PDF Version
TO: All Providers
RE: COVID-19 Unwinding: Changes to Services
Per
federal guidance, the phase down for funds related to the COVID-19 public
health emergency (PHE) ends on September 30, 2024. Therefore, some
flexibilities the Alabama Medicaid Agency (Medicaid) implemented due to the
COVID-19 PHE will end at that time. Effective October 1, 2024:
- Pregnant adult
recipients (ages 21 and older) will only be eligible for dental benefits during
pregnant through the end of the month of 60 days postpartum when rendered
by enrolled dental providers.
- At-Home
over-the-counter (OTC) COVID-19 Diagnostic Tests from a pharmacy will no longer
be covered. Medicaid recipients may
still be tested for COVID-19 through a physician office or clinic.
- COVID-19 vaccine
administration reimbursement will change from $40 to $8 per administration.
This applies to pharmacy and non-pharmacy providers.
- COVID-19 vaccine
counseling reimbursement will change from $31.70 to $13.00. This applies to
pharmacy and non-pharmacy providers.
- All non-COVID vaccine
administration reimbursement will change from $5 to $8 per administration. This
applies to pharmacy and non-pharmacy providers.
- Copayments for Medicaid covered
services will be reinstated. The amounts are based on
the federally approved maximum amounts and are shown below (including Medicare
crossovers):
|
Services with Copayments
|
Copayment Amounts
|
Based on Medicaid’s Allowed Amount for the Services
|
|
Office Visits (including visits to physicians, optometrists, nurse practitioners)
|
$0.65 to $3.90 per office visit
code
|
$50.01 or more - $3.90
$25.01 - $50.00
- $2.60
$10.01 - $25.00
- $1.30
$10.00 or less - $0.65
|
|
Federally Qualified Health Centers (FQHC)
|
$3.90 per encounter
|
|
|
Rural Health Clinic
(RHC)
|
$3.90 per encounter
|
|
|
Inpatient Hospital
|
$50.00 per admission
|
|
|
Outpatient Hospital
|
$3.90 per visit
|
|
|
Ambulatory Surgical Centers
|
$3.90 per
visit
|
|
|
Durable Medical Equipment/
Medical Supplies and Appliances
|
$0.65 to $3.90 per line item
|
$50.01 or more - $3.90
$25.01 - $50.00
- $2.60
$10.01 - $25.00 - $1.30
$10.00 or
less - $0.65
|
|
Prescription Drugs
|
$0.65 to $3.90 per prescription
|
$50.01 or more - $3.90
$25.01 - $50.00 - $2.60
$10.01 - $25.00 - $1.30
$10.00 or less - $0.65
|
- Copayment does not apply to services provided
to/for:
- Pregnant women
- Nursing facility
residents
- Recipients less than 18 years of age
- Native American
Indians with an active user letter from Indian Health
Services (IHS)
- Emergencies
- Family Planning
- Vaccines and vaccine administration
A provider may not deny services to any eligible Medicaid
recipient because of the recipient’s inability to pay the
cost-sharing (copayment) amount imposed.
Please continue to visit
the Alabama
Medicaid website for up-to-date information related to
the ‘unwinding’ process. If you have questions, please contact the
Provider Assistance Line at (800) 688-7989.
The Current Procedural Terminology (CPT) and Current Dental Terminology (CDT) codes descriptors, and other data are copyright © 2024 American Medical Association
and © 2024 American Dental Association (or such other date publication of CPT and CDT). All rights reserved. Applicable FARS/DFARS apply.