Alabama MedicaidAlabama Medicaid

K lli Littl j h N Ph DKelli Littlejohn Newman, PharmDDirector

Clinical Services

ObjectivesObjectives

• Medicaid Transformation

• RCO Overview

• Current Pharmacy InitiativesPrescription Limit for Adults- Prescription Limit for Adults

- 3 month supply - Professional Services- Professional Services- Tobacco Cessation Counseling

Pregnant Femalesg

Regional Care Organizations: M di id R fMedicaid Reform

• The state of Alabama has established a new t f h lth fi i d isystem of healthcare financing and service

delivery for a subset of Medicaid recipients

• The goal is to improve care and reduce cost• The goal is to improve care and reduce cost that would otherwise be incurred through the existing fee-for-service system

• The strategy is to establish a capitated managed care system through regional care organizations (RCOs)

• An RCO is a corporate entity established under state law that is governed by a Board of Directors representing providers the publicDirectors representing providers, the public and investors

What’s in the RCO law?What s in the RCO law?Recap:

• Law enacted during 2013 Legislative Session; Law enacted during 2013 Legislative Session; changes made by 2014 Legislature

• Dental and long term care carved out for now

• Long term care and dental evaluations due 10/1/15

• Anti trust / collaboration requirements• Anti-trust / collaboration requirements

• Board composition outlined

Timeline for implementation• Timeline for implementation

• Medicaid will enroll recipients into RCOs– Recipient choice or assignment if no p g

choice is made

• Quality Assurance Committee required

Modifications in 2014 R i iRevision

Change in governing board– Board actions no longer require consent of at leastBoard actions no longer require consent of at least

one primary care physician– Primary care physicians previously selected by

caucus of county boards of health, now selected by MASAby MASA

Allows creation of executive committee– Executive committee limited to implementing

governing board policygoverning board policy– Primary care physician must be a member of all

committees– All risk-bearing classes given a seat on executive g g

committee

Establishes reimbursement floorCreates provider standards committee at RCO levelCreates provider standards committee at RCO level

– Must be 60% physician membership– Metrics subject to review of Q/A committee

Modifications in 2014 R i iRevision

• Establishes extensive provider pgrievance process

• Requires Medicaid consider qprovider input in renewal decisions

• Assures Medicaid right to review ll t tall contracts

• Allows one entity to have a j it f th i b dmajority of the governing board

only if no other entity offers to bear risk

Medicaid on schedule to l i h lcomply with law

• 10/1/13 – Medicaid established RCO regions

• 10/1/14 – RCO governing boards approved by Medicaid

• 4/1/15 – RCOs must prove they have an adequate provider network• 10/1/15 RCO must meet solvency• 10/1/15 - RCO must meet solvency requirements• 10/1/16 - RCO must demonstrate ability to yprovide services under a risk contract (RCOs start bearing risk) no later than this date

Current ProgressCurrent Progress• Regions established• New rules filed• 1115 waiver is being drafted• Quality Assurance Committee working on metrics

• One Health Record® pilot project approvedEast Alabama pilot project to test benefits of– East Alabama pilot project to test benefits of

EHR and HIE data exchange for patients and providers

Covered services and populations identified• Covered services and populations identified

• Working with actuary• Implementation vendor under contract• Implementation vendor under contract

RCO Regions EstablishedRCO Regions Established

R i d ith thRegions drawn with these considerations:

•Honor existing referral gpatterns•Keep health systems together when possibleAllow more than one•Allow more than one

RCO per region

Covered PopulationsCovered Populations

Approximately two-thirds of MedicaidApproximately two thirds of Medicaid population are projected to enroll in

RCOs:

Populationsp• Covered populations– Aged, blind & disabled recipients– Breast and Cervical Cancer Treatment Program– Breast and Cervical Cancer Treatment Program participants– Recipients of Medicaid for Low Income Families (MLIF)( )– SOBRA children and adults

• Excluded populationsM di /d l li ibl– Medicare/dual eligibles

– Foster children– Hospice patients– ICF-MR recipients– Nursing home/institutional recipients– Plan 1st and unborn recipients– Home and Community-Based Services waiver recipients

Covered PopulationCovered Population

RCO Covered ServicesRCO Covered Services• Some of the services to be covered by RCO:– Hospital inpatient and outpatient care– Emergency Room– Primary and Specialty Care– FQHCs/RHCs– Lab / Radiology– Mental/Behavioral Health/Substance Abuse– Pharmacy– Eye Care– Maternity– Maternity

• Long term care and dental services are excluded nowexcluded now

RCO Critical Success FFactors

• State funding must meet current operational needs.

• Medicaid must demonstrate that RCO, full risk strategy is less costly than current systemstrategy is less costly than current system.– Actuarial sound rates– Must be approved by CMS

• CMS must approve 1115 Waiver with Designated State Health Program (DSHP) matching and approve the resulting federal funds for the transformation with acceptable conditions.

• Probationary RCOs must transition to• Probationary RCOs must transition to operationally effective entities that can accept risk/capitation.

