Section 471-1-002 - NEBRASKA MEDICAID-COVERABLE SERVICES Medicaid covers the services included and outlined in each service specific chapter in Nebraska Administrative Code (NAC) Titles 471, 473, 480, and 482. Each service must be medically necessary and appropriate, in accordance with this chapter, and any additional medical necessity requirements imposed by each service specific chapter in Title 471 NAC.
002.01NEBRASKA MEDICAID MANAGED CARE PROGRAM. Each Managed Care Organization (MCO) provides behavioral health, physical health, and pharmacy services to eligible enrolled Medicaid clients. The Dental Benefits Manager is a Pre-Paid Ambulatory Health Plan (PAHP) that provides dental services to eligible enrolled Medicaid clients. Medicaid operates Managed Care in accordance with Title 482 NAC.
002.01(A)BENEFITS. The Heritage Health plan is required to provide the services in the core benefits package as defined in 482 NAC 4, in the amount, duration, and scope as described in this chapter. The Managed Care Organizations (MCOs) and Pre-Paid Ambulatory Health Plan (PAHP) can place appropriate limits on covered services consistent with medical necessity or based on utilization control.002.01(B)PRIOR AUTHORIZATION, BILLING, AND PAYMENT. Services provided to clients enrolled in Managed Care are not billed to Medicaid. The provider will provide services only under an arrangement with the Managed Care Organization (MCO) or PrePaid Ambulatory Health Plan (PAHP), and the Managed Care Organization (MCO) or PrePaid Ambulatory Health Plan (PAHP) will make timely payment in accordance with 482 NAC 4. The prior authorization requirements, payment limitations, and billing instructions outlined in Title 471 NAC do not apply to services provided to clients enrolled in Managed Care unless otherwise stated in this chapter.002.02GENERAL REQUIREMENTS FOR ALL SERVICES. Providers must be enrolled in Medicaid for the service provided, ordered, referred, or rendered to be coverable. 002.02(A)MEDICAL NECESSITY. Services and supplies which do not meet the definition of medical necessity are not covered. For purposes of Medicaid fee-for-service and Managed Care, medical necessity is health care services and supplies which are medically appropriate and: (i) Necessary to meet the basic health needs of the client;(ii) Rendered in the most cost-efficient manner;(iii) Rendered in a type of setting appropriate for the delivery of the covered service;(iv) Consistent in type, frequency, and duration of treatment with scientifically based guidelines of national medical, research, or health care coverage organizations or governmental agencies;(v) Consistent with the diagnosis of the condition;(vi) Required for means other than convenience of the client or the physician;(vii) No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency; and(viii) Relative to the goal of improved patient health outcomes.002.02(B)PLACE OF SERVICE. Covered services in fee-for-service and Managed Care must be provided at the least expensive appropriate place of service. As deemed appropriate by Medicaid, payment for services provided at alternate places of service may either be denied, or reduced to what would have been payable at the least expensive appropriate place of service.002.02(C)EXPERIMENTAL OR INVESTIGATIONAL. Medicaid in fee-for-service and Managed Care does not cover medical services which are considered investigational or experimental or which are not generally employed by the medical profession. While the circumstances leading to participation in an experimental or investigational program may meet the definition of medical necessity, payment for these services are prohibited. 002.02(C)(i)RELATED SERVICES. Medicaid does not pay for associated or adjunctive services that are directly related to non-covered experimental or investigational services.002.02(C)(ii)INVESTIGATIONAL OR EXPERIMENTAL CRITERIA. Services are deemed investigational or experimental by the Department. The Department may convene ad hoc advisory groups of experts to review requests for coverage. A service is deemed investigational or experimental if it meets any one of the following criteria: (1) The Food and Drug Administration (FDA), or other regulatory authority, has not approved the service or treatment for general marketing to the public for the proposed use;(2) Reliable evidence does not lead to the conclusion that there is a consensus within the medical community that the service is a generally accepted standard of care employed by the medical profession as a safe and effective service for treating or diagnosing the condition or illness for which its use is proposed. Reliable evidence includes peer reviewed literature with statistically significant data regarding the service for the specific disease and age group. Also, facility specific data, including short and long term outcomes, must be submitted to the Department;(3) The service is available only through an Institutional Review Board (IRB) research protocol for the proposed use or subject to such an Institutional Review Board (IRB) process; or(4) The service is the subject of an ongoing clinical trial that meets the definition of a Phase I, Phase II, or Phase III Clinical Trial, regardless of whether the trial is actually subject to Food and Drug Administration (FDA) oversight and regardless