On January 5, the Centers for Medicare and Medicaid Services (CMS) issued a letter clarifying when Medicaid and the Children’s Health Insurance Program (CHIP) will cover interprofessional consultations between a patient’s treating practitioner and a specialist. This guidance states that the specialist’s consultation will be covered, even if the beneficiary is not present, so long as the consultation is for the direct benefit of the beneficiary.

Why it matters: This new guidance supersedes the Agency’s previous policy that prohibited coverage and payment of interprofessional consultations unless the beneficiary was present during the consultation. This is an effort to make it easier for Medicaid and CHIP beneficiaries to access specialty care.

What to know: As stated above, to be covered under Medicaid and CHIP, the interprofessional consultation must be for the direct benefit of the beneficiary. This means the service “must be directly relevant to the individual patient’s diagnosis and treatment, and the consulting practitioner must have specialized expertise in the particular health concerns of the patient.”

For coverage, both the treating practitioner and the consulting specialist must be enrolled in Medicaid or CHIP, and for consultations that cross state lines, consulting specialists must be enrolled in Medicaid or CHIP in the beneficiary’s state.

Keep in mind, this new guidance does not include Medicare, which pays separately for interprofessional consultations. Learn more.