| Payer | Coverage | Reimbursement | Other |
|---|---|---|---|
| 1199 Health and Human Services Employees Union | Mifeprex is covered to the same extent as surgical abortion. | Providers should submit claims for Mifeprex using code W0846. Providers should use regular E&M codes for office visits. Office visits and related services should be billed separately. | Both OB/GYNs and family practitioners will be reimbursed. If a family practice physician is providing Mifeprex, but is not the primary care provider for the patient, a referral is not needed if the family practice physician is a member of the PPO. |
| 21st Century Health & Benefits | Mifeprex is covered to the same extent as surgical abortions. | Office visits are reimbursed using regular E&M codes. Providers should use S0190 for Mifeprex and S0191 for misoprostol. | Ob/gyns and family practitioners are covered. No referrals for FPs are needed. |
| Aetna US Healthcare | Mifeprex is covered to the same extent as surgical abortions. | Reimbursement for a patient’s non-primary care physician uses E/M codes for office visits; the drug is reimbursed using code J3490 and is paid based on the physician’s invoice cost. If the patient’s primary care physician is providing Mifeprex and s/he is capitated, the office visits are under the capitation. The drug cost is reimbursed separately based on the invoice cost. | OB/GYNS will not need a referral to provide Mifeprex to their patients. If an internist or family practice physician is providing Mifeprex but s/he is not the primary care provider for the patient, a referral will be needed. |
| CIGNA | Mifeprex is covered to the same extent as surgical abortion. | Mifeprex should be submitted using S0190 and misoprostol using S0191. Regular E&M codes should be used for office visits. | Family practitioners are covered. A referral is needed if a patient obtains Mifeprex from a family practitioner who is not her PCP. |
| Empire Blue Cross and Blue Shield | Mifeprex is covered to the same extent as surgical abortions. | Provision of Mifeprex will be covered as a bundled rate, which includes the office visits and the drug cost. The bundled rate for Mifeprex will be paid at the same rate for induced termination of pregnancy by dilation and evacuation. Providers can bill using one of 2 CPT codes: 59899 (unlisted procedure, maternity care and delivery) or 58999 (unlisted procedure, female genital system, non-obstetrical). If a physician uses ultrasound, the ultrasound will be billed separately. | Family practitioners and ob/gyns are covered. In the HMO plan, a referral is needed if the family practitioner is not the patient’s primary care physician. No referral is needed for the PPO plan, even if the doctor is not in network. |
| Empire Plan (not to be confused with Empire Blue Cross/Blue Shield) | Covered to the same extent as surgical abortions. | Office visits are reimbursed using regular E&M codes. Providers should use J3490 for Mifeprex and misoprostol. The J3490 code must be accompanied by a description of the medication. | |
| Excellus (Blue Cross and Blue Shield of Rochester, Central NY, Utica & Watertown | Mifeprex is covered to the same extent as surgical abortions. | Provision of Mifeprex is covered as a bundled rate including office visits and associated supplies with the HCPCS code S0199. The drugs are reimbursed separately at invoice cost using HCPCS code S0190 for Mifeprex and S0191 for misoprostol. | |
| GHI (Group Health Inc.) | Mifeprex is covered to the same extent as surgical abortions. | Office visits are reimbursed using E/M codes. The drug is reimbursed as a pass through based on the invoice cost using a local code, 4849A. | Family practitioners are not covered. |
| Great-West/One Health Plan | Mifeprex is covered to the same extent as surgical abortions. | Office visits are reimbursed using regular E&M codes. Providers should use S0190 for Mifeprex and S0191 for misoprostol. | Family practitioners are covered. A referral is needed if the family practitioner is not the patient’s primary care physician. |
| Guardian Life Insurance | Mifeprex is covered to the same extent as surgical abortions. | The office visits and associated supplies are reimbursed as a bundled rate with the code S0199. Drugs are reimbursed separately at invoice cost using code S0190 for Mifeprex and S0191 for misoprostol. | Family practitioners are covered. In the HMO plan a referral is needed if the family practitioner is not the patient’s primary care physician. In the PPO Plan, no referral is needed. |
