Service

Outpatient hospital services are covered when those services are rendered:

·         As preventive, diagnostic, therapeutic, rehabilitative or palliative outpatient services;

·         Within specified service limits;

·         By or under the direction or a physician or dentist;

·         To a recipient who has not been admitted as an inpatient; and

·         For a period of time not to exceed 24 hours.

Payment is made in accordance with fee schedules developed by DHHS for the individual services provided.

Covered services for an independent RHC include:

·         Services of a physician, when the physician has an agreement to be paid by the clinic for such services;

·         Services of a nurse practitioner or physician assistant, provided within the scope of his/her training or certification;

·         Services and supplies that are furnished as incidental to the professional services of a physician, nurse practitioner or physician assistant;

·         Laboratory services essential to immediate diagnosis and treatment of the patient; and

·         Other ambulatory services provided within the scope of the RHC practice.

Covered services for a hospital-based RHC include:

·         Services of a physician, when the physician has an agreement to be paid by the clinic for such services;

·         Services of a nurse practitioner or physician assistant, provided within the scope of his/her training or certification; and

·         Services and supplies that are furnished as incidental to the professional services of a physician, nurse practitioner or physician assistant.

Payment for RHC services is made on the basis of an all-inclusive rate per visit.  RHCs must bill using the encounter codes assigned by DHHS.

RHCs must be for services other than those included in the encounter rates must billed using CPT procedure codes.

Recipient encounters with more than one health professional, or multiple encounters with the same health professional that take place on the same day for the same diagnosis or treatment, are counted as one visit.

RHCs may bill for only one visit per recipient per day, except for cases in which the patient, subsequent to the first visit, suffers and illness or injury requiring additional diagnosis and treatment.

Covered services include:

·         Services of a physician, when the physician has an agreement to be paid by the clinic for such services;

·         Services of a nurse practitioner or physician assistant, provided within the scope of his/her training or certification;

·         Services and supplies that are furnished as incidental to the professional services of a physician, nurse practitioner or physician assistant;

·         Laboratory services essential to immediate diagnosis and treatment of the patient; and

·         Other ambulatory services provided within the scope of the FQHC practice.

Payment for FQHC services is made on the basis of an all-inclusive rate per visit.  FQHCs must bill using the encounter codes assigned by DHHS.

FQHCs must be for services other than those included in the encounter rates must billed using CPT procedure codes.

Recipient encounters with more than one health professional, or multiple encounters with the same health professional that take place on the same day for the same diagnosis or treatment, are counted as one visit.

FQHCs may bill for only one visit per recipient per day, except for cases in which the patient, subsequent to the first visit, suffers and illness or injury requiring additional diagnosis and treatment.

Radiological services ordered a physician or other licensed practitioner are covered, within scope of practice, including:

·         Diagnostic services (e.g., x-ray); and

·         Therapeutic services (e.g., radiation therapy).

Laboratory services are covered when ordered by a physician or other licensed practitioner within scope of practice.

Payment is made in accordance with fee schedules developed by DHHS for the individual services provided.

Nursing home services include:

·         Room and board

·         General nursing services;

·         Items furnished routinely and commonly to most or all patients;

·         Routine personal hygiene and grooming supplies;

·         Medical supplies and non-legend drug and pharmaceutical items;

·         Laundry services; and

·         Routine and emergency dental services.

Nursing homes are reimbursed prospective per diem rates based on actual allowable costs.

Covered services include the following (subject to specific limitations):

·         Anesthesia;

·         Consultation;

·         Eye care;

·         Family planning;

·         Inpatient hospital visits;

·         Lab and radiology;

·         Ob/gyn procedures;

·         Office visits;

·         Outpatient hospital visits;

·         Surgical procedures; and

·         Organ transplants.

Payment is made in accordance with fee schedules developed by DHHS for the individual services provided.

The following dental services are covered for recipients under age 21:

·         Prophylaxis twice per year;

·         Restorative treatment;

·         Period examinations;

·         Vital pulpotomy;

·         Extractions;

·         General anesthesia;

·         Orthodontic services (in accordance with specific guidelines);

·         X-rays;

·         Palliative treatment;

·         Prosthetic replacement of anterior permanent teeth, canine to canine removable prostheses only, subject to prior authorization;

·         Topical fluoride treatment applied twice per year until age 13;

·         Root canal therapy;

·         Sedative fillings when necessary for emergency relief of pain;

·         Anterior preformed or acrylic resin crowns;

·         Stainless steel crowns;

·         Periodontic services subject to prior authorization;

·         Preventive and diagnostic dental services for EPSDT-eligible children;

·         Sealants for permanent and deciduous molars every 5 years; and

·         Any other service deemed to be medically necessary.

For individuals age 21 and older, dental services are limited to:

·         Palliative treatment;

·         Extraction of the causative tooth or teeth;

·         Treatment of severe trauma;

·         Surgical procedure performed in a hospital; and

·         X-rays in certain cases.

Payment is made in accordance with fee schedules developed by DHHS for the individual services provided.  Rates are reviewed annually.

Coverage includes:

·         Preventive and diagnostic services, including comprehensive and age-appropriate medical assessments and screenings of a child’s physical and mental health status;

·         Health education information;

·         Assessment and testing for lead toxicity;

·         Dental screening;

·         Other diagnostic procedures;

·         Diagnostic and treatment required as revealed by screening services; and

·         Transportation services.

