Medicare AdvantageReimbursementHigh impact
Clarification of HealthChoice MCO Reimbursement for Specialty and Physician-Administered Drugs Provided by FQHCs and RHCs
Maryland Medicaid·MD·Managed Care Organizations
Effective date
Aug 29, 2024
We identified it
Jun 20, 2026
Summary
HealthChoice MCOs must now reimburse FQHCs and RHCs separately for drug acquisition costs (including specialty drugs, physician-administered drugs, and adult vaccines) outside of the cost-based prospective payment system rate. The cost-based rate covers only administration fees for these drugs, not the acquisition costs. Child vaccines remain covered under the Vaccines for Children program and are not reimbursed by MCOs.
Action Required
Effective immediately (August 29, 2024): Billing team must separate drug acquisition costs from administration fees on all claims to HealthChoice MCOs for FQHCs and RHCs. (1) Update billing system to bill acquisition costs for specialty drugs, physician-administered drugs, and adult vaccines as separate line items outside the cost-based rate. (2) Ensure administration fees (injections, vaccinations) continue to be included in the cost-based rate per MCO contract. (3) Remove acquisition costs for child vaccines from HealthChoice MCO claims—these are covered under the federal Vaccines for Children program. (4) Train billing and coding staff on the new split-billing requirement. (5) Contact mdh.healthchoiceprovider@maryland.gov with any questions about specific drug coverage policies. Failure to separate acquisition costs will result in underpayment or claim denials.