Medicaid Reimbursement Survey, Washington

Transcription

1 Medicaid Reimbursement Survey, 2015 Washington

2 Washington AAP Medicaid Reimbursement Survey Survey Summary As part of its effort to monitor the impact of the Medicaid program on pediatrics, the American Academy of Pediatrics (AAP) conducts its Medicaid Reimbursement Survey periodically. The Survey, which collects state-administered fee-for-service program payment rates for commonly reported pediatric Current Procedural Terminology/CPT codes and dental codes, was most recently mailed to State Medicaid Directors in the 50 states and the District of Columbia between January 2015 and September 2015 to request payment rates effective July 1, 2015, the beginning of the fiscal year for most states. In addition, the survey requested ACA rates, in effect as of October 1, As of publication of this report, 39 states have responded to the survey. This and earlier AAP Medicaid Reimbursement Survey reports can be found at URL: In this Report... This report provides state-reported fees paid for pediatric services represented by over 150 CPT and dental codes used by state-administered fee-for-service Medicaid programs to reimburse providers. Medicaid fees are compared to Medicare where available, or to other benchmark fees (such as prices listed in the Clinical Diagnostic Lab Fee Schedule, or prices based on the Ingenix Essential RBRVS) where Medicare comparisons are unavailable. Codes are selected for inclusion in the survey based on (i) utilization, and (ii) importance to Academy priorities, such as Bright Futures and the pediatric medical home. Also included in this report are summary updates on Medicaid managed care (MMC) enrollment, state-monitoring of MMC physician reimbursement, coverage of Bright Futures benefits, and reimbursement of pediatricians for providing certain mental and preventive oral health services to children.

3 Washington AAP Medicaid Reimbursement Survey Caveats and Notes Medicaid fees shown in this report represent fee-for-service payments reported by states for stateadministered Medicaid programs at the time of the study (January, September, 2015). The rates are subject to change. Nationally, the majority of children enrolled in Medicaid programs are enrolled in managed care plans, which may or may not benchmark provider payment rates to fees shown in this report. Depending on managed care penetration levels, the impact of state-administered fee-for-service Medicaid payment rates varies by state. Unless noted otherwise, non-facility rates and enhanced payment rates for pediatric services, where available and reported by the state, are included in this report. Washington reported that reimbursement for preventive medicine services does not include immunization and/or laboratory tests, that the state provides vaccines for children through a universal immunization program, that it pays the administration fee on the product code for vaccines administered through the Vaccines for Children (VFC) program, and that it paid a vaccine adminstration fee of (a) $23.44 to self-attested physican providers eligible for the ACA Medicaid, and (b) $5.96 to non-self-attested qualifying physician providers ineligible for the ACA Medicaid payment increase. The state reported also that it paid on the actual vaccine administration code. For more information on the state's fee schedule please see the following state-provided link: Medicare rates in this report are (a) based on non-facility Medicare payment published by the Centers for Medicare and Medicaid Services for 2011, and (b) adjusted with Geographic Practice Cost Index (GPCIs) published by CMS. Certain codes, including not not limited to and , are assigned RVUs but not covered by Medicare. CPT is a trademark of the American Medical Association. Dental codes (CDT Codes) are copyright 2016 American Dental Association. Reprinted with permission. Contact Information Contact Kelly Loes, Division of Quality, for comments on this report. Contact Dan Walter or Wendy Chill, Division of State Government Affairs, for Medicaid questions and advocacy advice. Contact Elizabeth Sobczyk, Division of Pediatric Practice, for pediatric immunization questions and advocacy advice. For coding or RBRVS questions, please contact the AAP Coding Hotline at aapcodinghotline@aap.org. Suggested Citation 2015 AAP Medicaid Reimbursement Survey. American Academy of Pediatrics. Elk Grove Village, Illinois. Available for download at the AAP Website, at URL:

