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August Leg. Update: Medicaid Billing & Bundling, Disease Mang., DMEPOS Accreditation Issues

HB 499:  Medicaid Bundling

This bill was introduced by Rep. Kenny Yuko to address the Medicaid bundling issue created during the Biennium Budget (HB 1) process.  The Ohio Pharmacists Association was approached about being placed in this legislation to replace the current bundled services.  We agreed to this proposal in return for the following.

1. Language in the bill to raise the Medicaid dispensing fee to 85 percent of the Medicaid Fee Survey, and fix the drug reimbursement at WAC + 7
2. Prompt pay language to insure that pharmacy would receive timely payment for services  
3. Nightly updates of formulary prices by ODJFS 

We felt that the protections we added regarding prompt pay for services, the increase in the dispensing fee and nightly updates of the formulary would make this a winning proposition for pharmacy.

 When HB 499 was introduced, the agreed upon language was not in the bill.  We were told it was a misunderstanding and that it would be rectified, and the agreed upon language would be amended into the bill.  However, we cannot be supportive of this bill in any way until the language changes are made. We have made this clear to the sponsor and to other interested parties.

SB 283:  Medicaid Bundling

This is the companion bill to HB 499.  It was introduced by Sen. Sue Morano and Sen. Jimmy Stewart.  The language is identical and, therefore, is being opposed by OPA until the agreed upon language changes are made.

HB 513:  Disease Management

Introduced by Rep. Barbara Sears, this bill would require ODJFS to implement a disease management component in the Medicaid program.  The bill would allow ODJFS to set the criteria for those who are allowed to participate in the program.  It would also allow other state agencies that contract with the Medicaid program to include disease management in their contracts.  The bill currently doesn’t mention any health care provider by name, although this is something that we may look to amend. We definitely want pharmacists to be involved in this program.

Part B Supplier, DMEPOS Accreditation Issues

NCPA has announced that the Centers for Medicare & Medicaid Services is indicating that it will propose exempting retail-provided diabetes testing supplies from competitive bidding.  CMS also proposed a national mail order competitive bidding program for such supplies, which would go into effect sometime after 2011, following Round 1.  This would allow your patients to continue to obtain these supplies through community pharmacies, at least those that are accredited, or qualify for the accreditation exemption. Only those suppliers who provide these items through mail order outlets would have to bid.

CMS recently issued guidance to the National Supplier Clearinghouse (NSC) on how it should implement the pharmacy DMEPOS accreditation exemption that was included in the new health care reform law.  Under the program, community pharmacies that are 1) not accredited; 2) have had a Part B supplier number for the last five years; 3) and have no adverse determinations against them will receive a communication from the NSC this fall, asking them to attest that their annual DMEPOS billings are 5 percent or less of their total pharmacy sales over the last three years.

Next spring, CMS will ask at least 10 percent of randomly-selected pharmacies to submit evidence that their DMEPOS billings are 5 percent or less of their pharmacy sales. This does not affect pharmacies that are already accredited. But when their accreditation expires, they can obtain the exemption as long as they meet the criteria. 

If you have any questions or comments about the issues mentioned in this article, please contact Kelly Vyzral, Director of Government Affairs, at 614.586.1497 or

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