Family and Children's Medicaid MA-3540 Medicaid Covered Services

ii. Policy Principles

A. Medicaid recipients receive 22 mandatory and 8 optional annual medical professional services visits per State fiscal year (July 1st through June 30th).

Mandatory professional services visits include visits to any one or combination of visits to a physician’s office, Nurse Practitioner, Nurse Midwife, health department, Rural Health Center and Federally Qualifies Health Clinic.

Optional professional services visits include visits to any one or combination of visits to optometrists, chiropractors and podiatrists.

1. The following services do not count toward the 22 mandatory annual visit limit:

a. Services provided to recipients under the age of 21,

b. Health Check examinations provided to recipients under the age of 21,

c. Home health services,

d. Inpatient hospital services,

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e. Services provided to residents of nursing facilities or ICF-MRs,

f. Prenatal and pregnancy-related services,

g. Dental services,

h. Mental health services requiring prior approval,

i. Recipients receiving Community Alternatives Program (CAP) services,

j. Services covered by both Medicare and Medicaid and,

k. Physical, occupational and speech therapy.

2. An exemption to the 22 mandatory annual professional services visit limits must be requested by the primary doctor and may be granted for recipients with the following conditions:

a. End stage renal disease,

b. End stage lung disease,

c. Chemotherapy and/or radiation therapy for malignancy,

d. Acute sickle cell disease,

e. Unstable diabetes (does not apply to diabetic recipients whose condition is controlled by oral medications, diet, or insulin),

f. Hemophilia or other blood clotting disorders, and

g. Any life threatening illness or terminal stage of any illness (as supported by the physician's documentation).

Refer to http://www.ncdhhs.gov/dma/provider/AnnualVisitLimit.htm for more information regarding the annual professional services visit limit.

B. Medicaid recipients without Medicare are limited to 8 prescriptions per month. At the discretion of the pharmacist, the monthly prescription limit may be overridden with three (3) additional prescriptions per recipient per month. Recipients under the age of 21 or residents of intermediate care facilities/mental retardation centers, skilled level of care facilities and recipients residing in assisted living facilities and group homes are exempt from the 8 prescription limit.

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CAP recipients are no longer exempt from the 8 prescription limit.

Medicare/Medicaid recipients have no prescription drug coverage (with a few exceptions), through Medicaid. Medicare recipients have prescription drug coverage through Medicare Part D unless they have coverage through a private insurance company.

C. Pharmacy Management Requirements

Medicaid recipients requiring more than 11 prescriptions per month are restricted to a single pharmacy each month except for emergencies. These recipients are identified under the Recipient Opt-In Program and are locked into a single pharmacy. Under the Recipient Opt-In Program, recipients must elect to participate in the opt-in program to receive more than 11 prescriptions per month; however, written consent is not required. Every 6 months, Opt-In Program recipients will be systematically removed from the opt-in program when fewer than 12 prescriptions were dispensed in 2 out of the last 3 months, or if fewer than 12 prescriptions were dispensed in the sixth month. The recipient’s primary care physician and pharmacy provider can contact DMA’s fiscal contractor to request changes to the pharmacy opt-in provider.

Emergency fills are allowed for recipients who are locked into a pharmacy when situations occur where the recipient may not be able to get to his pharmacy, but are limited up to a 4-day supply and a copayment will apply.

Note: Recipients under 21 years of age, recipients in a nursing facility, assisted living facility, group home, or recipients in an intermediate care facility/mental retardation center are EXEMPT from the Recipient Opt-In Program.

D. Recipient Management Lock-in Program

Medicaid recipients who over utilize opioid analgesics, benzodiazepines and certain anxiolytics will be locked-in to one prescriber and one pharmacy in order to obtain opioid analgesics, benzodiazepines and certain anxiolytics.

These recipients are identified under the Recipient Management Lock-in Program. The recipient must obtain all prescriptions for these medications from their lock-in prescriber and lock-in pharmacy in order for the claim to pay. Recipients who qualify for the program will be notified and locked in for one year after which time they will be removed from the program if they no longer meet the criteria.