4 AAP BC BI/BR/IC /MP/PR BO CMS C-NP DMS FFS Washington AAP Medicaid Reimbursement Survey American Academy of Pediatrics Abbreviations Billed amount / billed charges By invoice/ by report/ individual consideration/manually priced/per review, i.e., Carrier will establish payment amounts for these services on a case-by-case basis following review of documentation, such as an operative report Bundled with other services, i.e., Payment for covered services is always bundled into payment for other services not specified. If these services are covered, payment for them is subsumed by the payment for the services to which they are incident Centers for Medicare and Medicaid Services Covered, rate not provided Department of Medicaid Services/DMS system amount paid to Public Health Departments in the state of Kentucky only. Discounted fee-for-service RVUs not published for this code in the Medicare RBRVS; values are based on the IER Ingenix Essential RBRVS. Ratio (percentage listed under %Medicare column) represents Medicaid payment as a percentage of the rate calculated using the RVUs published in the Ingenix Essential RBRVS. Amount per Clinical Diagnostic Lab Fee Schedule. Ratio (percentage listed under LFS %Medicare column) represents Medicaid payment as a percentage of the mount listed for the state in the Clinical Diagnostic Lab Fee Schedule. NA Not applicable NC Not covered Code non-eligible for Medicaid fee increase for Affordable Care Act NIS Not priced by the current Physician Fee Schedule, or RVUs not included in RBRVS Payment information specific to procedure code not listed on state Medicaid website NL or physician fee schedule. Note: absence of such information from fee schedule often indicates that the service is either not covered, or covered under alternate code(s). NP Information not provided by state in returned AAP survey OM Other method used QMB Qualified Medicare Beneficiary RBRVS Resource-Based Relative Value Scale, the physician payment schedule for Medicare RNE Rate not established RVU(s) Relative Value Unit(s), the numeric value of the resources needed to provide services according to the Resource-Based Relative Value Scale SE Data not available due to survey error.

5 List of CPT and Dental Codes Included in Report Service Type Code Description Page # Preventive Medicine Services Office and Other Outpatient Services New patient, under 1 year New patient, 1 through 4 years New patient, 5 through 11 years New patient, 12 through 17 years Established patient, under 1 year Established patient, 1 through 4 years Established patient, 5 through 11 years Established patient, 12 through 17 years Smoking and tobacco use cessation counseling; >3-10 mins Smoking and tobacco use cessation counseling: >10 mins Alcohol/substance abuse structured screening/sbi srvc; mins Alcohol/substance abuse structured screening/sbi srvc; >10 mins Administration+interpretation of health risk assessment instrument New patient, problem-focused New patient, expanded New patient, low complexity New patient, moderate complexity New patient, high complexity Established patient, nurse only Established patient, problem-focused Established patient, low complexity Established patient, moderate complexity Established patient, high complexity Screening test, hearing evaluation Tympanometry, hearing evaluation Screening test, visual acuity Ocular photoscreening Application of topical fluoride varnish by a physician or other qualified health care professional Developmental testing; limited 4 Newborn Care Initial newborn care Subsequent newborn care Admit and discharge on same day Physician attendance at delivery Newborn resuscitation Circumcision, using clamp or other device with regional dorsal penile or ring block 5 Immunizations Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component 5 Service Type Code Description Page # Immunizations Continued Evaluation and Management Non-physician Provider (NPP) Services Hospital Care Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine/toxoid component One immunization administration Each additional immunization administration One immunization administration, oral or intranasal Each additional administration, oral or intranasal Prolonged service outpatient, 1st hour, face-to-face Same as 99354, each additional 30 minutes Prolonged service, inpatient, 1 st hour, face-to-face Same as 99356, each additional 30 minutes Prolonged service, inpatient, 1 st hour, nonface-to-face Same as 99356, each additional 30 minutes Medical team conference, patient/family not present, 30 min Care plan oversight, supervision of patient in home, minutes per month Telephone evaluation and management minutes Physician to physician tele/internet consultation minutes Physician to physician tele/internet consultation minutes Chronic care management services 20 mins clinical staff time directed by a physician or other qualified health care professional, per calendar month Health and Behavior assessment; by NPP Health and Behavior re-assessment; by NPP Health and Behavior intervention; by NPP Medical Nutrition Therapy, individual, initial Medical Nutrition Therapy, individual, follow-up Initial hospitalization, per day, moderate complexity Initial hospitalization, per day, high complexity Subsequent hospitalization, per day, mod complexity Subsequent hospitalization, per day, high complexity 6

