HAR §17-1739.1-6.1. Hawaii Medicaid fee schedule

(a) Payment to providers of medical care who are individual practitioners, including doctors of medicine, dentists, podiatrists, psychologist, osteopaths, optometrists, and other individuals providing services, shall be based upon the Hawaii Medicaid fee schedule. (b) Payment for noninstitutional items and services, with the exception of prescribed drugs and UNOFFICIAL 1739.1-14 EPSDT services, shall be based on the Hawaii Medicaid fee schedule. These items and services include, but are not limited to: (1) Laboratory services; (2) X-ray services; (3) Physician services; (4) Podiatric services; (5) Optometric services; (6) Other practitioner services including nurse midwife, pediatric nurse practitioner, advanced practice registered nurse in behavioral health, and licensed social worker in behavioral health; (7) Dental Services (including dentures); (8) Physical therapy; (9) Occupational therapy; (10) Services for persons with speech, language, and hearing disorders (exception: There shall be a flat rate for hearing evaluations.); (11) Durable medical equipment, except eye glass frames and hearing aides; (12) Medical supplies; (13) Sleep services; (14) Other services specified by the department. (c) Providers who are visiting consultants to the neighbor islands may be reimbursed travel charges on the condition that an addendum to their provider agreement is submitted with the following information for approval by the department: (1) The neighbor island to be visited; (2) Frequency of visits; and (3) Location where individuals are to be seen. (d) Reimbursements may be made to providers who are visiting consultants as follows: (1) $8 per patient visit; and (2) An additional $7 per patient visit if hospital charges for supplies and equipment are assessed to the visiting consultant. Justification shall be required on the individual claim form when requesting this additional fee. [Eff 05/10/03 ] (Auth: HRS §346-59) (Imp: 42 C.F.R. §§405.502, 405.503, 447.10) §17-1739.1-7 Payments to individual practitioners providing therapy services in long-term UNOFFICIAL 1739.1-15 care facilities. (a) Payment for physical and occupational therapy, and speech, language, and hearing disorder services provided to a Medicaid recipient in a long-term care facility shall be based on a fee schedule established by the department for services provided at fifteen minute time increments. (b) Payment shall be made for only those covered therapy services specified in sections 17-1737-79, which are determined to be medically necessary, prescribed by a physician, and provided by a licensed or certified therapist approved by the Medicaid program. (c) Payment shall be made only upon submission of a Hawaii claim form (UB-82 or DHS-1500), by a provider eligible to bill for the services under the Medicare and Medicaid programs. Facilities with Medicare numbers shall use the form UB-82. Individual therapists shall use the form DHS-1500. (d) In the case of speech evaluation and training, and hearing evaluation and hearing aids, an authorization form (DHS 1144), shall be attached to the claim form. (e) In the case of persons eligible for both Medicare and Medicaid who reside in an intermediate care facility, payment shall be made only if Medicare payment has been sought and denied. [Eff 10/26/01; am 05/10/03 ] (Auth: HRS §346-59) (Imp: 42 C.F.R. §§447.252, 447.253) §17-1739.1-8 Medicaid payments for other noninstitutional items and services not included in the Medicaid fee schedule. The following services shall be limited to billed charges not to exceed Medicare's upper limit of payment or the rate established by the department: (1) Hearing aids; (2) Home health agency services; (3) Outpatient hospital services; (4) Emergency room services; (5) Frames for eyeglasses; (6) Hearing devices shall be the actual claim charge or $300, whichever is lower. Exceptions may be made for special models or modifications. (7) Clinic services (other than physician-based clinics); The types of clinics include UNOFFICIAL 1739.1-16 government sponsored non-profit, and hospital-based clinics. (8) Teaching physicians shall be paid to the teaching fund, not to the physician; (9) Prescribed drugs shall be made as described in section 17-1739.1-11. (10) The Hawaii Medicaid program shall not pay more than the billed amount for any noninstitutional item or service or more than the amount permitted by federal law or regulation; and (11) Payments to a facility for non-emergency care rendered in an emergency room and to an emergency room physician for the screening and assessment of a patient who receives non-emergency care. [Eff 10/26/01; am 05/10/03 ] (Auth: HRS §346-59) (Imp: 42 C.F.R. §§447.201, 447.304) §17-1739.1-9 Payments for intra-state transportation and related services. (a) Payments for the following intra-state transportation and related services are based upon the Hawaii Medicaid fee schedule: (1) Payments for emergency air ambulance. services; (2) Payments for emergency ground ambulance services; (3) Payments for non-emergency air and ground ambulance services. Air and ground ambulances must be authorized by the department; and (4) Payments for non-emergency transportation (e.g. handicabs, but not taxis). (b) Except for a recipient who is a stretcher patient, payment for air transportation shall not exceed the inter-island air fare charged the other persons on the recipient's flight, or a contracted amount previously agreed upon between the airlines and the department for emergency chartered flights, whichever is lower. For transportation of a stretcher patient by the scheduled inter-island carrier, payment shall not exceed the air fare charged for four seats on the recipient's flight. (c) A round trip air fare shall be paid for an attendant whose services are recommended by the UNOFFICIAL 1739.1-17 attending physician or are required by the airline. Prior approval of the department's medical consultant is necessary, except in emergency situations, when the attending physician's authorization is sufficient, subject to the department's medical consultant's review. (d) Payments for medical taxi services shall be by purchase order issued by the department and only on trips to or from a physician's office, clinic, hospital, or airport (for covered medical transportation) and the patient's home. Reimbursement for those services shall be further limited as follows: (1) No detours or side