New Hampshire’s EPSDT program is called the Child Health Assurance Program (CHAP).

Payment is made in accordance with fee schedules developed by DHHS for the individual services provided.

Covered services include those services and supplies provided by or under the supervision of a physician including:

·         Physician services;

·         Contraceptive devices or drugs, both prescription and non-prescription; and

·         Sterilization (in accordance with specific guidelines).

Sterilization is not covered for any recipient who is under age 21 or is mentally incompetent or institutionalized.

Medical, surgical or pharmaceutical treatment is not covered for the sole purpose of enhancing, promoting or restoring fertility.

Payment is made in accordance with fee schedules developed by DHHS for the individual services provided.

Preventive, diagnostic, therapeutic, rehabilitative and palliative services provided to outpatients are covered.

Payment is made in accordance with fee schedules developed by DHHS for the individual services provided.

The following are covered:

·         Legend and non-legend medications when prescribed as part of a course of medical treatment for a specific illness, injury, disease for use specified by the FDA, or for non-experimental purposes as supported by accepted medical practice;

·         Compound pharmaceuticals when at least one ingredient can be identified by a National Drug Code (NDC); and

·         Nutritional supplements needed to sustain life.

Pharmaceuticals must be FDA-approved, rated effective, and produced by manufacturers who are participating in the U.S. Department of Health and Human Services drug rebate agreement.

Pharmaceuticals are reimbursed at the lesser of the following:

·         Estimated Acquisition Cost (EAC) plus a dispensing fee;

·         Usual and customary charge to the general public;

·         The New Hampshire Maximum Allowable Cost (MAC) plus a dispensing fee; or

·         The Federal Upper Limit (FUL) plus a dispensing fee.

EAC is equal to the Average Wholesale Cost (AWP) minus a discount of 12%.

MAC is the maximum cost allowed by DHHS for certain multiple-source drugs.

FUL is the maximum cost allowed by the federal government for certain multiple source drugs.

Case management of advance care planning and directives (CM-ACPD) for individuals with severe illnesses – Includes case management services for individuals enrolled in Medicaid who have been diagnosed as being severely ill, i.e., diagnosed with an illness or medical condition that is expected to result in continuous deterioration and death within approximately two years. 

Examples:

·         Cancer

·         End Stage Cardio-Pulmonary Disease

·         Alzheimer’s Disease and Related Disorders

·         End Stage Cardiac Disease

·         AIDS

·         Post Cerebrovascular Accident (Stroke)

·         End Stage Renal Disease

·         Parkinson’s Disease

·         Amyotrophic Lateral Sclerosis (Lou Gehrig’s Disease)

CM-ACPD is a covered service when it is provided by agencies that are enrolled in the NH Medicaid program, licensed as a home health agency by the state in they practice, and are certified Medicare hospice providers.

Payment is made in accordance with fee schedules developed by DHHS for the individual services provided.

The following ambulance services are covered:

·         Transportation, in the case of a medical emergency, to and from the nearest institution with appropriate treatment facilities; and

·         Transportation to medical providers when other methods of transportation are medically inadvisable due to the recipient’s condition and so certified in writing by the recipient’s attending physician.

Wheelchair van services are covered for transportation to and from hospitals, clinics, rehabilitation center, and physician offices.

General medical transportation via private vehicle, tax, bus, etc. to in-state, border or advanced authorized out of area medical providers is covered, subject to certain restrictions.

Wheelchair van services are limited to 24 trips, either one-way or round trip, per recipient per state fiscal year.

Payment for ambulance services is made in accordance with the rates established by DHHS.   Payment is made for loaded miles only.

Wheelchair van services are reimbursed according to the rates established by DHHS (includes base rate plus mileage).

Private transportation is reimbursed the lesser of

·         Actual number of miles billed multiplied by the rate per mile; or

·         The maximum allowable mileage for the trip.

Public transportation is reimbursed to either the Medicaid recipient or to the transportation provider depending on which party is designated as the payee, at the usual and customary charge made to the general public.

Services provided by an Advanced Registered Nurse Practitioner (ARNP) are covered as long as the ARNP is certified and legally recognized to perform them.

The following services are covered when provided by Certified Midwives:

·         Supervision and advice during pregnancy, labor and postpartum period;

·         Care during pregnancy, including preventive care, detection of abnormal conditions and execution of emergency measures in the absence of medical help;

·         Care during labor, including vaginal deliveries and execution of emergency measures in the absence of medical help;

·         Care during postpartum period, including preventive care, detection of abnormal conditions and execution of emergency measures in the absence of medical help;

·         Administering medications.

Payment is made in accordance with fee schedules developed by DHHS for the individual services provided.

Services rendered to pregnant and postpartum women in addition to routine medical prenatal and postpartum care with the purpose of improving birth outcomes and parent skills.

Includes:

·         Social services;

·         Care coordination between client and any other individuals or agencies involved in the client’s care;

·         Client education; and

·         Nutritional services.

The payment rate for extended services is established by DHHS.

Medicaid covers the following major components of prenatal care:

·         Early and continuous risk assessment;

·         Health promotion; and

·         Medical monitoring, intervention and follow-up.

Payment is made in accordance with fee schedules developed by DHHS for the individual services provided.