Medicaid Add-on Payment for LAI Antipsychotic Drugs

MEMORANDUM

On Sept. 19, the Illinois Dept. of Healthcare and Family Services issued a Provider Notice informing hospitals of a new add-on payment to psychiatric inpatient claims for certain long-acting injectable (LAI) antipsychotic drugs, effective retroactively for dates of service beginning Jan. 1, 2022.

IHA worked with the Department to implement the new payment, required by IHA-supported Public Act 102-0043 and 89 Ill. Admin. Code section 148.110, and successfully advocated to expand provider eligibility. This advocacy follows member hospital feedback that supported separate payment for LAI antipsychotic drugs, in order to improve patient access to these medications in hospital inpatient psychiatric settings. PA 102-0043 extends this add-on payment to LAI substance use disorder drugs, which the Department plans to implement separately at a future date.

The add-on is applicable to both Medicaid fee-for-service (FFS) and HealthChoice Illinois managed care organization (MCO) claims. Specific LAI antipsychotic drugs covered and associated codes for billing are detailed in the notice. To be eligible for payment, the following criteria must be used by providers for both FFS and MCO customers:

  • As detailed in the Public Act, prior approval must be sought through the Medicaid FFS program or the MCO;

  • The prescriber must be a board-certified psychiatrist or a board-eligible psychiatrist, as outlined in the notice. The Department proposed in rule that only board-certified psychiatrists receive payment, and IHA advocacy resulted in payment expansion to board-eligible psychiatrists;

  • The LAI atypical antipsychotic drug prior approval will follow the Food and Drug Administration’s (FDA) approved labeling for the indication for each medication; and

  • The prescriber must coordinate a follow-up outpatient appointment for administration of the next recommended dose of the LAI atypical antipsychotic agents and provide documentation of the follow up appointment with request for prior approval.

Contact IHA with questions.