| HealthFirst | Mifeprex is covered to the same extent as surgical abortion. | Providers should submit claims for Mifeprex using code S0190 and for misoprostol using S0191. Providers should use regular E&M codes for office visits. The drugs will be paid at the AWP. | Family practitioners are covered. No referral is needed if a patient obtains Mifeprex from a family practitioner who is not her regular PCP. |
| Healthnet | Mifeprex is covered to the same extent as surgical abortion. | Providers should submit claims for Mifeprex using code J8499. The claim form should include the name of the drug, the NDC number and the dosage. Providers should use regular E&M codes for office visits. | Healthnet will reimburse family practitioners. Under the Passport plan, if a family practitioner is providing Mifeprex, but is not the primary care provider for the patient, a referral (either prescription or telephone) will be needed. Under the Charter plan, no such referral is needed. |
| HIP | Mifeprex is covered to the same extent as surgical abortions. | Office visits should be billed using normal E&M codes and will be paid at regular office visit rates. Providers should submit claims for Mifeprex using code S0190 and for misoprostol using S0191. All other services (i.e., ultrasounds) can be submitted separately and will be paid according to the normal fee-for-service rates. | Family practitioners are not covered. |
| MVP | Mifeprex is covered to the same extent as surgical abortion. | Office visits are billed using regular E&M codes. The drugs should be submitted under J8499. | Both OB/GYNs and family practitioners will be reimbursed. If a patient visits a family practitioner who is not her regular PCP, a referral is needed or else the patient can temporarily change her PCP. MVP will not reimburse if Mifeprex is given to someone whose pregnancy is past 49 days LMP. |
| New York Medicaid | Mifeprex is covered to the same extent as surgical abortions. New York City (NYC) covers all elective abortions with 100% NYC funding; the rest of New York state covers all medically necessary abortions with 100% state funding. | Office visits in physicians’ offices are paid at the standard office visit rate of $30; for office visits to a clinic, payment will be based on the clinic visit rate of $60-$80. The drug cost will be reimbursed as a pass through based on the invoice cost. | To obtain full reimbursement for the Mifeprex regimen, 2 separate claims need to be submitted. One claim contains the office visits and other ancillary services; the second claim should be submitted for the drugs (Mifeprex and misoprostol). The drug claim is submitted using the following codes: Procedure code S0190 should be used to bill for Mifeprex and Procedure code S0191 should be used to bill for misoprostol. Diagnostic and Treatment centers should use the Referred Ambulatory Category of Service (0163) and hospital based clinics should use the Hospital Ordered Ambulatory Category of Service (0282). The total cost of the drugs should be included on the claim form. |
| Oxford | Mifeprex is covered to the same extent as surgical abortions. | Mifeprex is covered using code S0199 for the procedure, S0190 for Mifeprex and S0191 for Misoprostol. Primary care physicians, including family practitioners, can bill for the service. The mifeprex claim should include the NDC# 64875-001-03. Office visits, ultrasound, and other ancillary services are billed separately and are reimbursed based on the regular fee schedule. | |
| United HealthCare | Mifeprex is covered to the same extent as surgical abortion. | Office visits should be billed using normal E&M codes and will be paid at regular office visit rates. Providers should submit claims for Mifeprex using code J8499. All other services (i.e., ultrasounds) can be submitted separately and will be paid according to the normal fee-for-service rates. | |
| Vytra Health Plans | Mifeprex is covered to the same extent as surgical abortion. Only the Medicaid plan covers abortion. | Providers submit claims using Mifeprex NDC code: 6487500103. Mifeprex is reimbursed at full invoice price. Office visits and ultrasound are reimbursed according to fee schedule. |
New York State Medicaid Information
New York State Department of Health Office of Medicaid Management
Governor Nelson A. Rockefeller Empire State Plaza, Corning Tower Building
Albany, NY 12237
Local: 1-518-486-9057
Toll free: 1-800-541-2831
http://www.health.state.ny.us/health_care/medicaid/