Posted on April 10, 2017
Medicaid Pharmacy-related Changes Take Effect
The Medical Services Administration recently released a concurrent proposed and final policy outlining changes to pharmacy claim reimbursement and announcing Medicaid coverage of medication therapy management (MTM) services. These changes are dependent on approval by the Centers for Medicare & Medicaid Services.
Effective for dates of service on and after April 1, 2017, Medicaid fee-for-service (FFS) and health plan beneficiaries can choose to receive MTM services, which are consultations provided by pharmacists to optimize drug therapy and improve therapeutic outcomes. These services must be provided by a licensed pharmacist enrolled in the Community Health Automated Medicaid Processing System who has successfully completed either the American Pharmacists Association’s “Delivering Medication Therapy Management Services” certificate training program or another MTM program approved by the Accreditation Council of Pharmacy Education.
MTM services will be paid through the Medicaid FFS program for beneficiaries enrolled either in Medicaid FFS or a Medicaid health plan, with no cost sharing responsibility to the beneficiary for the MTM service. For the MTM service to be covered, the claim must include at least one diagnosis code from the list of eligible chronic conditions. Examples of covered chronic conditions include asthma, bipolar disorder, cancer, cystic fibrosis, glaucoma, obesity, stroke and viral hepatitis.
In addition, the policy implements certain changes to pharmacy claim reimbursement for Medicaid FFS pharmacy claims processed on and after April 1, 2017, based on the federal rule on covered outpatient drugs. The changes to pharmacy claim reimbursement do not impact Medicaid claims for hospital outpatient services that include pharmacy. Members with questions should contact Vickie Kunz at the MHA.
Posted in: Monday Report