New York’s Medicaid program will begin reimbursing hospitals outside the inpatient rate for pasteurized donor human milk (PDHM). Reimbursement went into effect on December 1 for Medicaid fee-for-service (FFS) and is effective on February 15, 2018, for Medicaid managed care (MMC) plans. PDHM coverage is only available for infants with a birth weight of under 1,500 grams or a condition that places them at high risk for developing necrotizing enterocolitis and/or an infection, and where maternal breast milk or breast feeding is not possible. To provide PDHM, hospitals must have a tissue bank license that includes human milk.
Hospitals can bill and be paid for PDHM at the actual acquisition cost for Medicaid FFS patients. MMC plans must also cover PDHM, but billing and payment procedures are determined by individual plans. Hospitals should check with the plans for billing and payment information.