Limits: Medicaid reimbursement for physician services is limited to:
- One physician-recipient contact per provider specialty, per day (except for emergencies);
- One long-term care facility service per physician, per month, per recipient (except for emergencies);
- One physician consultation per 365 days, per physician of any specialty, per recipient (for non-hospitalized Medicaid recipients);
- Ten prenatal visits per recipient per pregnancy. Additional visits, up to 14, may be reimbursed for high risk pregnancies. Two medically necessary postpartum visits per recipient per pregnancy; and
- One new patient evaluation and management service per physician specialty, every three years, if no services were rendered by the physician to the recipient during the prior three years. Subsequent encounters must be reimbursed as established patient evaluation and management services.
Medicaid does not reimburse cosmetic surgery or experimental or investigational
procedures.
Eye exams are reimbursable only if related to reported vision problems, illness,
disease or injury.
Elective surgery performed within the inpatient hospital setting must be medically
necessary and prior authorized, except for recipients 20 years of age or younger who
have been screened in the Child Health Check-Up program within 12 months prior to
the date of surgery.
Medicaid does not reimburse abortions except for one of the following reasons:
- The woman suffers from a physical disorder, physical injury or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself that would place the woman in danger of death unless an abortion is performed;
- The pregnancy is the result of incest; or
The pregnancy is the result of rape. |