trips shall be permitted; (2) The amount of payment shall be made on the basis of metered rates charged the public; and (3) Payments shall not include compensation for the driver's waiting time at the clinic, hospital, physician's office, or at the location of other providers of medical services. (e) Lodging and meals for Medicaid patients or attendants authorized by the attending physician, in an emergency situation, or the department's medical consultant shall be paid through purchase orders to the providers issued by the department. [Eff 10/26/01; am 05/10/03 ] (Auth: HRS §346- 59) (Imp: 42 C.F.R. §§447.201, 447.304) §17-1739.1-10 Payments for out-of-state transportation and related services. (a) Payments shall be made for out-of-state transportation, meals and lodging when these services are authorized in accordance with section 17-1739.1-9. (b) Out-of-state air transportation shall be paid by a purchase order made out to the airlines or travel agency. (c) Ground transportation expenses, subject to subsection 17-1739.1-9(f), shall be allowed when these expenses are incurred by the recipient. Verification of ground transportation expenses shall be documented completely on the proper departmental form when reimbursement is requested. (d) Payment for meals and lodging shall be the lesser of the per diem rate of $100 a day or the UNOFFICIAL 1739.1-18 actual charge for lodging plus a daily per diem of $30 for meals. (e) The $30 per diem shall be prorated equally for three meals and shall begin with the first meal upon arrival at the specified destination and ending with the last meal prior to flight departure home. [Eff 10/26/01 ] (Auth: HRS §346-59; 42 C.F.R. §431.10) (Imp: 42 C.F.R. §§447.201, 447.304) §17-1739.1-11 Payment for drugs and related supplies. (a) The state medical assistance program shall determine reimbursement for the ingredient cost of prescription drugs using the following criteria: (1) Single source drugs shall not exceed the lower of: (A) The provider’s invoice price; (B) The provider's usual and customary charge to the general public; or (C) The estimated acquisition cost (EAC). (2) Multiple source drugs shall not exceed the lower of: (A) The provider’s invoice price; (B) The provider's usual and customary charge to the general public; (C) The EAC; (D) The federal upper limit (FUL) price; or (E) The state maximum allowable cost (SMAC). (3) The FUL price shall not apply if the practitioner: (A) Certifies in his or her own handwriting or by an electronic method compliant with national standard approved by the Centers for Medicare and Medicaid Services that a specific brand medication is medically necessary for a particular recipient. A check-off box is not acceptable but a notation of “brand medically necessary” or “do not substitute” is allowable; and (B) Obtains prior authorization for medical necessity from the state medical assistance program. In such cases, the payment shall be according to the methodology in this section. UNOFFICIAL 1739.1-19 (4) The State medical assistance program requires that the lower cost equivalent drug product be dispensed if available in the marketplace and substitution is not prohibited by part VI of chapter 328, Hawaii Revised Statues, relating to drug product selection. The recipient may refuse lower cost drug products but must pay the entire cost of the higher price equivalent. (5) If a published WAC is unavailable for the medication and the provider does not submit documentation of the invoice price, then the medication and dispensing fee shall not be reimbursed. (b) The dispensing fee for prescription medications dispensed by a licensed pharmacy shall be: (1) $5.00 (five and no/100 dollars) per prescription. (2) The dispensing fee for any maintenance or chronic medication shall be extended only once per thirty (30) days without medical authorization from the medical assistance program. Other appropriate limits regarding the number of dispensing fees paid per interval of time shall be determined as necessary by the medical assistance program. (c) The Department may cover selected over-the- counter medications. (1) Reimbursement for over-the-counter medications shall be according to the methodology in subsection (a). (2) Reimbursement for over-the-counter drugs shall be limited to the over-the-counter drugs prescribed by a licensed practitioner and specifically designated by the medical assistance program. Over-the-counter drugs not specifically designated shall require prior authorization for medical necessity by the medical assistance program. (3) Under no circumstances shall the program pay more than the general public for the same prescription or item. (d) The following conditions shall apply to payment for drugs dispensed by physicians and dentists from the physicians’ and dentists’ offices: (1) Physicians and dentists dispensing medications from the physicians’ and UNOFFICIAL 1739.1-20 dentists’ offices shall be reimbursed at the EAC plus $0.50 (fifty cents); and (2) If there is no pharmacy within five miles of the provider’s office, special consideration for payment at the pharmacy rate may be made upon written request to the department’s med-QUEST division administrator for approval. (e) Payment for prescribed drugs dispensed to outpatients and patients of long-term care facilities shall be made only upon the submission of an itemized claim by the dispensing provider (Form 204), hardcopy or electronic media claim or via point-of-sale. (f) Emergency calls by the pharmacist to the long-term care facility: (1) Shall be paid up to a maximum of four calls for each one hundred beds in the facility at the time services are rendered, at $25 (twenty-five and no/100 dollars) per emergency call. Any fraction of one hundred shall be prorated accordingly; and (2) Facilities with less than twenty-five beds at the time services are rendered may charge up to one full emergency call per month. (A) An emergency call shall be one that cannot be delayed, i.e. non-routine call to the patient of a facility by the pharmacist in a life-threatening situation. (B) All other services shall be handled during the pharmacist’s routine visits whenever possible. (g) Payments for medical supplies shall be the lower of: (1) The rate set by the department; (2) Medicare’s upper limit of payment; or (3) The EAC for a medical supply. [Eff 10/26/01; am 05/10/03; am 05/05/05; am 04/12/13 ] (Auth: HRS §346-59) (Imp: 42 C.F.R. §§447.331, 447.332,447.333)