Monroe Plan IPA and YourCare IPA Network Providers
As per your agreement with Monroe Plan for Medical Care or YourCare IPA, we are excited to bring you the latest updates to the Community Based Fee Schedules for services provided to Molina Healthcare of New York Medicaid Managed Care, HARP, Child Health Plus, and Essential Plan members.
Community Fee Schedule
The Community Fee Schedule for professional services in all counties and regions covered by your agreement will be updated to cover all codes in the CMS RBRVS Medicare Fee Schedule. Administrative fees paid for all vaccines and injectables are included in the Professional Community Fee Schedule.
Laboratory Services
Per current processing and payment methodologies lab services rendered will be paid at 100% of the prevailing New York State Medicaid Laboratory fee schedule rates.
View 2024 details here
The Community Fee Schedule for professional services in all counties and regions covered by your agreement will be updated to cover all codes in the 2023 CMS RBRVS Medicare Fee Schedule.
Please refer to the posted fee schedules in order to review the 2024 pricing by code as there are significant increases for in-office services rendered. Please note that codes that are billed and not included in the posted CPT-4 code set, but are included in the 2024 CMS code set, will be paid at the same percentage rates as 2023 codes based on place of service (Facility or Non-Facility). Mid-level reimbursement will continue to be paid at 85% of the supervising physician rates.
Vaccine and Injectable Reimbursement
Immunization administration fees paid for all vaccines and injectables are included in the Professional Community Fee Schedule. Vaccine and injectables not provided to the office through the Vaccine For Children’s Program (VFC) will be reimbursed at the Average Sales Price (ASP). ASP codes and rates for injectable drugs and vaccines will be updated on a quarterly basis
Click here to download
View 2024 details here
Per current processing and payment methodologies lab services rendered will be paid at 100% of the prevailing New York State Medicaid Laboratory fee schedule rates.
In addition, as previously notified and to mirror NYS Medicaid billing guidelines, the information below is applicable to payment rates when modifiers are used by your office for lab services:
- Modifier 26 / Professional Component: Lab procedures are a combination of a physician component and a technical component. When the professional component, only, is performed and reported separately, the service may be identified by adding the modifier “26” to the procedure number. Reimbursement will then equate to 40% of the maximum global Community Lab Fee Schedule amount.
- Modifier TC / Technical Component: When the technical component, only, is performed and reported separately, the service may be identified by adding the modifier “TC” to the procedure number. Reimbursement will then equate to 60% of the maximum global Community Lab Fee Schedule amount.
- If no modifier is included with the laboratory code billed, then the full global fee as reflected in the community-based fee schedule will be reimbursed.
Anesthesia Services
Anesthesia Services will be reimbursed at 100% of the CMS Medicare based rate utilizing posted base and time units multiplied by the final CMS Medicare conversion.
Durable Medical Equipment
Per current processing and payment methodologies Durable Medical Equipment (DME) rates will be paid at 100% of the prevailing New York State Medicaid Durable Medical Equipment fee schedule rates.
View 2024 details here
Anesthesia Services will be reimbursed at 100% of the CMS Medicare based rate utilizing posted base and time units multiplied by the final 2024 CMS Medicare conversion factor posted for Upstate New York ($19.77). The base unit schedule will be posted on the IPA’s website as referenced above.
When pain management services are provided by Anesthesiologists (physician or midlevel) and a CPT-4 code is billed the reimbursement rate will be the same as reflected in the 2024 Professional Provider Services Community Fee Schedule.
View 2024 details here
Per current processing and payment methodologies Durable Medical Equipment (DME) rates will be paid at 100% of the prevailing New York State Medicaid Durable Medical Equipment fee schedule rates. If a valid DME code is billed and does not appear on the NYS Medicaid fee schedule, then the claim will be denied, and the provider must appeal the denial by submitting the invoice and appropriate prior authorization documentation. If the denial is reversed, then the provider will be reimbursed at invoice cost plus 30%.