Covered Services

Covered Services A. Covered inpatient services include: 1. Ancillary services. 2. Drugs, excluding take home drugs. 3. Supplies. 4. Oxygen. 5. Durable Medical Equipment. 6. The cost of implantable programmable baclofen drug pumps used to treat spasticity which are implanted in an inpatient hospital setting are reimbursed through the Mississippi Medicaid APR-DRG payment. 7. Newborn Hearing Screens - refer to Part 218. 8. Therapy Services a) Therapeutic services ordinarily furnished to inpatients by the hospital, or by others under arrangements made by the hospital, are covered. b) Inpatient services rendered by a psychologist or a therapist who is employed by the hospital, and whose services are normally included in the billing of the hospital, are covered in the same manner as the services of other non-physician hospital employees. 9. Inpatient Psychiatric Services are covered in the following settings as outlined: a) Acute Freestanding Psychiatric Facility 1) Services available for children up to age twenty-one (21). 2) Certification by the UM/QIO is required for the admission and for a continued stay after nineteen (19) days. b) Psychiatric Unit at a Medical Surgical Facility 1) Services available to children or adults. 2) Certification by the UM/QIO is required for the admission and for a continued stay after nineteen (19) days. 10. Inpatient or outpatient hospital services rendered to a beneficiary who leaves the hospital against medical advice. 11. Canceled or incomplete procedures related to the beneficiary’s medical condition. Services performed before the surgical or other procedure is canceled or terminated before completion due to a change in the beneficiary’s condition. B. The division of Medicaid covers medically necessary inpatient procedures. Refer to Part 202, Chapter 5. 1. Moved to Rule 5.3. 2. Moved to Rule 5.6. 3. Moved to Rule 5.4. 4. Moved to Rule 5.1. 5. Moved to Rule 5.2. 6. Moved to Rule 5.5. C. Hospitals with Multiple Accommodations: The Division of Medicaid does not specifically reimburse hospitals for the cost of accommodations. Billed charges do factor into the calculation of the APR-DRG outlier payments. 1. Private Room: When private room accommodations are furnished, the following rules will govern: a) Private Room/Critical Care Units – Medically Necessary – The reasonable cost/charges of a private room or other accommodations more expensive than semi- private are covered services when such accommodations are medically necessary. Private rooms will be considered medically necessary when the physician documents that the patient’s condition requires him/her to be isolated for his/her own health or for the health of others. This includes the use of critical care units. b) Private Room – Not Medically Necessary – Based on Availability – When accommodations more expensive than semi-private are furnished, the assigned accommodations are considered medically necessary and cost/charges are covered by The Division of Medicaid if at the time of admission less expensive accommodations are not available (this includes hospitals with private rooms only.) The subsequent availability of semi-private or ward accommodations would offer to the hospital the right to transfer that patient to such accommodations or, at the express request of the patient, to allow him/her to continue occupancy of the private room as a private-room patient enjoying a personal comfort item and subject to be billed the room differential charge. c) Private Room – Requested by Beneficiary – When a private room is not medically necessary but is furnished at the beneficiary’s request, the hospital may charge the patient no more than the difference between the customary charge for the accommodations furnished and the customary charge for the semi-private accommodations at the rate in effect at the time services are rendered. No such charge may be made to the patient unless he/she requested the more expensive accommodations with the knowledge that he/she would be charged the differential. The patient’s account file, over the signature of an authorized hospital employee, should reflect the patient’s knowledge that the differential charge will be expected. d) Deluxe Accommodations – The Division of Medicaid does not cover deluxe accommodations and/or deluxe services. These would include a suite/birthing suite, or a room substantially more spacious than is required for treatment, or specifically equipped or decorated, or serviced for the comfort and convenience of persons willing to pay a differential for such amenities. A room differential cannot be charged to the beneficiary when the differential is based on such factors as differences between older and newer wings, proximity to lounge, elevators or nursing stations, or a desirable view. Such rooms are standard on-bed units and not deluxe rooms for purposes of this instruction. 2. Semi-private Room – Two (2) beds per room – The Division of Medicaid will cover the reasonable cost/charges of semi-private accommodations. 3. Ward Accommodations – Three (3) or more beds per room – If less than semi-private accommodations are furnished, The Division of Medicaid will cover the cost/charges or the accommodation furnished only if the patient requests such or when semi-private accommodations are not available. If less than semi-private accommodations are furnished because all semi-private rooms are filled, the patient should be transferred to semi-private accommodations as soon as one becomes available.