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PA Bulletin, Doc. No. 00-1868



Public Notice of Intent to Change the Payment Amount and Payment Method for the HIV-1 Viral Load Test (CPT Code 87536)

[30 Pa.B. 5576]

   The purpose of this announcement is to provide public notice of the Department's intent to change the payment amount and payment method for the HIV- 1 Viral Load Test (CPT Code 87536) to be consistent with the national limitation amount (NLA) established by the Health Care Financing Administration (HCFA) for the Medicare program.

   In June 1997, when HIV-1 Viral Load Tests were relatively new, HCFA advised State Medicaid Agencies to establish an appropriate payment amount for the HIV-1 Viral Load Test, which would assure efficiency, economy and access to this laboratory service. HCFA also advised Medicare contractors to set an interim amount for the payment of these tests. During the past 2 1/2 years, HCFA collected and examined cost and payment data relating to the HIV-1 Viral Load Test. HCFA now has used this information to establish the Medicare NLA of $117.59 for the HIV-1 Viral Load Test (CPT Code 87536) effective January 1, 2000.

   Prior to the designation of CPT Code 87536 for the HIV-1 Viral Load Test, the Department paid for HIV-1 Viral Load Testing under CPT Code 87179. The Department's method of payment for HIV-1 Viral Load Testing mirrored that of the payment method already in place for chlamydia and gonorrhea testing. Specifically, the Department paid for this testing on a ''per probe'' basis. Utilizing this method of payment, the Medical Assistance (MA) Program has been paying a maximum of $139.14 for HIV Viral Load Testing ($23.19 per probe, up to a maximum of six probes.)

   Since under Federal and State law, MA payment for laboratory services cannot exceed the Medicare NLA established by HCFA, the Department is required to change the maximum amount paid for CPT Code 87536 so as not to exceed the Medicare NLA of $117.59. Concomitantly, since there now exists a CPT Code specific to HIV-1 Viral Load Testing, the Department will stop paying for this test on a ''per probe'' basis, and will instead adopt the Medicare NLA of $117.59 for CPT Code 87536. This change will be effective November 30, 2000.

Fiscal Impact

   For Fiscal Year 2000-2001, the fiscal impact as a result of changing the payment amount for the HIV-1 Viral Load Test will be $0.107 million in total funds ($0.051 million in State General Funds and $0.056 million in Federal Funds). For Fiscal Year 2001-2002, the fiscal impact as a result of changing the payment amount for the HIV-1 Viral Load Test will be $0.256 million in total funds ($0.120 million in State General Funds and $0.136 million in Federal Funds).

Contact Person

   A copy of this notice is available for review at local County Assistance Offices. Interested persons are invited to submit written comments to the notice within 30 days of this publication. These comments should be sent to the Department of Public Welfare, Office of Medical Assistance Programs, c/o Deputy Secretary's Office, Attention: Suzanne Love, Room 515 Health and Welfare Building, Harrisburg, PA 17105-2675.

   Persons with a disability may use the AT&T Relay Service by calling (800) 654-5984 (TDD users) or (800) 654-5988 (voices users). Persons who require an alternate format should contact Thomas Vracarich at (717) 783-2209.


   Fiscal Note:  14-NOT-262. (1) General Fund; (2) Implementing Year 2000-01 is $51,000; (3) 1st Succeeding Year 2001-02 is $120,000; 2nd Succeeding Year 2002-03 is $120,000; 3rd Succeeding Year 2003-04 is $120,000; 4th Succeeding Year 2004-05 is $120,000; 5th Succeeding Year 2005-06 is $120,000; (4)  1999-00 Program--$622.669 Million; 1998-99 Program--$695.935 Million; 1997-98 Program--$662.740 Million; (7)  Medical Asisstance--Outpa-tient; (8)  recommends adoption. Funds are available in the Department's current budget to cover the costs created by this change.

[Pa.B. Doc. No. 00-1868. Filed for public inspection October 27, 2000, 9:00 a.m.]

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