6 List of CPT and Dental Codes Included in Report (Continued) Service Type Code Description Page # Hospital Care Hospital discharge, day management, 30 min Continued 6 Pathology and Laboratory Urinalysis, non-automated with microscopy Urinalysis, non-automated without microscopy Tuberculosis, intradermal Throat culture Rapid Streptococcus screen 7 Mental Health Psychiatric diagnostic eval Psychiatric diagnostic eval w/ medical services Psychotherapy, 30 mins w/ patient/family Consultation w/ family Preparation of report Developmental testing, extended Interpretation of explanation of psychiatric or other medical exams Preparation of reports on patient s psychiatric status, history, treatment or progress Brief emotional/behavioral assessment 7 Allergy and Immunology Percutaneous tests with allergenic extracts Allergy testing, with venoms Allergy testing, with drugs or biologics Intracutaneous tests, with allergenic extracts Allergen immunotherapy, single injection Allergen immunotherapy, two or more injections 8 Cardiology Tube thoracostomy, includes water seal Cardiopulmonary resuscitation Transthoracic echocardiography Echocardiography, real-time w/ image documentation Doppler echocardiograph Right heart catheterization Left heart catheterization 8 Critical Care Intubation, endotracheal Insertion of non-tunneled center venous cathether; < 5 yrs Insertion of peripherally inserted CVC; under 5 years Arterial puncture, diagnostic Arterial line placement Critical care, first hour 8 Emergency Simple surgical removal of foreign body Care Venipuncture necessitating physician skill; < 3 8 yrs Venipuncture necessitating physician skill; >= 3 8 yrs Routine venipuncture Lumbar puncture, diagnostic ED visit, problem focused ED visit, expanded ED visit, detailed 8 Service Type Code Description Page # Gastrointestinal Upper gastrointestinal endoscopy Colonoscopy with biopsy Sigmoidoscopy with biopsy 8 Ophthalmology Strabismus surgery, horizontal Strabismus surgery, vertical Nasolacrimal probing 8 Otolaryngology Tonsillectomy/adenoidectomy, < 12 years Tonsillectomy/adenoidectomy, > 12 years Tympanostomy and tubes 8 Neonatal and Pediatric Critical Care Initial and Continuing Intensive Care Services Umbilical vein catheterization Umbilical artery catheterization Initial pediatric critical care (29d-24m) Subsequent pediatric critical care (29d- 24m) Initial pediatric critical care (2-5 yrs) Subsequent pediatric critical care (2-5 yrs) Initial neonatal critical care Subsequent neonatal critical care Initial neonatal intensive care Subsq intensive care, < 1500 gm Subsq intensive care, gm Subsq intensive care, gm 9 Plastic Surgery Cleft lip repair Cleft palate repair 9 Pulmonology Bronchoscopy Thoracentesis for aspiration Spirometry, including graphic record Inhalation treatment Continuous inhalation treatment, first hour Demonstration/evaluation 9 Radiology Frontal chest x-ray 9 Surgery Extensive clubfoot release Appendectomy Bilateral inguinal hernia, 6 mos to < 5 years Bilateral inguinal hernia, 5 years or over 9 Urology and Dialysis Renal biopsy; percutaneous, by trocar or needle ESRD services; yrs, 4+ physician visits/mo Same as above, 1 physician visits/mo Same, home dialysis for full month Peritoneal dialysis 9 Dental Services D0120 Periodic exam 10 D0145 Caries Risk Assessment 10 D1206 Topical fluoride varnish 10 D1120 Prophylaxis, child 10 D2150 Amalgam 2 surfaces, primary or perm 10 D2330 Resin-based composite 1 surface anterior 10 D1351 Sealant, per tooth 10 D2930 Stainless steel crown on a primary tooth 10 D3220 Pulpotomy 10 D7140 Extraction 10