RCO WebsiteRCO Websitehttp://www.medicaid.alabama.gov

RCO Web Page:• Collaboration information Collaboration information• Applying for Certificate• Reporting of Activities• Links to proposed and Links to proposed and final rules• District map• 1115 waiver concept paper 1115 waiver concept paper• QA Committee activity and webinars• Legislation• Legislation• Presentations

Pharmacy OverviewPharmacy Overview

FY13 statsFY13 stats• 610,836 pharmacy recipients• Approx 8 9mill claimsApprox 8.9mill claims• $566 mill expenditure (total dollars)• 87% generic/OTC utilization• 87% generic/OTC utilization

(85% current)Avg claim cost $70 48• Avg claim cost $70.48

(B$318 / G$26 / O$39)

Prescription LimitPrescription Limit• Adults only (21 years and older)• Children and LTC recips excluded• 5 rxs per month• Allowances up to 10 rxs per month*• Allowances up to 10 rxs per month

– Antipsychotics– Antiretrovirals– Antiepileptics

• 3 month supply meds excluded*Switchovers• Switchovers

• Reverse claims/generics/PAPs*

*website

3 Month Supply3 Month Supply

• MandatoryMandatory • Maintenance medications*• Does NOT count toward rx limit• Does NOT count toward rx limit• Stable therapy (60 days in past 90)• One copay, one disp fee• Opt out available/clinical justification• New rx required to change qty

*website

Current Professional S iServices

• Vaccine AdministrationVaccine Administration- pneumococcal

Td- Tdap• Reimbursement is $5 per

administration with no dispensing fee or co-pay applied

• Coordination of Care (form)• State law (rx)State law (rx)

Tobacco Cessation Counseling P t F lPregnant Females

• ACA: Face-to-face counselingACA: Face to face counseling services must be provided:– by or under the supervision of a

physician; or– by another health care professional

who is legally authorized to furnishwho is legally authorized to furnish such services under State law within their scope of practice and who is authorized to provide Medicaidauthorized to provide Medicaid covered services other than tobacco cessation services

Tobacco Cessation Counseling P t F lPregnant Females

• Reimburse up to 4 face- to-faceReimburse up to 4 face to face counseling sessions in a 12-month period

• Reimbursement period = prenatal period through the postpartum p g p pperiod (60 days after delivery or pregnancy end)

• Pharmacies= MUST BILL through DME NPI

Tobacco Cessation Counseling P t F lPregnant Females

The following CPT Codes are applicable:99406 S ki d t b ti li– 99406—Smoking and tobacco use cessation counseling visit; intermediate, greater than three minutes up to 10 minutes ($8.60)

– 99407—Smoking and tobacco use cessation counseling visit; intensive greater than 10 minute ($17 12)visit; intensive, greater than 10 minute ($17.12)

The following diagnosis codes must be billed on the claim (UB-04 or CMS-1500 claim form):( )

V220-V222: Normal pregnancyV230-V233: Supervision of high-risk pregnancyV2341-V237: Pregnancy with other poor b t t i hi tobstetric history, or

V242: Routine postpartum follow-up

AND3051—Tobacco use disorder

FAQ: Cash v MedicaidFAQ: Cash v MedicaidCan a Medicaid recipient pay cash f “l ft ” d th i tfor “leftover” meds on the script (controls over #68/month)?

ANSWER:

Yes, ONLY (emphasis added) if a max unit override has been filed a u o e de as bee edand denied….

(MORE NEXT SLIDES)( )

FAQ: Cash v MedicaidFAQ: Cash v Medicaid• If the prescription to be paid by Medicaid exceeds

the drug’s maximum unit limit allowed per month, the prescriber or pharmacist must request an p p qoverride for the prescribed quantity.

• If the override is denied, then the excess quantity above the maximum unit limit is non-covered and th i i t b h d h i i t fthe recipient can be charged as a cash recipient for that amount in excess of the maximum unit limit.

• A prescriber should not write separate prescriptions one to be paid by Medicaid andprescriptions, one to be paid by Medicaid and one to be paid as cash, to circumvent the override process.

• A provider's failure or unwillingness to go throughA provider s failure or unwillingness to go through the process of obtaining an override does not constitute a non-covered service.

Provider Billing Manual, Chapter 27, PharmacyProvider Billing Manual, Chapter 27, Pharmacy Services, 27.2.3 Quantity Limitations

FAQ: Cash v MedicaidFAQ: Cash v MedicaidPharmacy Quantity Limitations and Controlled Substances • The pharmacist or prescriber must request an

override when the prescription exceeds Medicaid’s maximum limit allowed per month.

• The prescriber should not write separate prescriptions, one to be paid by Medicaid and one to be paid as cash, to circumvent the override processprocess.

• For further information on pharmacy quantity limitations and prescriptions for controlled substances refer to Chapter 27 section 27 2 3substances, refer to Chapter 27, section 27.2.3 “Quantity Limitations”.

Provider Billing Manual Physician Chapter 28 2Provider Billing Manual, Physician Chapter, 28.2 Benefits and Limitations

Contact InformationContact InformationHealth Information Designs (PAs)

(800) 748-0130(800) 8 0 30

Hewlitt Packard (HP) Claims ProcessingClaims Processing

(800) 456-1242

RECIPIENT HOTLINE(800) 362-1504

FRAUD Hotline(866) 452-4930

Contact InformationContact Information

Pharmacy Services (334) 242-5050

Kelli Littlejohn Newman, Pharm DDirector, Clinical Services and Support

Alabama Medicaid Agency(334) 353-4525

kelli littlejohn@medicaid alabama govkelli.littlejohn@medicaid.alabama.gov

www medicaid alabama govwww.medicaid.alabama.gov