Benefit: Physician Assistant (PA) services

Definition: PAs are medically trained and licensed health care providers who practice medicine with a doctor’s supervision. PAs perform examinations and procedures, order treatments, diagnose illnesses, prescribe medication, interpret diagnostic tests, refer patients to specialists when appropriate and assist in surgery. PAs may practice in any medical or surgical specialty.

Limits:  Medicaid reimbursement for physician assistant services is limited to:

• One physician assistant-recipient contact per day (except for emergencies);
• One long-term care facility visit per month, per recipient (except for emergencies); and
• One new patient evaluation and management service per physician assistant, per recipient every three years, if no services were rendered by the physician assistant to the recipient during the three years. Subsequent encounters must be reimbursed as established patient evaluation and management services. An additional new patient visit cannot be done by the supervising doctor of the PA for a patient already seen as a new patient by a physician assistant.

Medicaid cannot reimburse a physician assistant and a physician for the same procedure, same recipient, and same date of service. Medicaid may reimburse a surgeon for a surgical service and a physician assistant for the assist-at-surgery service.

Exceptions: The provider may request authorization for reimbursement for services in excess of the service limitations.

Co-pays: $2 for PA services, per provider, per day, unless exempt.

Reform items that can vary: Co-pays