7 AAP Medicaid Reimbursement Survey: Washington Coverage of Bright Futures Preventive Services Washington uses the periodicity schedule provided by the CDC: Washington provides an enhanced rate for EPSDT screenings Medicaid Payments for Commonly Reported Pediatric CPT TM Codes Medicaid Medicare %Medicare Current/ACA Ratio* Preventive Medicine Services New Patient, under 1 yr New Patient, 1-4 yrs New Patient, 5-11 yrs New Patient, yrs Established patient, under 1 yr Established patient, 1-4 yrs Established Patient, 5-11 yrs Established Patient, yrs Smoking and tobacco use cessation counseling; >3-10 mins $ $ $ % % $91.31 $ $ % % $ $ $ % % $95.36 $ $ % % $ $ $ % % $99.40 $ $ % % $ $ $ % % $ $ $ % % $ $ $ % % $82.06 $ $ % % $ $ $ % % $ Smoking and tobacco use cessation counseling; >10 mins $ $ % % $ $ $ % % $87.27 $ $ % % $ $ $ % % $95.65 $ $ % % NC $ $14.83 NC $ $14.93 $27.58 $ $ % % $16.41 $ $ % % 81.83% 81.90% 81.89% 81.79% 81.72% 81.95% 81.70% 81.77% 59.50% * Current/ACA Ratio = 2015 state-reported Medicaid rates divided by 2015 state-reported Medicaid rates.

8 AAP Medicaid Reimbursement Survey Report, Washington, Continued (page 2 of 10 ) Medicaid Medicare %Medicare Current/ACA Ratio* Preventive Medicine Services (Continued) Alcohol/Substance abuse structured screening/sbi srvc; min $35.43 $ $ % % $21.03 $ $ % % Alcohol/Substance abuse structured screening/sbi srvc; >10 min $69.03 $ $ % % $40.80 $ $ % % Administration+interpretation of health risk assessment instrument Office and Other Outpatient Services New patient, problem focused $43.61 $ $ % % $34.96 $ $ % % New patient, expanded $74.88 $ $ % % $59.81 $ $ % % New patient, low complexity $ $ $ % % $86.11 $ $ % % New patient, moderate complexity $ $ $ % % $ $ $ % % New patient, high complexity $ $ $ % % $ $ $ % % Established patient, nurse only $20.32 $ $ % % $16.47 $ $ % % Established patient, problem focused $43.98 $ $ % % $35.25 $ $ % % Established Patient, low complexity $73.39 $ $ % % $58.37 $ $ % % 59.36% 59.10% 80.17% 79.87% 79.49% 79.19% 79.04% 81.05% 80.15% 79.53% * Current/ACA Ratio = 2015 state-reported Medicaid rates divided by 2015 state-reported Medicaid rates.

9 AAP Medicaid Reimbursement Survey Report, Washington, Continued (page 3 of 10) Medicaid Medicare %Medicare Current/ACA Ratio* Office and Other Outpatient Services (Continued) Established patient, moderate complexity $ $ $ % % $86.11 $ $ % % Established patient, high complexity $ $ $ % % $ $ $ % % Screening test, hearing evaluation $7.15 $ $ % % Tympanometry, hearing evaluation Screening test, visual acuity $8.83 $ $ % % BO $ $ Instrument-based ocular screening,bilatera Current Rate... $4.63 NIS Application of topical fluoride varnish by a physician or other qualified health care professional Developmental screening $5.05 $ $ % % 79.52% 79.33% Washington reports that it does not pay for multiple units of on the same day, that and are bundled with the preventive service, and that 92551, 92567, 99174, and were paid separately when reported with a preventive service code. * Current/ACA Ratio = 2015 state-reported Medicaid rates divided by 2015 state-reported Medicaid rates.

