2016 LARC Updates: What You Need to Know for Reimbursements and Prescriptions

Date: 02/02/16

LARC Procedure Code Changes Affecting Reimbursements

On October 13, 2015, the Texas Health and Human Services Commission (HHSC) issued operational guidance to Medicaid managed care organizations (MCOs) to implement changes in order to reimburse hospitals and federally qualified health centers (FQHCs) appropriately for providing Medicaid-covered long acting reversible contraception (LARC) devices in the same amount, duration, and scope as the Medicaid benefit requires. This included adopting claims processing procedures to implement add-on FQHC reimbursement for LARC devices and hospital reimbursement for immediate postpartum LARC devices.

Effective January 1, 2016, Texas Medicaid benefit changes related to LARC were applied to support the 2016 annual Healthcare Common Procedure Coding System (HCPCS) updates. The added 2016 HCPCS procedure codes, J7297 and J7298, may be billed beginning January 1, 2016.

Procedure code J7302 was discontinued on December 31, 2015, and will no longer be reimbursed.

Procedure codes J7297 and J7298 will not require a rate hearing for pricing. Proposed reimbursement rate changes for LARC devices were presented at a public rate hearing on November 12, 2015 for procedure codes J7302 and J7302 with modifier U1. Procedure codes J7297 and J7298 will replace procedure codes J7302 and J7302 with modifier U1.  The new rates will be effective for dates of services on or after January 1, 2016.

For more information on LARC reimbursement, visit:

• Reimbursement Methodology to Change for Long-Acting Reversible Contraception (LARC) Devices Effective January 1, 2016
• Reimbursement Rate Changes for Some Procedure Codes to Be Effective November 1, 2015, and January 1, 2016, for Texas Medicaid

Please note, for dual eligible members, LARC devices and insertion of LARC devices are covered by Medicaid only and are not covered Medicare benefits. Providers are not required to submit a Medicare denial for LARC devices when seeking Medicaid reimbursement.

LARC Pharmacy Updates

On January 7, two additional LARC products were added to the Texas Medicaid and Texas Women’s Health Program (TWHP) drug formularies. Providers can prescribe and obtain LARC products that are on these drug formularies from certain specialty pharmacies for women participating in Texas Medicaid and TWHP. LARC products are only available through a limited number of specialty pharmacies that work with LARC manufacturers.  Providers who prescribe and obtain LARC products through the specialty pharmacies listed will be able to return unused and unopened LARC products to the manufacturer’s third-party processor. Providers may also continue to obtain LARC products through the existing buy-and-bill process.

The following LARC products are currently available through the Texas Medicaid benefit:

• Mirena® (NDC 50419042101)
• Skyla® (NDC 50419042201)
• Nexplanon® (NDC 0052433001) – Added on 1/7/16
• Paragard® (NDC 51285020401) – Added on 1/7/16

To view a list of specialty pharmacies, or for more information, review the Texas Health and Human Services Commission’s LARC FAQ (PDF).

Reference:  http://www.txvendordrug.com/formulary/larc.shtml

A link to the state’s LARC Toolkit is also available on the Pharmacy Resources page.