Summary — HB 573: Fair Medicaid Ambulatory Surgery Center Reimbursements
Status and basic info
- Bill number: HB 573
- Short title: Fair Medicaid Ambulatory Surgery Center (ASC) Reimbursements
- Subjects: Medicaid, health services, hospitals, appropriations, insurance, public/social services
- Introduced: (per materials) Nov 12, 2024; Status: Passed 1st Reading (provided legislative history shows prior related activity in 2023–2025)
- Jurisdiction: North Carolina (text refers to NC Medicaid/Department of Health and Human Services)
Purpose and intent
- Ensure Medicaid reimbursement for services performed in licensed ambulatory surgical centers (ASCs) is set at a predictable, Medicare‑based level so ASCs receive fair payments for procedures that may not have previously been reimbursed equitably through Medicaid.
Key provisions
1. ASC reimbursement benchmark
- The Department of Health and Human Services (DHHS), Division of Health Benefits (DHB), must set and adjust rates for new ASC services so they are reimbursed at 95% of the applicable Medicare Ambulatory Surgical Centers fee schedule in effect each January 1.
2. Treatment of HCPCS code G0330 (dental/surgical)
- For HCPCS code G0330 (adopted into NC Medicaid clinical coverage on Jan 1, 2023), DHB shall not reimburse ASCs based solely on procedure length.
- As of July 1, 2023, services billed under G0330 must be reimbursed at 95% of the total payment rate shown on the Medicare Part B Hospital Outpatient Prospective Payment System (OPPS) in effect Jan 1, 2023.
- Beginning Jan 1, 2024 and each year thereafter, DHB must update the payment so it equals 95% of the Medicare Part B OPPS payment rate for that procedure (using Jan 1 of each year).
3. Mandatory coverage by Medicaid plans
- Because G0330 is treated as a surgical procedure (not a traditional dental procedure), all standard Medicaid benefit plans and the BH‑IDD tailored plans are required to cover procedures billed under G0330.
4. Appropriation / fiscal implementation
- Appropriates $500,000 recurring from the General Fund to DHHS/DHB for each year of the 2023–2025 fiscal biennium as state match to secure $950,000 recurring in federal funds per year — to implement the act.
Who is affected
- Beneficiaries: Medicaid enrollees receiving ASC procedures (including procedures billed under G0330).
- Providers: Licensed ambulatory surgical centers (payment rates and eligibility to bill for certain procedures affected).
- Payers/administration: DHHS / Division of Health Benefits (rate‑setting and program administration); Medicaid managed care plans and BH‑IDD tailored plans (coverage requirements).
- State budget: Requires recurring state funding to draw federal matching funds (specified appropriation for 2023–25 biennium).
Timeline and procedural notes
- The bill directs immediate implementation dates for the G0330 payment rule (July 1, 2023 baseline) and annual updates effective Jan 1 each year thereafter. The act is effective when it becomes law.
- Fiscal appropriation language is specific to the 2023–2025 biennium; ongoing funding needs beyond that period are not detailed in the bill text.
Potential impacts (summary)
- Providers: ASCs would receive higher and more predictable reimbursement for specified services, potentially improving access and financial viability for ASC‑delivered surgical procedures.
- Beneficiaries: May have improved access to ASC‑based surgical care covered by Medicaid plans.
- State budget: Requires a recurring state appropriation to draw federal matching funds; actual net fiscal impact depends on utilization, federal match rates, and whether the appropriation is continued beyond the specified biennium.
- Policy: Aligns Medicaid ASC payments to a Medicare benchmark (95%), standardizing reimbursement methodology and eliminating payment structures based solely on procedure length for the specified code.
If you want, I can:
- Extract the exact statutory language for the reimbursement formula and coverage requirement; or
- Draft a one‑page one‑paragraph summary suitable for newsletters or stakeholder alerts.