of whether an Institutional Review Board (IRB) process is required at any one particular institution.002.02(C)(iii)DEFINITION OF CLINICAL TRIALS. For services not subject to Food and Drug Administration (FDA) approval, the following definitions apply: (1) Phase I: Initial introduction of an investigational service into humans;(2) Phase II: Controlled clinical studies conducted to evaluate the effectiveness and safety of the service being investigated; and(3) Phase III: Clinical studies to further evaluate the effectiveness and safety of a service that is needed to determine the overall risk and benefit and to provide an adequate basis for determining patient selection criteria for the service as the recommended standard of care. These studies usually compare the new service to the current recommended standard of care.002.02(D)FAMILY PLANNING SERVICES. Medicaid in fee-for-service and Managed Care covers family planning services, including consultation and procedures, when requested by the client. Family planning services and information must be provided to clients without regard to age, sex, or marital status, and must include medical, social, and educational services. The client must be allowed to exercise freedom of choice in choosing a method of family planning. Family planning services performed in family planning clinics must be prescribed by a physician, and furnished, directed, or supervised by a physician or registered nurse. 002.02(D)(i)COVERED SERVICES. Covered services for family planning include initial physical examination and health history, annual and follow-up visits, laboratory services, prescribing and supplying contraceptive supplies and devices, counseling services, and prescribing medication for specific treatment.002.02(E)SERVICES PROVIDED OUTSIDE NEBRASKA. Payment in fee-for-service and Managed Care may be approved for services provided outside Nebraska in the following situations. (1) When an emergency arises from accident or sudden illness while a client is visiting in another state and the client's health would be endangered if medical care is postponed until the client returns to Nebraska;(2) When a client customarily obtains a medically necessary service in another state because the service is more accessible; and(3) When the client requires a medically necessary service that is not available in Nebraska. 002.02(E)(i)PRIOR AUTHORIZATION REQUIREMENTS. Prior authorization in fee-for-service is required for services provided outside Nebraska when: (1) The service is not available in Nebraska; or(2) The service requires prior authorization under the applicable service specific chapter of Title 471 NAC.002.02(E)(ii)PRIOR AUTHORIZATION PROCEDURES FOR OUT-OF-STATE SERVICES. In fee-for-service, the referring physician must submit request to the Department in written or electronic form. The request must include the following information or explanation as appropriate to the case. (1) A summary evaluation by a licensed provider for the type of service rendered, and a statement indicating that the service is not available in Nebraska or is inadequate to meet the client's needs;(2) The name, address, and telephone number of the out-of-state provider;(3) An indication of whether the out-of-state provider is enrolled or is willing to enroll as a Nebraska Medicaid provider and accept the Medicaid allowable payment as payment in full for the services;(4) A description of the client's condition. The physician must certify, based on a thorough evaluation, that the services being requested are medically necessary and not experimental or investigational;(5) Identification of the physician who will be assuming follow-up care when the client returns to Nebraska;(6) Any plan for follow-up and return visits, including a timeline for the visits and an explanation of the medical necessity for the return visits;(7) If the client is requesting assistance with transportation, the type of transportation appropriate for the client's condition, and when ambulance, air ambulance, or commercial air transportation is being requested, the request must provide an explanation of medical necessity; and(8) The client's name, address, and Medicaid recipient identification number, or date of birth.002.02(E)(iii)MANAGED CARE PROVIDERS. In Managed Care, the provider must provide services only under an arrangement with the Managed Care Organization (MCO).002.02(F)SERVICES NOT DIRECTLY PROVIDED FOR TREATMENT OR DIAGNOSIS. Unless otherwise expressly allowed in Title 471, Medicaid in fee for service and Managed Care does not cover services provided to a client that are not directly related to diagnosis or treatment of the client's condition.002.02(G)SERVICES REQUIRED TO TREAT COMPLICATIONS OR CONDITIONS RESULTING FROM NON-COVERED SERVICES. Medicaid in fee-for-service and Managed Care may consider payment for medically necessary services that are required to treat complications or conditions resulting from non-covered services. Coverage of complication or conditions resulting from non-covered services will be determined at the discretion of the Department. If the services in question are determined to be part of a previous non-covered service, that is, an extension or a periodic segment of a non-covered service or follow-up care associated with it, the subsequent services will be denied.