10 AAP Medicaid Reimbursement Survey Report, Washington, Continued (page 4 of 10) Medicaid Medicare %Medicare TM Current/ACA Ratio* Newborn Care Initial newborn care $93.28 $ $ % % $77.44 $ $ % % Subsequent newborn care $42.65 $ $ % % $34.39 $ $ % % Admin and discharge on same day $ $ $ % % Current Rate... $93.62 $ $ % % Physician attendance at delivery $78.65 $ $ % % $42.07 $ $ % % Newborn resuscitation $ $ $ % % $87.29 $ $ % % Circumcision, using clamp or other device with regional dorsal penile or ring block NC $ $ $93.18 $ $ % % 83.02% 80.63% 78.71% 53.49% 57.93% Immunizations* Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component NC $ $27.91 NC $ $ Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each addtional vaccine/toxoid component NC $ $13.58 NC $ $ Immunization administration; one vaccine $25.46 $ $ % % $15.35 $ $ % % 60.29% Each additional vaccine $12.63 $ $ % % $7.57 $ $ % % 59.94% Immunization administration by intranasal or oral route; one vaccine NC $ $27.91 NC $ $ Each additional vaccine NC $ $13.58 NC $ $13.93 * For state-specific information on vaccine administration, please refer to the 'Caveat' section on page three of this report. ** Current/ACA Ratio = 2015 state-reported Medicaid rates divided by 2015 state-reported Medicaid rates.

11 AAP Medicaid Reimbursement Survey Report, Washington, Continued (page 5 of 10) Evaluation and Management * Medicaid Medicare %Medicare Current/ACA Ratio* Prolonged service outpatient, 1st hour, face-to-face $ $ $ % % $59.52 $ $ % % Same as 99354, each additional 30 minute $98.09 $ $ % % $58.26 $ $ % % Prolonged service, inpatient, 1st hour, face-to-face $92.26 $ $ % % $54.69 $ $ % % Same as 99356, each additional 30 minute $91.52 $ $ % % $54.27 $ $ % % Prolonged service, 1st hour, non-face-to-fac BO NIS Same as 99358, each additional 30 minute BO NIS Medical team conference, patient/family not present 30 minutes $56.80 NIS $52.58 NIS Care plan oversight, supervision of patient in home, minutes per month. NC $ $83.30 $46.69 NIS Telephone evaluation and management minutes $27.21 $ $ % % $16.20 $ $ % % Physician to physician tele/internet consultation min Physician to physician tele/internet consultation min Chronic care management services, >= 20 mins clinical staff time directed by a physician or other qualified health care professional, per calendar mont NC $ $ % 59.39% 59.28% 59.30% *State reports payments for 99490, 99447, and are bundled with the E/M code, and that 99367, 99339, and were paid separately % 59.54% ** Current/ACA Ratio = 2015 state-reported Medicaid rates divided by 2015 state-reported Medicaid rates.

12 AAP Medicaid Reimbursement Survey Report, Washington, Continued (page 6 of 10) Medicaid Medicare %Medicare Current/ACA Ratio* Non-physician Provider (NPP) Services Health and behavior assessment; by NPP $12.83 $ $ % % Health and behavior re-assessment; by NPP $12.41 $ $ % % Health and Behavior intervention; by NPP $11.57 $ $ % % Medical Nutrition Therapy, individual, initial; by NPP $21.45 $ $ % % Medical Nutrition Therapy, individual, follow-up; by NPP $18.30 $ $ % % Hospital Care Initial hospitalization, per day, moderate complexity $ $ $ % % $78.24 $ $ % % Initial hospitalization, per day, high complexity $ $ $ % % $ $ $ % % Subsequent hospitalization, per day, moderate complexity $72.28 $ $ % % $42.91 $ $ % % Subsequent hospitalization, per day, high complexity $ $ $ % % $61.63 $ $ % % Hospital discharge, day management, 30 min or less $72.84 $ $ % % $43.12 $ $ % % 56.78% 56.80% 59.37% 59.15% 59.20% * Current/ACA Ratio = 2015 state-reported Medicaid rates divided by 2015 state-reported Medicaid rates.

