SECTION 12 - REIMBURSEMENT METHODOLOGY 12.1 THE BASIS FOR ESTABLISHING A RATE OF PAYMENT...2 12.2 DETERMINING A FEE...2 12.2.A LONG-TERM CARE DISPENSING FEE REQUIREMENTS...3 12.3 MEDICARE/MEDICAID REIMBURSEMENT (CROSSOVER CLAIMS)...3 12.4 PARTICIPANT COST SHARING...4 12.5 PUBLIC HEALTH SERVICE (340B) DRUG PRICING PROGRAM...4 12.6 DIRECT DEPOSIT...4 1
SECTION 12 REIMBURSEMENT METHODOLOGY 12.1 THE BASIS FOR ESTABLISHING A RATE OF PAYMENT The MO HealthNet Division is charged with establishing and administering the rate of payment for those medical services covered by the Missouri Title XIX Program. The Division establishes a rate of payment that meets the following goals: Ensures access to quality medical care for all participants by encouraging a sufficient number of providers; Allows for no adverse impact on private-pay patients; Assures a reasonable rate to protect the interests of the taxpayers; and Provides incentives that encourage efficiency on the part of medical providers. Funds used to reimburse providers for services rendered to eligible participants are received in part from federal funds and supplemented by state funds to cover the costs. The amount of funding by the federal government is based on a percentage of the allowable expenditures. The percentage varies from program to program and in some cases different percentages for some services within the same program may apply. Funding from the federal government may be as little as 60% or as much as 90%, depending on the service and/or program. The balance of the allowable, (10-40%) is paid from state General Revenue appropriated funds. Total expenditures for MO HealthNet must be within the appropriation limits established by the General Assembly. If the expenditures do not stay within the appropriation limits set by the General Assembly and funds are insufficient to pay the full amount, then the payment for services may be reduced pro rata in proportion to the deficiency. 12.2 DETERMINING A FEE Under a fee system each procedure, service, medical supply and equipment covered under a specific program has a maximum allowable fee established. MO HealthNet reimbursement for pharmacy claims is determined by applying the following methodology. Payment is made at the lower of the: 1. Applicable Wholesaler Acquisition Cost (WAC), plus 10%, plus professional dispensing fee 2. Applicable Missouri Maximum Allowable Cost (MAC) plus professional dispensing fee 3. Applicable Federal Upper Limit plus professional dispensing fee 4. Usual and customary charge 2
MO HealthNet may not be billed an amount in excess of the provider s usual and customary charge for a particular service. Pharmacy claims must be submitted using the precise 11-digit national drug code (NDC) number of the package from which each prescription is dispensed. Reference the traditional and specialty Missouri Maximum Allowable and Federal Upper Limit Drug Products list in the Frequently Updated Documents section of our website or by accessing the following link: http://www.dss.mo.gov/mhd/cs/pharmacy/pages/mac.htm. 12.2.A LONG-TERM CARE DISPENSING FEE REQUIREMENTS The qualifications for determining the controlled dose long-term care prescription fee differential that must be met are as follows: The medication was dispensed in unit-dose and/or controlled-dose containers which meet at a minimum, Class B standards for moisture permeation as defined in the United States Pharmacopoeia. The pharmacy provides emergency services at 24 hours a day, 7 days a week availability and the willingness to assist the facility and the facility s residents in accessing medications through the MO HealthNet exception process. The provider certifies by completing the MO HealthNet Long Term Care Pharmacy Dispensing Fee Provider Specialty Application form that these requirements are met. Each prescription is identified as having been dispensed in qualifying controlled dose or unit-dose packaging by entering an X in the nursing home indicator field (Field #4) of the Pharmacy Claim form. The participant is identified as a resident of a long term care facility on the MO HealthNet participant eligibility file. Reference the MO HealthNet Long Term Care Pharmacy Dispensing Fee Provider Specialty Application form at http://manuals.momed.com/manuals/presentation/forms.jsp. 12.3 MEDICARE/MEDICAID REIMBURSEMENT (CROSSOVER CLAIMS) For MO HealthNet participants who are also Medicare beneficiaries and receive services covered by the Medicare Program, MO HealthNet pays the deductible and coinsurance amounts otherwise charged to the participant by the provider. Certain drugs have been determined by the Centers for Medicare & Medicaid Services (CMS) to be eligible for consideration as a Part B Medicare benefit. For more detailed information on Medicare Part B versus Medicare Part D drugs reference the CMS website at www.cms.hhs.gov/prescriptiondrugcovgenin/downloads/partbandpartddoc_07.27.05.pdf. 3
12.4 PARTICIPANT COST SHARING Certain MO HealthNet services are subject to participant cost sharing, referred to as copay, coinsurance, or shared dispensing fee (pharmacy). The cost sharing amount is paid by the participant at the time services are rendered. Services of the Pharmacy Program described in this manual are subject to a cost sharing amount. The provider must accept in full the amounts paid by the state agency plus any shared dispensing fee amount required of the participant. Refer to the Benefits and Limitations (Section 13) of the manual, for program specific information. 12.5 PUBLIC HEALTH SERVICE (340B) DRUG PRICING PROGRAM 340B is a drug pricing program that resulted from the enactment of Public Law 102-585 and the Public Health Service Veterans Health Care Act of 1992. The 340B program limits the cost of covered outpatient drugs to Disproportionate Share Hospitals (DSH), federally qualified health center look-alikes and to certain federal grantees. 340B also results in additional cost savings to 340B participants registered in the Prime Vendor Program. The MO HealthNet Division follows the guidelines set forth by Health Resources and Services Administration (HSRA). Covered entities that use 340B Drug Pricing and bill MO HealthNet must follow the rules outlined in HRSA s website at http://www.hrsa.gov/opa/introduction.htm. Covered entities who participate in the public health service drug pricing program must bill their actual net cost in the gross amount due field, NOT the usual and customary. These entities must not charge above their net charge plus a reasonable dispensing fee. 12.6 DIRECT DEPOSIT All payments are direct deposited and providers must complete the Application for Provider Direct Deposit form. Direct deposit begins following a submission of a properly completed application form to the MO HealthNet Division, the successful processing of a test transaction through the banking system and the authorization of the Division to make payment using the direct deposit option. The state conducts direct deposit through the automated clearing house system, utilizing an originating depository financial institution. The rules of the National Clearing House Association and its member local Automated Clearing House Association shall apply, as limited or modified by law. The Application for Provider Direct Deposit form provides instructions for completion on page 2. This form must also be used if providers wish to change an account number. Exact copies of the form may be used. One form must be completed for each provider number. Providers may obtain additional forms by contacting the Provider Enrollment Unit of the Missouri Medicaid Audit and Compliance (MMAC) Unit at P.O. Box 6500, Jefferson City, MO 65102-6500. The provider may also download this form from the website or by accessing the following link: 4
http://manuals.momed.com/forms/application_for_provider_direct_deposit.pdf. Please read the form and instructions carefully; Section C contains statements regarding legal obligations. The MO HealthNet Division will terminate or suspend the direct deposit for administrative or legal actions, including but not limited to: ownership change, duly executed liens or levies, legal judgments, notice of bankruptcy, administrative sanctions for the purpose of ensuring program compliance, death of a provider, and closure or abandonment of an account. Providers and their representatives are not permitted to accept delivery of MO HealthNet checks in person. END OF SECTION TOP OF PAGE 5