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New York State Medicaid Coverage Changes for Federally Qualified Health Centers (FQHCs): Long-Acting Reversible Contraception (LARC)


Earlier this year, the Centers for Medicare & Medicaid Services (CMS) approved New York’s State Plan Amendment (SPA) 16-0028 proposing increased access and outreach for long acting reversible contraceptives (LARCs). LARCs are methods of birth control that provide effective contraception for an extended period without requiring user action. Two commonly supplied LARCs are estonogestrel implant systems, such as Implanon or Nexplanon, and intrauterine devices like Mirena or ParaGard.  
 
SPA 16-0028 allows for separate reimbursement to FQHCs for the cost of LARCs in addition to the Prospective Payment System (PPS) rate. The new reimbursement method is retroactive for dates of service beginning April 1, 2016.  
 
Reimbursement Procedures
 
FQHCs requesting reimbursement for the cost of the LARC must be enrolled with the New York State Department of Health (NYSDOH) as an Ordered Ambulatory provider. Delay reason code”3” is permitted on retroactive LARC claims until 12/31/2016.  Subsequent claim submission must meet timely filing requirements for payment consideration. Further detail may be found in the September 2016 Medicaid Update accessed here.  
 
Additional billing requirements were shared by the Department of Health during the Community Health Care Association of New York State (CHCANYS) 2016 statewide conference accessed here.  
 
What Does CohnReznick Think?
 
A cohesive revenue cycle is critical to FQHCs seeking this additional revenue opportunity.  Each FQHC must ensure:
 
  • Providers and billing staff are educated on the policy change
  • The charge master is updated with correct LARC HCPCS codes
  • Meaningful reports are created to ensure 100% charge capture
  • Monthly purchase orders for LARCs are compared to monthly utilization 
  • Procedures are developed and implemented to include the actual cost of the LARC on the claim
  • Revenue associated with LARC reimbursement is recognized accurately in the accounting records
  • It maintains auditable records to reduce its risk in future audits by
    • Updating its retention policy to include purchase orders/invoices for each LARC 
    • Identify LARCs purchased at 340B pricing  
 
Contact
 
For more information, please contact Peter Epp, Partner, Healthcare Industry Practice, at peter.epp@cohnreznick.com or 646-254-7411, or Dolores Di Re, Senior Manager, at dolores.dire@cohnreznick.com or 646-625-5703.
 
 
This has been prepared for information purposes and general guidance only and does not constitute professional advice. You should not act upon the information contained in this publication without obtaining specific professional advice. No representation or warranty (express or implied) is made as to the accuracy or completeness of the information contained in this publication, and CohnReznick LLP, its members, employees and agents accept no liability, and disclaim all responsibility, for the consequences of you or anyone else acting, or refraining to act, in reliance on the information contained in this publication or for any decision based on it.
 
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