13 AAP Medicaid Reimbursement Survey Report, Washington, Continued (page 7 of 10) Medicaid Medicare %Medicare Pathology and Laboratory* Urinalysis, non-automated with microscopy $3.46 NIS Urinalysis, non-automated without microscopy $2.80 NIS Tuberculosis, intradermal $4.84 $ $ % % Throat culture $7.26 NIS Rapid Streptococcus screen $13.12 NIS *State reports payments for Pathology and Laboratory codes 81000, 81002, 86580, 87081, and are paid separately when reported with an E/M code. In addition, Washington requires the five tests listed in the Pathology and Laboratory section to be performed at approved facilities in order to qualify for payment. Mental Health ** Psychiatric diagnostic eval NR $ $ Psychiatric diagnostic eval w/ medical services NR $ $ Psychotherapy, 30 mins w/ patient/family NR $ $ Psychotherapy, 60 mins w/ patient/family NR $ $ Developmental testing, extended $76.77 $ $ % % Interpretation of explanation of psychiatric or other medi NR NIS Preparation of reports on patient s psychiatric status NR NIS Brief emotional/behavioral assessment SE $ $5.96 **State reports it reimburses general pediatricians for mental health code(s): In addition, Washington currently reimburses developmental/behavioral pediatric subspecialists the same rates as general pediatricians for providing the services listed above.

14 AAP Medicaid Reimbursement Survey Report, 2014/15 - Washington, Continued (page 8 of 10) Specialty Care Codes Allergy/Immunology Percutaneous tests with allergenic extracts Allergy testing, with venoms Allergy testing, with drugs or biologics Intracutaneous tests, with allergenic extracts Allergen immunotherapy, single injection Allergen immunotherapy, two or more injections Medicaid Medicare %Medicare $4.00 $ $ % % $5.05 $ $ % % $12.20 $ $ % % $4.84 $ $ % % $5.47 $ $ % % $6.31 $ $ % % Cardiology Tube thoracostomy, includes water seal $ $ $ % % Cardiopulmonary resuscitation $82.57 $ $ % % Transthoracic echocardiography $ $ $ % % Echocardiography, real-time with image documentatio $80.98 $ $ % % Doppler echocardiograph $33.44 $ $ % % Right heart catheterization $ $ $ % % Left heart catheterization $ $ $ % % Critical Care Intubation, endotracheal Insertion of non-tunneled center venous catheter; < 5 yrs Insertion of peripherally inserted CVC; under 5 year Arterial puncture, diagnostic Arterial line placement Critical care, first hour Emergency Care Simple surgical removal of foreign body Venipuncture necessitating physician skill; < 3 years Venipuncture necessitating physician skill; 3 yrs Routine venipuncture Lumbar puncture, diagnostic ED visit, problem focused ED visit, expanded ED visit, detailed $65.83 $ $ % % $ $ $ % % $ $ $ % % $18.93 $ $ % % $30.71 $ $ % % $ $ $ % % $92.12 $ $ % % $18.30 $ $ % % $10.31 $ $ % % $2.41 NIS $97.38 $ $ % % $24.40 $ $ % % $36.18 $ $ % % $68.99 $ $ % % Gastrointestinal Upper gastrointestinal endoscopy with biopsy $ $ $ % % Colonoscopy with biopsy $ $ $ % % Sigmoidoscopy with biopsy $ $ $ % % Opthalmology Strabismus surgery, horizontal $ $ $ % % Strabismus surgery, vertical $ $ $ % % Nasolacrimal probing $ $ $ % % Otolaryngology Tonsillectomy/adenoidectomy, under 12 years $ $ $ % % Tonsillectomy/adenoidectomy, over 12 years $ $ $ % % Tympanostomy and tubes $98.43 $ $ % %

