Reimbursement Rates

NDMS Definitive Care Reimbursement Program

Reimbursement Rates for Facilities

For facilities actively participating in the Medicare program, subject to the Coordination of Benefits Guidelines, the Program will reimburse the facility at the lesser of:

1. Billed charges for covered services; or
2. 125% of the amount that the facility would be paid under Medicare Part A or Medicare Part B (excluding pass-through payment components) if the facility has executed a Memorandum of Agreement (MOA) for Definitive Medical Care with NDMS; or
3. 100% of the amount that the facility would be paid under Medicare Part A or Medicare Part B (excluding pass-through payment components) if the facility chooses not to execute a MOA with NDMS; or
4. 100% of the amount that the facility would be paid under Medicaid if the facility does not currently participate in the Medicare program or if the qualifying service is not covered under Medicare Part A or Part B but is covered under Medicaid.

Reimbursement Rates for Practitioners

For practitioners actively participating in the Medicare program, subject to the Coordination of Benefits Guidelines, the Program will reimburse the practitioner at the lesser of:

1. Billed charges for covered services; or
2. 100% of the amount that the practitioner would be paid under Medicare Part B; or
3. 100% of the amount that the practitioner would be paid under Medicaid if the practitioner does not currently participate in the Medicare program or if the qualifying service is not covered under Medicare Part B but is covered under Medicaid.

For more detailed information on specific reimbursement rate questions, please contact us at DefinitiveCare@hhs.gov​.