Section 471-11-003 - SERVICE REQUIREMENTS NMAP reimburses IHS facilities for inpatient and outpatient services at the Medicare/Medicaid rates established by the federal Department of Health and Human Services (HHS).
Rate changes are effective the first day of the month following the Department's receipt of the Medicare Interim Rate Notice. Because specific Medicare/Medicaid rates are used and there is 100 percent federal match of these costs, NMAP will not make an end-of-year settlement for Indian Health Service facilities.
003.01 General Requirements 11-003.01A Eligibility: Medically necessary services will be made available to any Indian, as that term is defined herein, who is also determined to be eligible for Medicaid in accordance with Title 477 of the Nebraska Administrative Code.11-003.01B Services Provided for Clients Enrolled in the Nebraska Medicaid Managed Care Program: See 471 NAC 1-002.01.11-003.01C HEALTH CHECK (EPSDT) Treatment Services: See 471 NAC Chapter 33.11-003.01D Copayments / Cost Sharing: American Indians or Alaskan Natives who are eligible for, and have received, Medicaid covered services from an IHS or Tribal (638) facility shall be exempt from all copayment and cost sharing obligations.003.02 Covered Services 11-003.02A Scope of an Encounter An encounter includes:1. A practitioner visit which may be a: a. Physician, doctor of osteopathy, physician assistant, nurse practitioner, or certified nurse midwife;f. Speech, audiology, physical or occupational therapist;g. Mental health provider such as a psychologist, psychiatrist, licensed mental health practitioner, certified drug and alcohol counselor, or a certified nurse practitioner providing psychotherapy or substance abuse counseling or other treatment with family and group therapy; or,2. Diagnostic services such as: c. Psychological testing; or,d. Assessment (mental health)3. Supplies used in conjunction with a visit such as dressings, sutures, etc.;4. Medications used in conjunction with a visit such as an antibiotic injection; and,5. Prescribed drugs dispensed as a part of the encounter. 11-003.02B Encounters: Visits with more than one health professional, and multiple visits with the same health professional, that take place during the same day within the IHS or Tribal (638) facility constitute a single encounter. 11-003.02B1 Exceptions: a. When the patient is seen in the clinic, or by a heath professional, more than once in a 24-hour period for distinctly different diagnosis. Documentation must include unrelated diagnosis codes;b. When the patient must return to the clinic for an emergency or urgent care situation subsequent to the first encounter that requires additional diagnosis or treatment;c. When a patient requires a pharmacy encounter in addition to a medical health professional or mental health encounter on the same day. Medicaid covers only one pharmacy encounter per day; or,d. When the patient is seen in the clinic by a clinical social worker or psychologist for a mental health encounter in addition to a medical health professional encounter on the same day.003.03 Non-Encounter Services Services rendered outside the office setting, office services that do not meet the criteria for the encounter, non-IHS Facility services, pharmacy services that are not provided by a designated tribal pharmacy or pharmacist, or services provided to non-American Indian or non-Alaskan Native clients. Examples of non-encounter services include, but are not limited to: Inpatient hospital visits, home and nursing facility visits, home health visit, durable medical equipment, ambulance, brief visit with nurse for blood pressure check, telehealth or telephone consultations.
471 Neb. Admin. Code, ch. 11, § 003