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Pharmacies’RoleinthePASSEModel
Speakers:Jennifer Morales, MPHMedical Assistance Manager, DHS Division of Medical Services
Cynthia Neuhofel, Pharm. D.Program Administrator, DHS Prescription Drug Program
• The Provider-led Arkansas Shared Savings Entity (PASSE) is a model of organized care created by Act 775 of 2017.• Providers have entered into partnerships with each other along with
an experienced organization that performs administrative functions similar to insurance companies• Under Act 775, the governing body of each PASSE must include
several types of providers licensed or certified to deliver services in Arkansas:
• a Developmental Disabilities Services specialty provider• a Behavioral Health Services Specialty provider• a Hospital• a Physician• a Pharmacist
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WhatisaPASSE?
Arkansas Total Care PBM : Envolve Pharmacy Solutionswww.arkansastotalcare.com | 1-866-282-6280
John Ryan – [email protected] Coordination Contact: Amber Baker | (501) [email protected]
Empower Healthcare Solutions PBM: CVS Caremarkwww.getempowerhealth.com | 1-866-261-1286
Nicole May – [email protected] Coordination Contact: Jamie Ables | Office (501) 707-0961 [email protected]
Summit Community Care PBM: Express Scripts Inc.www.summitcommunitycare.com | 1-844-405-4295
Jason Miller - [email protected] Coordination Contact: Tiffany Parkhurst | (501) [email protected] 4
PHASEII-PASSEs
ResponsibilitiesofPASSEsinPhaseII• Development of a Person Centered Service Plan (PCSP) based on
results received from the Independent Assessment
• Providing care coordination for every member
• Ensuring every member receives the medically necessary services in his/her plan of care
• Maintaining a formal network of providers
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PASSE Enrollment Popula0on includes only:‒ Individuals receiving services through DD Waiver‒ Individuals who are on the DD Waiver Waitlist‒ Individuals who are in private DD Intermediate Care Facili0es‒ Individuals that have a Behavioral Health Diagnosis and have received an
Independent Assessment that determines they need services in Tiers 2 or 3
The PASSE popula0on is approximately 47,000 beneficiaries and does not include all Medicaid beneficiaries. However, the PASSE popula0on is known to have a high pharmacy spend.
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WhoisservedbythePASSEs?
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Whatservicesarecovered?
Community & Employment Supports Respite Supplemental Support Consultation Supported Employment Adaptive Equipment Crisis Intervention Supported Living Specialized Medical Supplies
Community Transition Services Environmental Modifications
Arkansas Community Independence Services Supportive Employment Planned Respite Behavior Assistance
Peer Support Emergency Respite Crisis Intervention
Family Support Partners Therapeutic Host Home Mobile Crisis Intervention
Child & Youth Support Services
Community Reintegration Program
Individual Life Skills Development
Therapeutic Communities Supportive Housing Partial Hospitalization
Adult Rehabilitation Day Treatment
Supportive Life Skills Group Life Skills Development
State Plan Services Personal Care Physician Specialists Family Planning Primary Care Physician Pharmacy Inpatient Psychiatric Durable Medical Equipment Hospital Services Outpatient Behavioral
Health Counseling Occupational Therapy Physical Therapy Speech Therapy Nursing Services
• All types of providers are needed, including pharmacies, in the network. Each PASSE is required to operate on a statewide basis.• Pharmacy providers are allowed to choose how they will par?cipate. They
may join simply as a par?cipa?ng provider just like for an insurance company.• Pharmacy providers are NOT limited to the number of PASSE networks in
which they can par?cipate. • Pharmacy providers may likely want to be a network provider in all
PASSEs to ensure that there is con?nued coverage for the beneficiaries it serves. Exclusivity is a business decision.• Pharmacy providers can’t be excluded as network providers if they accept
the terms of the PASSE and are qualified licensed or cer?fied providers of services. The Arkansas Any Willing Provider protec?ons apply to the PASSE.• Pharmacies will need to work with your Pharmacy Benefit Manager
(PBM) Coordinator to contract with each PASSE. 8
WhichofyourproviderscanjoinaPASSEnetwork?
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WhyshouldpharmaciesjoinaPASSE?The PASSE system is a shift in the ways that clients’ care is managed, and how pharmacy providers bill for services if they serve PASSE clients.
Pharmacy providers should join the PASSEs to be in-network providers for their current clients whose care will be managed by the PASSEs.
If a pharmacy provider joins a PASSE, they will be assured of the rate that they will be paid by that PASSE.
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HowcanapharmacyjoinaPASSE?Each PASSE should be able to provide you more informa;on about how to join their networks. Once a provider receives informa;on from the PASSEs, the provider can choose to join any and all PASSEs. How a provider chooses to par;cipate is a business decision.
Pharmacies will need to work with your Pharmacy Benefit Manager (PBM) Coordinator to contract with each PASSE.
