NOTICES
DEPARTMENT OF
PUBLIC WELFARE
Changes to Payment Methodology for Birth Centers
[43 Pa.B. 4029]
[Saturday, July 13, 2013]The Department of Public Welfare (Department) is announcing it will modify the current payment methodology for birth center services to include separate payments for the facility and the practitioner for dates of service on and after September 1, 2013.
Background
On March 23, 2010, the Patient Protection and Affordable Care Act (Pub. L. No. 111-148) was enacted and on March 30, 2010, the Health Care and Education Reconciliation Act of 2010 (Pub L. No. 111-152) was enacted. Together, they are known as the Affordable Care Act (ACA). Section 2301(a)(3)(C) of the ACA, regarding coverage for freestanding birth centers, requires state Medicaid programs to make separate payments to the birth center and practitioners for administering antepartum, labor and delivery and postpartum care (42 U.S.C.A. § 1396d(1)(3)(c)).
The Department currently pays an all-inclusive trimester payment to birth centers, which includes payment for the services provided by individual practitioners for antepartum, labor and delivery, and postpartum care.
To comply with 42 U.S.C.A. § 1396d(1)(3)(c), the Department will make separate payments to the birth center for facility services and to the practitioners who provide antepartum, labor and delivery, and postpartum care in birth centers.
Payment Methodology
The Department recognizes the importance of birth centers as part of the continuum of care for female Medical Assistance (MA) beneficiaries.
The Department obtained 12 months of cost data from the MA Program enrolled birth centers and summarized the data to determine an average reported cost per birth for both the facility and practitioner. The average reported cost per birth for the facility and practitioner were used to determine the rate of payment to both the birth center and the practitioner for providing antepartum, labor and delivery, and postpartum services in the birth center. The Department apportioned the payments currently made to birth centers based on the percentage of the birth centers costs that reflect facility costs and practitioner costs.
The new birth center facility and practitioner trimester payments are structured on a payment percentage basis similar to the trimester payments made under the MA Program's Healthy Beginnings Plus Program.
The maximum allowable payment to the birth center over the course of all three trimesters, when a delivery occurs at the birth center, will be $1,328. The maximum allowable payment to the birth center over the course of all three trimesters when a delivery occurs at the hospital will be $628.
Payments are restricted to only one practitioner per trimester. The maximum allowable payment to the practitioner over the course of all three trimesters, when a delivery occurs at the birth center, will be $1,060. The maximum allowable payment to the practitioner over the course of all three trimesters when a delivery occurs at the hospital will be $510.
The Department will pay birth centers for antepartum, labor and delivery and postpartum care on a trimester basis as follows:
• First Trimester: $149 (11% of total payment) • Second Trimester: $179 (14% of total payment) • Third Trimester:
(With Delivery at Birth Center)$1,000 (75% of total payment) • Third Trimester:
(When Delivery occurs at Hospital)$300 The Department will pay practitioners for antepartum, labor and delivery and postpartum care services provided in a birth center on a trimester basis as follows:
• First Trimester: $80 (8% of total payment) • Second Trimester: $80 (8% of total payment) • Third Trimester:
(With Delivery at Birth Center)$900 (84% of total payment) • Third Trimester:
(When Delivery occurs at Hospital)$350 Similar to the Healthy Beginnings Plus Program model, the Department will make a ''per visit'' payment to the facility and the practitioner when the beneficiary makes only a single visit, during the trimester, to the birth center. Once the beneficiary makes a second visit during the trimester, the facility and practitioner are paid the trimester package rate. The birth center facility and practitioner ''per visit'' payments are structured on a payment percentage basis similar to the percentage distribution between the facility and the practitioner trimester payments. The facility payment for a single beneficiary visit will be $24 (60% of total payment). The practitioner payment for a single beneficiary visit will be $16 (40% of total payment).
