Changes to the HIV Primary Care Medicaid Program

• Changes to the HIV Primary Care Medicaid Program (2006) (PDF)
  • Per 2008 NYS Ambulatory Payment Group (APG) reimbursement guidelines, the HIV Primary Care Medicaid Program is only available to Federally Qualified Health Centers (FQHCs).

This Memorandum supersedes the following Department of Health communications regarding the HIV Primary Care Medicaid Program:

1. DOHM 93-26: Reimbursement Rates for Facilities Participating in the HIV Primary Care Medicaid Program,
2. Department of Health AIDS Institute Memorandum (April 2003): Counseling Protocol and Billing Instructions for HIV Counseling and Rapid HIV Testing Visits.

Table of Contents

• Section 1: Program Description
  • Eligibility
  • Visit Descriptions
  • HIV Testing in Emergency Departments
  • Compliance with Department of Health Rules & Regulations
  • Tools and References
• Section 2: Enrollment Information
  • Enrollment Instructions
  • Department of Health/Facility Agreement
    • Part 1 - Agreement
    • Part 2 - Primary Care Information Form
• Section 3: Billing Instructions
  • Patient Eligibility
  • Rapid HIV Tests and Laboratory Services
  • Same-day Billing
    • Chart 1 - Allowable Same Day Payments
  • Utilization Limits and Medical Record Documentation Standards
    • Chart 2 - Summary of Utilization Limits and Medical Record Documentation Standards
• Section 4: Quality of Care Requirements
• Section 5: Frequently Asked Questions on Rapid HIV Testing and Prevention Services in Hospital Emergency Departments
• Section 6: Tools and Resources
• Section 7: Clinical Guidelines and Resources for Care and Clinical Training

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Introduction

In 1989, the New York State Department of Health initiated the HIV Primary Care Medicaid Program with the goal of ensuring early identification and access to quality care for persons with HIV infection. The goal has remained the same; however, the Department has revised the reimbursement structure several times over the past 17 years to respond to advances in HIV treatment and testing technology, evolving standards of care, and changes in public health policy. This memorandum and its attachments provide a comprehensive overview of the HIV Primary Care Medicaid Program, including changes in the reimbursement structure effective November 1, 2006.

2006 Changes to the HIV Primary Care Medicaid Reimbursement Structure

As of November 1, 2006, facilities enrolled in the HIV Primary Care Medicaid Program will have access to reimbursement for the following visits:

1. HIV Testing,
2. HIV Counseling without Testing,
3. HIV Counseling (Positive),
4. Initial/Annual Comprehensive HIV Medical Evaluation, and
5. HIV Monitoring.

Detailed descriptions of these visits are included in Section 1 - Program Description.

The new description for the HIV Testing visit reflects the Department's 2005 Guidance on HIV Counseling, Testing, and Laboratory Reporting Requirements, which removes barriers to integrating HIV testing into routine health care by promoting a streamlined approach to pre-test counseling and the use of a simplified Informed Consent to HIV Testing form. As of November 1, 2006, the HIV Testing Visit and the HIV Counseling (Positive) Visit may be billed by hospital emergency departments. The HIV Testing Visit may only be billed when rapid testing technology is used. This change reflects the increasing importance of emergency departments in providing HIV prevention and care services. In addition to HIV testing, EDs are front-line providers for diagnosing Acute HIV Infection (AHI) and for providing non-occupational post-exposure prophylaxis (nPEP) for persons with significant HIV exposure due to sexual assault or other sexual or percutaneous exposure.

Additional opportunities to expand HIV testing in the community were recently approved by the Department. Facilities participating in the HIV Primary Care Medicaid Program may apply to bill for HIV testing visits provided in DOH-approved part-time clinics.

The name of the HIV Post-test Counseling (Positive) Visit has been changed to the HIV Counseling (Positive) Visit. Changes to the visit description and utilization threshold reflect both the increased responsibilities of providers for reporting and partner notification under Article 21 of the Public Health Law and the emergence of prevention as a standard of clinical care for persons with HIV infection.

Two of the original program visits have been eliminated. Since streamlined post-test counseling is now recommended for patients who test negative, the HIV Post-Test Counseling (Negative) Visit (1696/2984) is no longer included in the visit structure. The Drug and Immunotherapy Visit (1698/298 6) has also been eliminated due to clinical advances in HIV care.

Renewal of the Program Agreement

The Department has revised the Agreement for the HIV Primary Care Medicaid Program to reflect these changes and others related to the elimination of training requirements for non-clnician HIV counselors and to the requirements of the AIDS Institute's nationally recognized HIV Quality of Care Program. Article 28 licensed facilities wishing to continue participation in the program must sign and return the revised agreement by January 1, 2007.

Thank you for your participation in the HIV Primary Care Medicaid Program and for your continued commitment to early identification and access to care for persons with HIV infection. If you have any questions, please contact:

HIV Primary Care Medicaid Program
Division of HIV Health Care & Community Services
New York State Department of Health AIDS Institute
Empire State Plaza, Corning Tower - Room 459
Albany, NY 12237
HIVPCMP@health.state.ny.us

Endorsements:

Guthrie S. Birkhead, M.D., M.P.H.
Director
AIDS Institute

Dennis P. Whalen
Executive Deputy Commissioner
New York State Department of Health