002.02(H)DRUG REBATES. Medicaid covers prescribed drugs only if the labeler has signed a Rebate Participation Agreement with the Secretary of Health and Human Services, Centers for Medicare and Medicaid Services (CMS). 002.02(H)(i)REBATE DISPUTE RESOLUTION. In any quarter, if a manufacturer discovers a discrepancy in Medicaid utilization information that the manufacturer and the Department are unable to resolve in good faith, the manufacturer must provide written notice of the discrepancy by National Drug Code (NDC) number to the Department within 30 days of receipt of the quarterly drug rebate invoice which contains the Medicaid utilization information. 002.02(H)(i)(1)MANUFACTURER DISPUTE. If the manufacturer, in good faith, believes that the Medicaid utilization information is erroneous, the manufacturer must pay the Department that portion of the rebate amount claimed that is not disputed within 30 days after receiving the Medicaid utilization information. Following resolution of the dispute, the balance due, if any, plus a reasonable rate of interest as set forth in Section 1903(d)(5) of the Social Security Act must be paid or credited by the manufacturer or by the Department by the due date of the next quarterly payment.002.02(H)(i)(2)WRITTEN REQUEST. The Department and the manufacturer must use their best efforts to resolve the discrepancy within 60 days of receipt of notification. If the Department and the manufacturer are not able to resolve a discrepancy within 60 days, the manufacturer may file a written request for an administrative hearing under 465 NAC 6. 002.02(H)(i)(2)(a)HEARING DECISION. The hearing decision is not binding on the Secretary of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), for purposes of their authority to implement a civil money penalty provision in accordance with the statute or rebate agreement.002.02(H)(i)(3)PAYMENT ADJUSTMENTS. Adjustments to rebate payments must be made if information indicates that either Medicaid utilization information, average manufacturer price (AMP), or best price is greater or less than the amount previously specified.002.02(H)(ii)MANUFACTURER RIGHT TO APPEAL. Every manufacturer of a rebatable drug that has a signed rebate agreement has the limited right to appeal to the Medicaid Director for a hearing. This appeal right is limited to any discrepancies in the quarterly Medicaid utilization information only. No other matter relating to that manufacturer's drugs may be appealed to the Director. 002.02(H)(ii)(1)HEARING REQUEST. A manufacturer must request a hearing within 90 days of the date the Department gives notice to the manufacturer of the availability of the hearing process for the disputed drugs.002.02(H)(ii)(2)HEARING PROCEDURES. Hearings are scheduled and conducted according to 465 NAC 6.002.02(H)(iii)SUPPLEMENTAL DRUG REBATES. In addition to the requirements for drug rebates as described in this chapter. Medicaid may negotiate and contract for supplemental rebates with labelers of prescribed drugs. The negotiations and contracts may be between the labeler and the Department or an entity under contract with the Department to negotiate these supplemental rebates, including a single or multi-state drug purchasing pool. Any entity under contract with the Department will be fee based, and there will be no financial incentives or bonuses based on inclusion or exclusion of medications from the Preferred Drug List.002.02(I)REQUIREMENTS FOR WRITTEN PRESCRIPTIONS. Medicaid in fee-for-service and Managed Care will not pay for written prescriptions for prescribed drugs unless executed on a tamper-resistant pad as required by federal law. 002.02(I)(i)EXCLUSIONS. The following prescriptions and other items are not required to be written on tamper-resistant prescription pads. (1) Orders for drugs provided in Nursing Facilities, Intermediate Care Facility for clients with Developmental Disabilities (ICF/DD) facilities, and other specified institutional and clinical settings for which the drug is not separately reimbursed, but is reimbursed as part of a total service including: (a) Inpatient and outpatient hospital; (3) Telephoned, or otherwise orally transmitted prescriptions; and(4) E-prescribed, when the prescription is transmitted electronically.002.02(I)(ii)REQUIREMENTS. A written Medicaid prescription must contain at least one of the three following characteristics. (1) An industry-recognized feature designed to prevent unauthorized copying of a completed or blank prescription form, such as a high security watermark on the reverse side of the blank or thermochromic ink;(2) An industry-recognized feature designed to prevent erasure or modification of information written on the prescription by the prescriber, such as tamper-resistant background ink that shows erasures or attempts to change written information; or(3) An industry-recognized feature designed to prevent the use of counterfeit prescription forms, such as sequentially numbered blanks or duplicate or triplicate blanks.002.02(I)(iii)EMERGENCY FILLS. Medicaid will pay for emergency fills for prescriptions written on non-tamper resistant pads only when the prescriber provides a verbal, faxed, electronic, or compliant written prescription within 72 hours after the date on which the prescription was filled. In an emergency situation, this allows a pharmacy to telephone a prescriber to obtain a verbal order for a prescription written. on a non-compliant paper. The pharmacy must document the call on the face of the written prescription.002.02(J)MANAGED CARE CLIENTS. Clients participating in the Managed Care plans and Dental Benefits Manager are required to access services through their primary care provider.471 Neb. Admin. Code, ch. 1, § 002
Amended effective 11/8/2016.Amended effective 9/21/2020