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E. Copayments

Copayments apply to all Medicaid recipients except those specifically exempted by law from copayments. Providers cannot deny services to any Medicaid patient because of the individual’s inability to pay a deductible, coinsurance, or co-payment amount. An individual’s inability to pay shall not eliminate his liability for the cost sharing charge. The provider may open an account for the patient and collect the amount owed at a later date. Providers may not charge copayments for the following services:

1. Services to individuals under the age of 21

2. Prescribed drugs related to pregnancy

3. Health Check related services

4. Services provided to participants in the Community Alternative Program (CAP)

5. Family planning services and prescribed drugs (birth control medication)

6. Services provided to residents of nursing facilities, intermediate care facilities for mental retardation (ICF-MR), and psychiatric hospitals

7. Hospital emergency department services including physician services delivered in the emergency department

8. Services in state owned psychiatric hospitals

9. Rural Health Clinic (RHC) core services

10. Federally Qualified Health Center (FQHC) core services

11. Non-hospital dialysis facility services

12. Hospital inpatient services (inpatient physician services are not exempt)

13. Home health services

14. Hearing aid services

15. Ambulance services

16. Area Program/Local Management Entity (LME) Mental health clinic services

17. Hospice services

18. Durable medical equipment (DME)

19. Private duty nursing (PDN) services

20. Home infusion therapy (HIT)

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21. Dental services provided in a health department

22. In Home Care (IHC). This includes In Home Care for Adults (IHCA) and In Home Care for Children (IHCC).

23. Routine Eye Exams

24. Eyeglasses and Visual aids

F. The Medicaid identification card must be presented to the provider at each visit. If the provider accepts Medicaid as the payment source, the Medicaid payment must be accepted as payment in full, with the exception of applicable copayment amounts.

G. Prior approval may be required for some services.

1. Prior approval (PA) may be required to verify medical necessity before rendering some services. PA is for medical procedure approval only. Obtaining PA does not guarantee payment or ensure recipient eligibility on the date of service.

2. Prior approval is required for all non-covered state Medicaid plan services and for covered state Medicaid plan services that exceed clinical coverage policy limits. See the website identified below for further information http://www.ncdhhs.gov/dma/epsdt/

3. Before admitting patients for procedures requiring PA, hospital staff must determine that the physician has completed all of the necessary PA forms and obtained PA. NOTE: The primary surgeon is responsible for obtaining PA from Medicaid.

4. Unless a service is exempt from the CCNC/Carolina ACCESS (CCNC/CA) referral authorization requirement, providers must obtain a referral authorization from the CCNC/CA enrollee’s primary care provider in addition to requesting PA for any service or procedure that requires PA.

5. Most requests for PA are submitted in writing. However, requests for approval for services to recipients with a diagnosis of mental retardation may be faxed. Other services may be approved verbally and followed up with the written request.

6. Confirmation for routine eye exams and refraction only, are obtained through the Automated Voice Response System

7. Prior approval requests for Outpatient Specialized Therapies should be submitted electronically.

8. Except in emergency situations, all services provided to Medicaid recipients by out-of-state providers, beyond a 40 mile radius, must be approved prior to rendering the service.

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H. Medicaid Recipient Due Process Rights

When a Medicaid service request is denied, reduced, terminated, or suspended, recipients (or their personal representatives) must receive written notice of the adverse decision and have an opportunity for a fair hearing pursuant to the Social Security Act, 42 C.F.R. 431.200 et seq., and N.C.G.S. §108A-70.9

If the recipient decides to appeal Medicaid’s decision to deny, terminate, reduce, or suspend the services requested by the CCNC/CA provider, the recipient or personal representative must sign and date the appeal request form and send it to the Office of Administrative Hearings (OAH) by mail or fax within 30 days of the date the notice was mailed. The mailing address and telephone and fax numbers for OAH are located on the appeal request form. Providers may not file appeals on behalf of recipients unless the recipient lists the provider as the representative on the appeal request form.

Services may be provided while the appeal is pending under maintenance of services, as long as the recipient remains otherwise Medicaid eligible, unless he gives up this right. For more information refer to Medicaid Recipient Due Process Rights and Prior Approval Policies and Procedures

http://www.ncdhhs.gov/dma/provider/index.htm