Birth centers and practitioners are to submit claims to the MA Program using the applicable procedure code, provider type/specialty and modifier combinations as follows:
Procedure Code National
DescriptionOld Birth Center MA Description Provider Specialty Place of
ServicePricing
ModifierInfo
ModifierMA
FeeMA
unitsLimits 59425 Antepartum care only; 4-6 visits First trimester OB services (Birth Center) 47 470 25 TH $149 1 1 per 1st trimester 59426 Antepartum care only; 7 or more visits First Trimester OB services (CRNP) 09 All Spec 25 TH SA $80 1 Payment restricted to 1 practitioner/
practitioner group per 1st trimester59426 Antepartum care only; 7 or more visits First Trimester OB services (physician) 31 All Spec 25 TH AF $80 1 Payment restricted to 1 practitioner/
practitioner group per 1st trimester59426 Antepartum care only; 7 or more visits First Trimester OB services (nurse midwife) 33 335 25 TH SB $80 1 Payment restricted to 1 practitioner/
practitioner group per 1st trimester59425 Antepartum care only; 4-6 visits Second trimester OB services (Birth Center) 47 470 25 U9 $179 1 1 per 2nd trimester 59426 Antepartum care only; 7 or more visits Second Trimester OB services (CRNP) 09 All Spec 25 U9 SA $80 1 Payment restricted to 1 practitioner/
practitioner group per 2nd trimester59426 Antepartum care only; 7 or more visits Second Trimester OB services (physician) 31 All Spec 25 U9 AF $80 1 Payment restricted to 1 practitioner/
practitioner group per 2nd trimester59426 Antepartum care only; 7 or more visits Second Trimester OB services (nurse midwife) 33 335 25 U9 SB $80 1 Payment restricted to 1 practitioner/
practitioner group per 2nd trimester59425 Antepartum care only; 4-6 visits Third trimester OB services with delivery at Birth Center (Birth Center) 47 470 25 U5 $1,000 1 1 per 3rd trimester 59426 Antepartum care only; 7 or more visits Third trimester OB services with delivery at Birth Center (physician) 31 All Spec 25 U5 AF $900 1 Payment restricted to 1 practitioner/
practitioner group per 3rd trimester59426 Antepartum care only; 7 or more visits Third trimester OB services with delivery at Birth Center (nurse midwife) 33 335 25 U5 SB $900 1 Payment restricted to 1 practitioner/
practitioner group per 3rd trimester59425 Antepartum care only; 4-6 visits Third trimester OB services with delivery at Hospital (Birth Center) 47 470 25 U4 $300 1 1 per 3rd trimester 59426 Antepartum care only; 7 or more visits Third trimester OB services with delivery at Hospital (CRNP) 09 All Spec 25 U4 SA $350 1 Payment restricted to 1 practitioner/
practitioner group per 3rd trimester59426 Antepartum care only; 7 or more visits Third trimester OB services with delivery at Hospital (physician) 31 All Spec 25 U4 AF $350 1 Payment restricted to 1 practitioner/
practitioner group per 3rd trimester59426 Antepartum care only; 7 or more visits Third trimester OB services with delivery at Hospital (nurse midwife) 33 335 25 U4 SB $350 1 Payment restricted to 1 practitioner/
practitioner group per 3rd trimester99211 First Trimester Individual Visit First Trimester Individual Visit (Birth Center) 47 470 25 U4 $24 1 First visit only; first trimester 99211 First Trimester Individual Visit First Trimester Individual Visit (CRNP) 09 All Spec 25 U5 SA $16 1 First visit only; first trimester 99211 First Trimester Individual Visit First Trimester Individual Visit (physician) 31 All Spec 25 U5 AF $16 1 First visit only; first trimester 99211 First Trimester Individual Visit First Trimester Individual Visit (nurse midwife) 33 335 25 U5 SB $16 1 First visit only; first trimester 99212 Second Trimester Individual Visit Second Trimester Individual Visit (Birth Center) 47 470 25 U4 $24 1 First visit only; second trimester 99212 Second Trimester Individual Visit Second Trimester Individual Visit (CRNP) 09 All Spec 25 U5 SA $16 1 First visit only; second trimester 99212 Second Trimester Individual Visit Second Trimester Individual Visit (physician) 31 All Spec 25 U5 AF $16 1 First visit only; second trimester 99212 Second Trimester Individual Visit Second Trimester Individual Visit (nurse midwife) 33 335 25 U5 SB $16 1 First visit only; second trimester 99213 Third Trimester Individual Visit Third Trimester Individual Visit (Birth Center) 47 470 25 U4 $24 1 First visit only; third trimester 99213 Third Trimester Individual Visit Third Trimester Individual Visit (CRNP) 09 All Spec 25 U5 SA $16 1 First visit only; third trimester 99213 Third Trimester Individual Visit Third Trimester Individual Visit (physician) 31 All Spec 25 U5 AF $16 1 First visit only; third trimester 99213 Third Trimester Individual Visit Third Trimester Individual Visit (nurse midwife) 33 335 25 U5 SB $16 1 First visit only; third trimester Note: The Department does not pay certified registered nurse practitioners for obstetrical deliveries.
Fiscal Impact
The payment methodology maintains budget neutrality for birth center services and does not impose any additional or new fiscal impact on the MA Program.
Public Comment
Interested persons are invited to submit written comments regarding the revised payment methodology to the Department of Public Welfare, Office of Medical Assistance Programs, c/o Regulations Coordinator, Room 515, Health and Welfare Building, Harrisburg, PA 17120. Comments received within 30 days will be reviewed and considered by the Department.
Persons with a disability who require an auxiliary aid or service may submit comments using the Pennsylvania AT&T Relay Service at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
BEVERLY D. MACKERETH,
SecretaryFiscal Note: 14-NOT-839. No fiscal impact; (8) recommends adoption.
[Pa.B. Doc. No. 13-1260. Filed for public inspection July 12, 2013, 9:00 a.m.]
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