Arkansas Total Care PBM-Envolve Pharmacy Solutions [email protected] 1-844-631-6830 | www.arkansastotalcare.com
Empower Healthcare Solutions PBM-CVS Caremark [email protected] 1-866-261-1286 | www.getempowerhealth.com
Summit Community Care PBM-Express Scripts Inc. [email protected] 1-844-405-4295 | www.summitcommunitycare.com
WhatwillhappenstartinginMarch2019?• On March 1, 2019, Phase II will begin.
• A transi:on plan will help to smoothly shi? clients fromPhase I to Phase II.
• The PASSEs will receive the global payment, and they will make sure that services are provided for their members.
• Providers will begin to bill the PASSEs.
• Beneficiary cost-sharing is not permiKed.
• Payments to out-of-network providers will be limited to 20% of total payments for services.
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HowwillbillingbedifferentstartingonMarch1,2019?
Beginning on March 1, 2019, the Arkansas Department of Human Services (DHS) will give each PASSE a global payment, and the PASSEs will be responsible for using that global payment to reimburse providers for the services of their clients’ PCSPs.
Pharmacies will begin billing the PASSEs, not Medicaid, onMarch 1, 2019 for ONLY your clients who are in a PASSE.
Please keep in mind DHS requires PASSEs to pay providers within a certain Kmeframe. Please contact each PASSE for more informaKon on how you will be reimbursed and at which frequency.
HowwillbillingbedifferentstartingonMarch1,2019?
• Pharmacy claims submitting Fee-For-Service for PASSE recipients on or after 3/1/19 will reject at point of sale.
• If you receive a message that the recipient is in a PASSE you can check the following things:ü Log into the DXC Eligibility Portal to find out the recipient’s PASSE
assignment
üContact the PASSE if you do know the PASSE assignment
üContact the Pharmacy Benefit Manager (PBM) for each PASSE
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Howandwhenwillprovidersbeabletocheckeligibility?
Each client will receive a new ID card with the PASSE logo prior to March 1, 2019 that iden>fies which PASSE they are in. Providers will want to get a copy of their clients’ cards.
Pharmacies can log into the DXC Provider Portal to verify Medicaid eligibility and to find out which PASSE the recipient has been assigned to.
For more informa>on on how to log into the DXC Provider Portal click the link below:• hMps://portal.mmis.arkansas.gov/armedicaid/provider/Home/tabid/13
5/Default.aspx• Click “Register Now”
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Whatistheplantotransitionfromfee-for-servicetothePASSEsystem?• PASSEs have a plan to shift from the current fee-for-service
system to the new PASSE system. • The PASSE must honor current PCSPs for clients, which include
any current Prior Authorizations (PA) and current rates, for a minimum of sixty days and up to six months.
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HowdoesCareCoordinationaffectproviders?
A$er a client is assigned to a PASSE, each client is given a Care Coordinator who helps him or her develop a Person Centered Service Plan (PCSP). PASSE Care Coordinators help clients to get and coordinate needed services across many systems.
Care Coordinators may contact you to ask for your clients’ plans of care and to assist clients in con5nuing services, iden5fying needs for supports, and coordina5ng mul5ple plans. The Care Coordinator should be able to provide you with a HIPAA release.
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WillopioidMMElimitsandcriteriabethesameforPASSE?• The PASSE programs will mirror the current Medicaid MME
limits and criteria, but cannot be more restrictive.
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DothePASSEprogramshavetoutilizethecurrentMedicaidPDL?• Yes, the PASSE PDL will need to be identical to the State's PDL.
• The PASSE will be able to initiate individual formularies for non-PDL drugs.
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Willtheday’ssupplylimitbethesameaswellasmonthlylimits?• Yes, each PASSE will mirror current day’s supply limits and
monthly limits.
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WillthePASSEcoverDMEasapharmacybenefit?• DME will be covered in the PASSE. Currently in the Fee-For-
Service environment, DME is billed outside of tradiBonal pharmacy. However, aEer 3/1/19 it will be up to each PASSE on whether to bill DME as medical or pharmacy.
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• Otherquestionsreceived
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Resources:PASSEProviderContacts
If a provider has a question or concern to share with DHS, the provider can contact:
Tanya Giles | [email protected]| 501-320-6189
Arkansas Total Care PBM-Envolve Pharmacy Solutions [email protected] 1-844-631-6830 | www.arkansastotalcare.com
Empower Healthcare Solutions PBM-CVS Caremark [email protected] 1-866-261-1286 | www.getempowerhealth.com Summit Community Care PBM-Express Scripts Inc. [email protected] 1-844-405-4295 | www.summitcommunitycare.com
Pharmacies will need to work with your Pharmacy Benefit Manager (PBM) Coordinator to contract with each PASSE.
If a pharmacy has a question or issue-1. Log into the DXC Eligibility Portal to find out the recipient’s PASSE
assignment2. Contact the PASSE if you do know the PASSE assignment3. Contact the Pharmacy Benefit Manager (PBM) for each PASSE
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ResourcesIf a beneficiary has a question or issue-
1. The beneficiary should contact the PASSE first.2. If the beneficiary has a concern about their PASSE, that member can
call the PASSE Ombudsman office at 1-844-843-73513. AFMC is also available for Choice Counseling at 1-833-402-0672
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Questions
