Attention OPA members,
Weeks ago, OPA was made aware of one of the state’s Medicaid Managed Care Organizations (United Healthcare) moving to a limited, restrictive network, and that by March 1, 2015, approximately 800 pharmacies, ranging from large chains, small chains, and some independents, will be not be included in the new network.
We have since received many phone calls from frustrated pharmacists who are concerned about the possibility of cutting ties with long-time patients who have come to value the services they were receiving from their local pharmacy.
Last week, OPA staff sat down with the Director of the Department of Medicaid John McCarthy and some of his staff to discuss the ramifications for patients and pharmacies if restrictive networks are permitted within the managed care program. Unfortunately, there are no plans by the Department of Medicaid to prohibit restrictive networks by their managed care organizations; however, for patients who have been told by United Healthcare to use other pharmacies, there are still options for impacted patients.
For now, here is what you need to know...
First, because notices to patients of a change in their pharmacy networks were sent shortly after the enrollment period, there is an option for patients to change their enrollment to another managed care plan. According to the Department of Medicaid, if you encounter a patient who selected United Healthcare, and was under the impression that their current pharmacy was in-network, only to now be told that it isn’t, those patients will be allowed to switch managed care plans. This "open period" will extend through April 2015. Beginning May 1, 2015, this window will close, and patients will no longer be able to switch until the next open enrollment period begins.
If your patient wishes to change MCOs due to the reason stated above, the patient can call the Medicaid hotline at (800) 324-8680, press “4” when prompted, and speak with a representative about switching plans. Their hours of operation are 7:00 am-8:00 pm Monday-Friday and 8:00 am-5:00 pm on Saturday.
As a pharmacist, you can help guide them through this process, but is important not to tell patients to switch to a particular plan.
For legal reasons, if a patient prefers to switch to a plan in which your pharmacy is participating, do not say, “Switch to __________.” What you can say is, “Here are the managed care plans for which our pharmacy is currently participating in: ___________.”
OPA has reached out to United Healthcare to share our concerns with this new shift within the Medicaid Managed Care segment of their business. OPA has always felt that, above all else, what is good for the patient should be the top priority, and we disagree with any program that prohibits a patient from using the pharmacy that they are most comfortable with.
Knowing that preferred and restrictive networks are growing in terms of their impact on pharmacy, we will be working with the Department of Medicaid to help ensure patients have adequate pharmacy choice and access, and also to ensure fairness in treatment of pharmacies in our state.
If you would be interested in helping OPA in determining what access standards should be in place for patients and pharmacies for the Department of Medicaid, please contact Antonio Ciaccia at email@example.com. For example, should access standards require that pharmacy networks include pharmacies that do home delivery? Offer medication therapy management? Immunizations? Hospice care? Medication synchronization? In the end, Medicaid is asking for recommendations for how they can better provide value for their recipients, and they need to know what pharmacy services should be considered in their standards.
As we have already had several phone calls come in from the offices of state legislators about the harm of a lack of patient choice, we can tell you that your calls are making an impact and legislators are taking notice. If you feel that limited networks are bad for your patients and bad for your community – as with any pharmacy issue that impacts your patients – we highly recommend communicating that with your elected officials. Remember, oftentimes legislators do not know everything that goes on within our industry or even within the Medicaid program. It is always valuable to let them know about issues occurring in their district.
We would like to thank United Healthcare for discussing these issues with us, and we’d also like to thank Director McCarthy and his staff at the Department of Medicaid for listening to our members’ concerns, and for their willingness to work with us on improving the value and efficiency of the program to improve healthcare in Ohio.