Center for Medicare & Medicaid Services Announces Increased Flexibilities in Medicaid E-Consult Reimbursement

On January 5, 2023, CMS published a State Health Official letter clarifying
policy on reimbursement for interprofessional consultation services in
Medicaid and CHIP. The letter outlines that interprofessional consultation is
a distinct, coverable service in Medicaid and CHIP, and that payment can be
made directly to consulting providers. This welcomed change will bring
clarity to states in adding interprofessional consultation services to their
Medicaid and CHIP programs and reinforces parity with services coverable
and reimbursable in the Medicare program.

CMS recommends states consider existing billing codes used in Medicare;
these include 99446-9 and 99451-2. Currently, many states’ Medicaid
programs do not cover treating providers’ services.
The E-Consult Workgroup recommends that states follow CMS guidance in
reimbursing both treating and consulting providers’ interprofessional
consultation services.


Direct benefit to the patient: CMS clarifies that “To be coverable under
Medicaid and CHIP, interprofessional consultation must be for the direct
benefit of the beneficiary.” This means that the consultation is directly
related to diagnosis and treatment of the beneficiary’s health concerns.
CMS also notes that interprofessional consultations should not replace a
specialty visit when such a visit would be clinically indicated.
Relationship to state plan benefits: CMS notes that interprofessional
consultations can be covered under many required and optional benefits
including physician services. Regardless of the benefit, both the treating
and consulting providers must be enrolled in Medicaid or CHIP and
licensed in the beneficiary’s state of residence.
Cost-sharing: CMS recommends states review cost-sharing policies to
avoid unexpected costs to beneficiaries. CMS also reminds states that any
cost-sharing must comply with Sections 1916 and 1916A of the Social
Security Act.
Need for a State Plan Amendment: States may need to submit a State
Plan Amendment to cover interprofessional consultations, depending on
the benefit the interprofessional consultation services are related to. The
determination of need to submit a SPA to cover interprofessional
consultations is distinct from the separate requirement, outlined below, to
submit a SPA related to payment methodology.


Need for a state Plan Amendment: States will need to submit a SPA to
CMS to add a payment methodology for interprofessional consultations.
CMS recommends states consider existing billing codes used in Medicare;
these include 99446-9 and 99451-2. States may also consider Behavioral
Health Integration and Collaborative Care Model codes that also capture
interprofessional consultations.
Same-day billing restrictions: CMS encourages states to eliminate (or
modify) prohibitions on same day billing that may impede such
consultations and the integration of behavioral and primary care. CMS in
particular notes the importance of warm hand-offs between primary care
and behavioral health providers.


Documenting provision of interprofessional consultations: States will need
to develop mechanisms to show that these consultations are provided for
the direct benefit of the beneficiary. CMS does not specifically describe
what states must require providers document, other than to note State
Medicaid Manual requirements for claims. CMS recommends states
implement oversight and monitoring policies related to documentation.

A link to the full text is available here