Payment limitations

(a) The department shall pay only for physicians’ services performed by or under the personal supervision of a physician. (b) The department shall pay the fee for an initial visit by a provider in an office, home, ICF/IID or nursing facility only once per client. Initial visits refer to the provider’s first contact with the client and reflect high fees for the additional time required for setting up records and developing past history. The only exception to this is when the provider-client relationship has been discontinued for three or more years and is then reinstated. (c) The department shall pay non-hospital-based providers for evaluation and management services provided to the provider’s private practice clients in the emergency room. (d) The department shall pay fees to a consultant provider only when another provider or other appropriate referral source requests the opinions and advice of the consultant provider. The consultant provider shall document such provider’s opinion and any services ordered or performed by the consulting provider in the client’s medical record and submit a written report describing such opinion and services to the requesting physician or other appropriate referral source. The referring provider remains responsible for carrying out the plan of care after seeking a consultation. (e) If a client is referred to a provider for treatment of a condition that the referring provider does not usually treat, the department shall pay the treating provider the fee for an office visit rather than the fee for a consultation. (f) When the consultant provider assumes the continuing care of the client, the department shall pay the consultant provider for any subsequent service according to the fee listed for the procedure. (g) If a client’s medical condition necessitates the concurrent services and skills of two or more providers, the department shall pay each provider the listed fee for the service that each provider provides. (h) When a provider examines a Medicaid applicant for the purpose of substantiating whether a medical condition exists that would enable the department to determine eligibility for Medicaid disability, the department shall pay the billing provider only for the tests required to establish eligibility as requested by the department. The department shall not pay the billing provider for any other procedures. (i) Surgery (1) When a billing provider submits a claim for multiple surgical procedures performed on the same date, the department shall pay the listed fee for the primary surgical procedure. THE department shall pay for additional surgical procedures performed on that day at 50% of the listed fee. (2) When an assistant surgeon, in addition to staff provided by the general hospital or chronic disease hospital, is required, the department shall pay the assistant surgeon 20% of the listed fee for the surgery. (3) The department shall not pay for related evaluation and management encounters on the same day of surgery. (4) The listed fees for all surgical procedures include the surgery and typical postoperative follow-up care provided to clients in a general hospital or chronic disease hospital. The department shall pay for follow-up visits after a client is discharged from the general hospital or chronic disease hospital as office visits. (5) The listed fees for surgery on the musculoskeletal system includes payment for the application of the first cast or traction device. (j) Anesthesia (1) The listed fees for anesthesia services include pre- and post-operative visits, the administration of the anesthetic and the administration of fluids and blood incident to the anesthesia or surgery. (2) The department shall pay the listed fees for anesthesia services only when the anesthesia is administered by or under the supervision of a provider who remains in constant attendance during the procedure for the sole purpose of rendering anesthesia services. (3) The department shall not pay for local infiltration or digital block administered by the operating surgeon. (k) Radiology (1) The listed fees for all diagnostic radiology procedures, including nuclear medicine, magnetic resonance imaging, computerized axial tomography and diagnostic ultrasound, include consultation and a written report to the referring provider. (2) The listed fees for all diagnostic radiology procedures shall apply only when the provider’s own equipment is used. If a general hospital or chronic disease hospital or a related entity directly or indirectly owns the equipment used to perform the procedure, or if a hospital includes the operating expenses of the equipment in its cost reports, the department shall not pay the billing provider for the technical component of the listed fee. (l) Radiotherapy (1) The provider fee for radiological treatment includes one year of follow-up care unless otherwise specified. (2) The provider fee for treatment includes the concomitant office visits, but does not include surgical, radiological or laboratory procedures performed on the same day. (3) The fees listed for therapeutic procedures involving the use of radium and radioisotopes do not include the radioactive drug used or preliminary and follow-up diagnostic tests. Radioactive drugs may be billed separately. (4) The fees listed for diagnostic procedures involving the use of radium and radioisotopes do not include the radioactive drugs used. Radioactive drugs may be billed separately. (m) Laboratory (1) The following routine laboratory tests shall be included in the physician fee for an office visit and shall not be billed on the same date of service: urinalysis without microscopy, hemoglobin determination and urine glucose determination. (2) The department shall not pay for tests provided free of charge. (3) The department shall pay for panel or profile tests according to the listed fees for panel tests and not according to the fee for each separate test included in the panel or profile. (4) The department shall pay only for laboratory physicians’ services that the provider is authorized to perform and are performed in the provider’s office. The department shall not pay the referring provider for laboratory services performed in a laboratory or in any setting other than the provider’s office. (n) Drugs (1) The department shall pay up to the actual acquisition costs for oral medications incident to an office visit as billed by the provider. (2) The department shall pay for injectables, legend drugs and legend devices administered by the provider based on a fee schedule determined by the department. (3) The department shall not pay for drugs provided free of charge. (o) Newborn Care (1) The provider fee for routine care of a normal newborn infant in the general hospital includes history and examination of the infant, initiation of diagnostic and treatment programs, preparation of hospital records, history and physical examination of the baby and conferences with the parents. The department pays per day for subsequent hospital care for evaluation and management of a normal newborn. (2) When a newborn requires other than routine care following delivery, the provider shall bill for the appropriate critical care. The department shall not pay both the critical care and the routine or subsequent newborn care for the same child. (3) The provider may bill for newborn resuscitation in addition to billing for routine care or critical care of a newborn. (p) Payment for assessments and subsequent care for clients in a nursing facility, ICF/IID or chronic disease hospital (1) The department shall pay providers for evaluation and management only when performed in a nursing facility, ICF/IID