15 AAP Medicaid Reimbursement Survey Report, Washington, Continued (page 9 of 10) Specialty Care Codes Neonatal and Pediatric Critical Care Umbilical vein catheterization Umbilical artery catheterization Initial pediatric critical care (29d-24m) Subsequent pediatric critical care (29d-24m) Initial pediatric critical care (2-5 yrs) Subsequent pediatric critical care (2-5 yrs) Initial neonatal critical care Subsequent neonatal critical care Initial and Continuing Intensive Care Services Initial neonatal intensive care Subsq intensive care, < 1500 gm present body weight Subsq intensive care, gm present body weigh Subsq intensive care, gm present body weigh Plastic Surgery Cleft lip repair Cleft palate repair (Continued) Pulmonology Bronchoscopy Thoracentesis, puncture of pleural cavity for aspiration initial or subsq Spirometry, including graphic record Inhalation treatment Continuous inhalation treatment, first hour Demonstration/evaluation Medicaid Medicare %Medicare $59.73 $ $ % % $39.75 $ $ % % $ $ $ % % $ $ $ % % $ $ $ % % $ $ $ % % $ $ $ % % $ $ $ % % $ $ $ % % $81.61 $ $ % % $74.04 $ $ % % $71.30 $ % % $ NIS $ $ $ % % $ $ $ % % NC $22.08 $ $ % % $11.15 $ $ % % NC $ $50.56 $10.52 $ $ % % Radiology Frontal chest x-ray $14.51 $ $ % % Surgery Extensive clubfoot release Appendectomy Bilateral inguinal hernia, 6 months to under 5 years Bilateral inguinal hernia, 5 years or over $ $1, $1, % % $ $ $ % % $ $ $ % % $ $ $ % % Urology and Dialysis Renal biopsy; percutaneous, by trocar or needle $ $ $ % % ESRD services; yrs, 4+ face-to-face physician $ $ $ % % visits/mo ESRD services; yrs, 1 face-to-face physician $ $ $ % % visits/mo ESRD services; yrs, home dialysis for full month $ $ $ % % Peritoneal dialysis $51.53 $ $ % %

16 AAP Medicaid Reimbursement Survey Report, Washington, Continued (page 10 of 10) Dental and Oral Health Services Dental codes (CDT Codes) are copyright 2006 American Dental Association. Medicaid Non-Dental Medical Provider Rate D Periodic exam $29.46 $29.46 D Caries Risk Assessment D Topical flouride varnish D Prophylaxis, child D Amalgam - two survaces, primary or permanent D Resin-based composite - one surface anterior D Sealant, per tooth D Pulpotomy D Extraction $23.41 $22.98 $69.97 $63.61 $21.98 $95.41 $57.65 $13.25 Medicaid Reimbursement for Preventive Oral Health Services Performed by Non-dental Medical Providers

17 Washington AAP Medicaid Reimbursement Survey Additional Affordabale Care Act (ACA) and Managed Care Implementation Below is additional ACA and Managed Care Implementation-related information as provided by the state: Rates shown in this report apply to payment of services for children enrolled in stateadministered medical fee-for-service (FFS) plans only. Washington state reported that only 16 percent of its Medicaid children are enrolled in its state-administered FFS plan. It should be noted, therefore, that fees in other prepaid Medicaid plans, where the great majority of Washington state Medicaid children are enrolled, may vary from ones included in this report.on methodology used to determine the Medicaid payment increase in the managed care context, Washington remarked only that quarterly payments based on managed care utilization is paid to plans to pass to providers. The state noted that it monitored MCO implementation of the payment increase by requesting payment verification from plans on a quarterly basis. It estimated federal cost to implement the payment increase at $25M for FFS and $119M for managed care. The state reported using retroactive lump sum payments to pay providers the fee increase, and noted that 70% of total outstanding retroactive lump sum payments were paid as of January 1, It estimated that 38% of claims submitted under the 8 preventive services codes ( and ) during the 4th quarter of 2014 were paid the bumped-up rate as required by the ACA.State does include detnal services as managed care. The state does not monitor plan-to-provider rates in its Medicaid managed care plans. State cannot share provider fee data due to its confiential/proprietary nature.