Volume XXX, Number 6
Clarification on Reimbursement for GDT by MCOs
There has been some confusion regarding how Medicaid only therapy services (GDT) will be reimbursed by the MCOs. The therapy policy direction shared by HHSC indicates that the MCOs should pay either the employee rate or the contracted rate, depending on which type of therapist is providing the service.
Specifically the policy can be found in #4 “Rates: MCOs will not negotiate rates for physician ordered rehabilitative services or goal directed therapies. MCOs are directed to pay the NF (submitting a claim on a therapist’s behalf) or the contracted therapist rates as identified on the HHSC Rate Analysis website. These rates range from $37.70 to $101.39 depending on whether the therapist is an in-house/employed therapist (share same NPI/tax id as NF), or a contracted therapist.”
The Nursing Facility Implementation and Add-On Therapy Guideline can be found in the following policy direction from HHSC.
The September 5, 2014 directive from HHSC to the STAR+PLUS Managed Care Organizations states:
“Effective immediately, MCOs must modify systems and make other necessary adjustments to accommodate the following with regards to nursing facility (NF) physician ordered rehabilitative services or goal directed therapy services (a NF add-on service). This update relates only to therapy provided as a nursing facility add-on service (i.e., ancillary service provided outside of the NF unit rate/daily rate), and there are no changes to services provided as part of the NF unit rate (including therapies provided under the daily rate).
This policy direction applies only to add-on therapy services provided to NF residents, and is not applicable to other NF add-on services, including Durable Medical Equipment (DME). All other NF add-on service providers must:
Click Here to view the letter from HHSC to the STAR+PLUS Managed Care Organizations.
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