or chronic disease hospital. (2) The department shall pay for a maximum of one annual assessment per client per year. (q) Admission to a General Hospital If the department determines either prospectively or retrospectively pursuant to section 17-134d-80 of the Regulations of Connecticut State Agencies, that a general hospital admission was not medically necessary or did not fulfill the accepted professional criteria for appropriateness of setting or quality of care, the department shall not pay for the admitting provider’s services in a general hospital. (r) Family planning, abortion and hysterectomy (1) The department shall pay the provider for sterilization only if the client is at least age 21 and has given informed consent in accordance with 42 CFR 441.257 and 42 CFR 441.258, as amended from time to time. (2) The department shall pay for hysterectomies and related laboratory and hospital services that are medically necessary only if the client is at least age 21 and the physician or physician’s representative has obtained: (A) A consent form that complies with 42 CFR 441.257 and 42 CFR 441.258, as amended from time to time, or (B) a physician’s certification that complies with 42 CFR 441.255(d), as amended from time to time. (3) The department shall pay the billing provider for all abortions that a physician certifies as medically necessary whether or not the woman’s life would be endangered by carrying the fetus to term and whether or not the pregnancy is the result of rape or incest. For the purposes of abortion coverage and payment, a physician determines medical necessity. (4) The provider shall maintain all forms required by section 19a-116-1 of the Regulations of Connecticut State Agencies and section 19a-601 of the Connecticut General Statutes. (s) Maternity Bundled Payment. This subsection sets forth the rules for bundle payment methodology for maternity care to improve maternal health and birth outcomes and, to the extent applicable, includes payment to the billing provider for the services of certified doulas, lactation consultants, community health workers and any other non-licensed provider included in the bundle payment methodology. (1) General Provisions for Maternity Bundled Payment. (A) The department may pay for maternity services using monthly case rate payments for certain services included in the maternity bundle episode, as defined under the Medicaid State Plan, for services across all phases of the perinatal period (including prenatal, labor and delivery, and postpartum), which focuses on the accountability and quality of care for providers. (B) The department may provide incentive payments to maternity providers, as identified in subparagraph (C) of this subdivision, who deliver high-quality, cost-effective services throughout the episode. Providers shall be eligible for incentive payments when: (i) the provider’s target price, which is the expected total cost of care for a bundle based on the statewide average cost and the provider’s historical cost, is not exceeded, (ii) the provider meets quality performance criteria, and (iii) the provider complies with the department’s goals to monitor and prevent under-service, such as risk-based patient selection as well as decreased utilization of services. (C) This subsection shall apply to the following performing providers: Physicians, advanced practice registered nurses, physician assistants, and nurse-midwives with obstetrician-gynecology board certification or equivalent credential and expertise in maternity services. (2) Provider Participation Requirements for Maternity Bundled Payment. (A) All qualified maternity provider practices meeting the qualifications in subdivision (1) of this subsection shall participate in the bundle payment methodology. (B) Providers who do not meet the minimum episode volume threshold, as set by the department, shall not be eligible to participate in the bundle payment methodology and shall be reimbursed fee-for-service (FFS) with no opportunity to earn incentive payments. (3) Case Rate Payments for Maternity Bundled Payment. (A) The department’s bundle accountability methodology shall determine the accountable provider. (B) Prior to the establishment of bundle accountability, the department shall pay all maternity claims on an FFS basis. (C) After the establishment of bundle accountability, the department shall pay a monthly case rate to the accountable provider for a subset of services, as outlined under the Medicaid State Plan. All other covered services not included in the monthly case rate shall be paid FFS. (D) In accordance with the Medicaid State Plan, the case rate payment amount shall be based on the maternity provider’s historical cost, and the case rate shall be reassessed not more frequently than once every twelve months. (E) Payment to the maternity provider practice meeting the qualifications in subdivision (1) of this subsection may also include payment for services provided by non-licensed professionals as designated by the department, including, but not limited to, certified doulas, community health workers, and lactation consultants. (F) The bundled payment shall not change any reimbursement methodology for any provider other than as described in this subsection. (4) Incentive Payments for Maternity Bundled Payment. (A) Providers meeting the qualifications in subdivision (1) of this subsection shall be eligible to receive incentive payments in accordance with the applicable bundled payment methodology. The accountable provider meeting the qualifications in subdivision (1) of this subsection shall be eligible to earn incentive payments but shall not be subject to returning any portion of increased program expenditures accountable to the provider. (B) Except for exclusions listed under the Medicaid State Plan, all Medicaid claim costs for covered services related to maternity care shall be included in the incentive payment calculations of the bundle. The incentive payment calculation shall be based on the difference between the expected costs and the actual costs of all applicable covered services provided to the birthing member, regardless of the specific maternity provider who performed each service. (C) The distribution of incentive payments for savings for Medicaid shall be adjusted based upon the accountable provider’s performance of the quality measures established by the department. The distribution of incentive payments shall also be subject to clinical and social risk adjustment. (D) Not later than fifteen months after each performance year, the department shall provide each accountable provider with a written description of the accountable provider’s results regarding performance on quality measures, applicable Medicaid expenditures for maternity bundled payment members assigned to the accountable provider and calculation of incentive payments, as applicable, for said members. After receiving said description from the department, the accountable provider may respond to any calculations, results, or decisions contained therein. Such response shall be in writing, be received by the department not later than thirty days after the accountable provider receives the written description from the department and include all supporting documentation. The department shall issue a written decision not later than thirty days after receiving the accountable provider’s response. There shall be no further right to review the department’s decisions regarding the written description described in this subparagraph, other than as described in this subparagraph. There shall be no right to review the final distribution of incentive payments for the maternity bundled payment.