilities in Carson City, Churchill, Clark and Washoe Counties receive a per diem allowance to cover the cost of transporting residents to all routine off-site medical appointments.

The use of an ambulance service to transport a nursing facility resident to off-site appointments in these counties must be both medically necessary and prior authorized.

For air or ground ambulance, payment is the lower of billed charges of Medicaid maximum fees.  Rates increased 2.5% effective 10/1/98.  Mileage is paid in 10-minute increments (rounding up or down) and billed separately under codes T00380, T00381, T00390 or T00391.

Non-emergency transportation is reimbursed the lower of billed charges OR the fixed fee established in the Medicaid Fee Schedule.

Services of Certified Nurse Practitioners and Certified Nurse Midwives are covered within their scope of practice.

These practitioners are paid the lower of billed charges OR the fixed fee established in the Medicaid Fee Schedule.  These rates are calculated using the Relative Value Units (RVUs) used for physicians.

Program is called MOMS and provides case management services for Medicaid-eligible or pending-eligible pregnant women whose pregnancies are considered high risk.

Referrals are made to numerous resources, including:

·         Prenatal care;

·         Smoking cessation;

·         Alcohol and drug abuse treatment;

·         Domestic violence counseling and support;

·         Family planning services;

·         Prepared childbirth parenting classes; and

·         Employment training.

Women receive services throughout their pregnancy and postpartum periods.  The postpartum period is considered to be 60 days after delivery and the remainder of the month in which the 60^th day falls.

These services are reimbursed the lower of billed charges OR the fixed fee established in the Medicaid Fee Schedule.

Nevada Medicaid covers prenatal care, which is comprised of three major components:

·         Early and continuous risk assessment;

·         Health promotion; and

·         Medical monitoring, intervention and follow-up.

There is a global payment for prenatal care and delivery.