Pursuant to 42 C.F.R. §447.205, the Department of Human Services (“Department”), Bureau for Medical Services (“BMS”) provides notice of the filing of a state plan amendment (SPA), identified as SPA 25-0006, regarding Drugs Reimbursed Outside of the DRG methodology.
SPA 25-0006 ensures that drugs such as Casgevy™ and Lyfgenia™ provided in the inpatient hospital setting are reimbursed separately from the DRG bundled payment for inpatient hospital services. Changes to the State Plan are drafted in Attachment 4.19-A (Reimbursement for Inpatient Hospital Services) and Attachment 4.19-B (Payments for Medical and Remedial Care and Services).
This SPA will have an effective date of January 1, 2026, pending CMS approval. There is no expected increase in Medicaid expenditures at this time.
This SPA will be available for public comment on the WV BMS website under the public notices tab at this link between November 7, 2025 and December 7, 2025.
Written comments may be sent between the above referenced dates to the West Virginia Department of Human Services, Bureau for Medical Services, 350 Capitol Street, Suite 251, Charleston, WV 25301-3706, or by email at SPAComments@wv.gov .
Any written comments received will be available for review at the above address during normal business hours, 8:30 a.m. to 4:30 p.m.
SPA 25-0006 Drugs Reimbursed Outside of the DRG Methodology 4.19A
SPA 25-0006 Drugs Reimbursed Outside of the DRG Methodology 419.B
SPA 25-0006 Public Notice
