Medicaid State Plan Amendments

Updates and extends the Ambulatory Patient Group (APG) methodology for hospital based clinics and ambulatory surgery services for the effective period January 1, 2020 thru December 31, 2020 and revise the APG methodology to reflect the recalculated weights with component updates

Increases the rates for the Long-Acting Reversible Contraceptive devices (LARCs). Adds Healthcare Common Procedure Coding System (HCPCS) code J2350 - Ocrelizumab to the physician office and outpatient fee schedule at $57.42 based on the current approved Medicaid State Plan reimbursement methodology at 100% of the January 2020 Medicare Average Sales Price (ASP) Drug Pricing file for physician-administered drugs, immune globulins, vaccines and toxoids

This time-limited state plan amendment responds to the COVID-19 national emergency. The purpose of this amendment is to suspend co-payment obligations for outpatient hospital visits and for medications to treat the symptoms of COVID-19, remove 9-hour per week minimum for substance use disorder services and intensive outpatient treatment services (including alternative benefit plans), expand prior authorization for medications by automatic renewal, and make exceptions for brand name drugs.

amends outpatient hospital reimbursement, which are required by the state’s settlement agreement with in-state nongovernmental licensed short-term general hospitals and implements state legislation in Public Act 19-1 of the December special session: (1) the ambulatory payment classification (APC) conversion factor increases to $77.12 effective January 1, 2020 and will increase by 2.2% per year effective for dates of service each subsequent January 1st through and including January 1, 2026; (2) the outpatient hospital flat fee schedule based on Revenue Center Codes (RCCs) will increase by 2.2% per year effective January 1, 2020 and each subsequent January 1st through and including January 1, 2026; and (3) effective for dates of service from January 1, 2020 through June 30, 2026, the wage index used in calculating APC payments is 1.2563 for hospitals located in CBSA 14860 (Fairfield county) and 1.2538 for hospitals not located in CBSA 14860. The rate levels in effect on June 30, 2026 will continue at the same levels effective on and after July 1, 2026 unless modified by a future SPA. This SPA also sets the wage index at1.2575 for in-state governmental licensed short-term general hospitals and in-state licensed short-term children’s general hospitals.

Amends State Plan Attachment 3.1-F to implement a fixed enrollment process for beneficiaries that are enrolled into
the state’s Healthy Connections program

Quality improvement incentives

This time-limited state plan amendment responds to the COVID-19 national emergency. The purpose of this amendment is to waive cost-sharing for testing services, testing-related services and treatments of COVID-19 and suspend the face-to-face requirements for community mental health centers.

This plan amendment incorporates the 2020 Healthcare Common Procedure Coding System (HCPCS) changes (additions, deletions and description changes) to the Independent Therapy fee schedule. Codes that
are being added are being priced using a comparable methodology to other codes in the same or similar category. These changes are being made to ensure this fee schedule remains compliant with the Health
Insurance Portability and Accountability Act (HIPAA).

Updates the rates for Licensed Practical Nursing (LPN) private duty nursing services provided by a home health agency and adds more comprehensive language describing the reimbursement methodology for Extended Home Health Services.

Incorporates various 2020 Healthcare Common Procedure Coding System (HCPCS) changes (additions, deletions and description changes). Codes that are being added are being priced using a comparable methodology to other codes in the same or similar category and replacement codes are being priced in a manner designed to make the billing code updates cost-neutral.