Payment limitations

(a) The department shall pay for an initial visit by a nurse-midwife only once per client. Initial visits refer to the nurse-midwife's first contact with the client and reflect higher fees for the additional time required for setting up records and developing past history. The only exception to this is when the nurse-midwife-client relationship has been discontinued for three or more years and is then reinstated. (b) The department shall pay for an initial visit once per inpatient hospitalization. (c) Nurse-midwifes who are fully or partially salaried by a general hospital, public or private institution, group practice, or clinic shall not receive payment from the department unless the nurse-midwife maintains an office for private practice at a separate location from the hospital, institution, group, or clinic in which the nurse-midwife is employed. Nurse-midwifes who are solely hospital, institution, group, or clinic based, either on a full- or part-time salary are not entitled to payment from the department for services rendered to Medical Assistance Program clients. (d) A nurse-midwife who maintains an office for private practice separate from the hospital, institution, group, or clinic, shall be able to bill for services provided at the private practice location or for services provided to the nurse-midwife's private clients in the hospital, institution, group, or clinic only if the client is not a client of the hospital, institution, group, or clinic. (e) Fees for medical procedures shall include the fee for an emergency room visit. The department shall not pay a provider at a higher rate for any medical procedure which is performed in an emergency room. (f) Payment for the total obstetric care procedure, shall include office visits for maternity care six months prior to delivery and six weeks after delivery. (g) If antepartum care, vaginal delivery, or postpartum care are billed as separate procedures, total payment shall not exceed the fee for the total obstetric care procedure. (h) If a client's medical problem necessitates the concurrent services and skills of two or more providers, each provider shall be entitled to the listed fee for the service. (i) There shall be no payment for consultation and collaborative management services with an obstetrician-gynecologist when functioning as part of the health care team in the evaluation and treatment of a client. (j) Although a nurse-midwife shall always function within a health care system in a team relationship with a physician which is directed and shall never be independent of physician back-up for consultation and collaborative management, or referral, directed does not necessarily imply the physical presence of the physician when care is being given by a certified and licensed nurse-midwife. (k) 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 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.