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New Medicaid Rates Announced
June 14, 1999

PCPA has reached agreement with the Department of Public Welfare for new outpatient psychiatric clinic, D&A outpatient, and partial hospitalization rates effective July 1, 1999. The following rates have been agreed upon.

Services

Code

Current Rate

New Rate

MH Individual Psychotherapy W9801 $12.50/per 1/2 hour $26.00/per 1/2 hour
MH Group Psychotherapy W0981 $6.00/per hour/person $7.00/per 1/2 hour/person
(1 hour minimum)
MH Family Psychotherapy W0983 $12.50/per 1/2 hour $26.00/per 1/2 hour
MH Collateral Family Psychotherapy W0984 $12.50/per 1/2 hour $26.00/per 1/2 hour
Psychiatric Evaluation W0987 $35.00 $75.00
MH Medication Check W1855 $6.00/per 1/4 hr visit $15.00
Licensed Adult Psychiatric Partial Hospitalization W0860 $8.50/per hour (adult) $14.00/per hour (adult)
Licensed Adult Psychiatric Partial Hospitalization W0861 $8.50/per hour (child) $15.00/per hour (child)
Licensed Children's Psychiatric Partial Hospitalization W0864 $9.50/per hour (adult)
Licensed Children's Psychiatric Partial Hospitalization W0865 $9.50/per hour (child) $15.00/per hour (child)
D&A Individual Psychotherapy W9801 $15.00/per 1/2 hour $26.00/per 1/2 hour
D&A Group Psychotherapy W0981 $6.00/per hour/person $7.00/per 1/2 hour/person
(1 hour minimum)
D&A Family Psychotherapy W0983 $15.00/per 1/2 hour $26.00/per 1/2 hour

MA Copayment
As you know, Kirkpatrick & Lockhart, LLP (K&L) represented PCPA in this litigation. We have consulted with K&L regarding the effect of the new Medical Assistance (MA) rates on required MA copayments. K&L provided us with the following summary of the regulations.

Copayments fall into three categories under DPW regulations: (1) no copayment required, (2) copayment based upon the number of units of service, and (3) copayment based upon amount of MA fee. The services that fall into the third category are the only services affected by an increase in the MA fee.

Partial hospitalization falls into the first category; that is, DPW regulations do not require a copayment for this service. See 55 Pa. Code 1101.63(b)(2)(xi). The copayment for outpatient psychotherapy services for all patients other than General Assistance (GA) recipients, ages 21-65, whose MA benefits are funded solely by State funds, falls into the second category. The copayment is based upon the number of units of psychotherapy service provided. See 55 Pa. Code 1101.63(b)(5)(v).

Under the regulations, copayments for psychiatric evaluations, medication checks and all services for GA recipients, ages 21-65, whose MA benefits are funded solely by State funds are based upon the amount of the MA fee. See 55 Pa. Code 1101.63(b)(5)(vi), 1101.63(b)(6)(iv).

You are encouraged to confer with your local counsel to discuss how the increases in the MA fees will affect the amount of the copayments for services provided by your agency.

MA Billing Procedures
DPW regulations establish that MA shall pay providers, practitioners or clinics rendering outpatient services the lowest of:

  1. The provider's usual charge to the general public for the same service;
  2. The MA maximum allowable fee;
  3. A maximum reimbursement limit of $500 per day unless the outpatient procedure has a fee which exceeds $500, in which case the fee is the maximum reimbursement on a daily basis.

55 Pa. Code 1150.51(f)(1). Outpatient psychiatric clinics, outpatient drug and alcohol clinics and outpatient psychiatric partial hospitalization programs are required to "[p]ost a current written fee schedule for billing third party and private payors." 55 Pa. Code 1153.41(4), 1223.41(4). Moreover, an enrolled provider "may not, either directly or indirectly... [s]ubmit a claim for a service or item at a fee that is greater than the provider's charge to the general public." 55 Pa. Code 1101.75(a)(9). In light of these regulations and the revised fee schedule, the following steps are recommended:

  • Every provider should review its current posted fee schedule. In particular, providers that base their charges to the private paying public or third party payors on the MA fee schedule should consider whether changes to their posted fee schedule are needed.
  • Posted fee schedules should be amended to reflect adjustments, if any, to the provider's charges to the private paying public or third party payors.
  • Providers should review their current billing practices in order to ensure that the Medical Assistance claim form, MA 319, or any other billing program is adjusted accordingly. Providers should ensure that any procedure charge adjustments are accurately reflected when billing, e.g. block 29N (Usual Charge) on the MA 319 form. The MA Handbook for outpatient psychiatric services states that block 29N should reflect a provider's "usual charge to the self-paying public for the service(s) provided."

PCPA thanks McBee Associates for the analysis of this issue.

Copies of 55 PA Code relating to MA Copayment and Billing Procedures is available to Association members in the Members Only section of this web site.

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