Alabama Medicaid Kelli Littlejohn Newman, Pharm. D. Director, Clinical Services and Support
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Alabama Medicaid
Kelli Littlejohn Newman, Pharm. D. Director, Clinical Services and Support
Objectives
• Medicaid Overview
• Regional Care Organizations & Health Homes
• Pharmacy Initiatives
Medicaid Overview
Medicaid Provides Coverage For:
– 53% of All Alabama Deliveries
– 43% of All Alabama Children
– 60% of Nursing Home Residents
Medicaid Cost Drivers
• Enrollment – nearly 300,000 increase since 2007
• Inflation• Benefit Package – Alabama’s “bare bones”• Federal Match Rate (FMAP) – federally
issued rate based on economy• Alabama Medicaid has little, if any, control
over these factors• Even so, Alabama has one of the lowest
costs per member (recipient)
Medicaid Expenditures FY14
Hospital35%
Physicians9%
Pharmaceutical11%Mental
Health8%
Admin4%
Nursing Home16%
Other17%
Total FY14 expenditures: $5,783,130,402
Regional Care Organizations (RCOs)
• RCOs are locally-led managed care organizations that will provide services for Medicaid enrollees at an established cost when the program is implemented in October 2016.
• Certified RCOs will assume the risk of managing the full cost of covered Medicaid services and care coordination for most Medicaid recipients
RCO Populations• Covered populations
– Aged, blind, and disabled recipients– Breast and Cervical Cancer Treatment Program
participants– Recipients of Medicaid for Low Income Families
(MLIF)– SOBRA children and adults
• Excluded populations– Medicare/dual eligibles– Foster children– Hospice patients – ICF-MR recipients– Nursing home/institutional recipients– Plan 1st and unborn recipients– Home and Community-Based Services Waiver
recipients
RCO Covered Services• Medicaid covered services to be provided by RCOs
include:– Hospital inpatient and outpatient care– Emergency Room– Primary and Specialty Care– FQHCs/RHCs– Lab / Radiology– Mental/Behavioral Health/Substance Abuse– Eye Care– Maternity
–DME• Pharmacy is a Medicaid‐covered service, but will not
be part of RCOs • Long term care and dental services are excluded now
RCO Enrollment Summary Summary:• Enrollment process will begin in July 2016 and go
through August 28, 2016. • Significant outreach planned to encourage recipients
to choose an RCO• Recipients who do not select a PMP will be auto
assigned• Enrollment Broker:
– Will have a list of each RCO’s contracted PMPs• PMPs identified by name and practice group
– Will share information with recipients– Information to be shared in a uniform, unbiased manner
RCO Enrollment SummarySummary:• Recipients may change their choice of RCO
within first 90 days; after that time, may change during annual open enrollment period
• PMP selection process determined by RCOs• Panel size: Medicaid making recommendation to
maximize RCO flexibility to manage panels• Recipients will receive minimum services as
determined by Medicaid, the same as other Medicaid recipients; RCO may add services or benefits but will not receive additional capitation payments
Contracts, PAs, Referrals(non‐pharmacy)
• Providers must contract with at least one RCO in order to be paid for services; may contract with multiple RCOs.
• RCOs will determine how patients will be assigned to panels.
• “Any Willing Provider” rule applies; providers are eligible to contract with any or all RCOs.
• Medicaid requires payment to providers to be no less than the prevailing FFS fee schedule in place on October 1, 2016.
• Program, PAs and Referrals are to be no more restrictive than currently in place on October 1, 2016.
• Provider Contracts must be approved by Medicaid.
• NPs may participate via supervising physician
Contracting, PAs, Referrals (non‐pharmacy)
• EPSDT requirements must be met per contract
• Referral forms and process may vary from RCO to RCO
• RHCs, FQHCs all are eligible to participate as providers; will receive “wrap-around” payments
• RCOs must meet minimum requirements for their service delivery networks, including certain specialty care
• CMHCs included
RCOs with Probationary Certifications
• The Agency has certified 11 organizations as probationary organizations• These organizations must pass service delivery network requirements,
financial solvency standards, and a thorough readiness assessment to receive final certification from the Agency.
Region Probationary RCOs
A• Alabama Community Care – Region A• Alabama Healthcare Advantage North• My Care Alabama
B • Alabama Care Plan• Alabama Healthcare Advantage East
C • Alabama Community Care – Region C• Alabama Healthcare Advantage West
D • Care Network of Alabama• Alabama Healthcare Advantage
E• Alabama Healthcare Advantage South• Gulf Coast Regional Care
Organization
Probationary RCO Implementation of Health HomesFramework• 6 Probationary RCOs qualified to provide Health Home
services• Systems are being built out to support all 67 countiesServices• Outlier case identification• Case management and coordination of community
services for your patients • Improving adherence• Decreasing no‐shows• Help navigating prescription issues
RCOs versus Health Homes
The Health Home (HH) Program and RCO Program are different Medicaid Programs implemented by the same organizations
Health Home Qualifying Chronic Conditions
Health Homes provide quality‐driven, cost effective, culturally appropriate, and person‐ and family‐centered health home services for Patient 1st recipients with:• Asthma• Diabetes• Cancer• COPD• HIV • Mental Health Conditions• Cardiovascular Disease
• Substance Use Disorders• Transplants• Sickle Cell• Heart Disease• Obesity
• BMI > 25• Hepatitis C
Health Home Overall Benefits
Assistance transitioning from an inpatient setting back to the community
Assessment by a nurse or social worker to determine barriers to healthy living and develop a plan to assist in managing chronic conditions
Availability of a pharmacist to review medication and assist with medication regime
Referrals to needed commresources
Linkage to medical or behavioral health services
Education on chronic diseases or behavioral health condition
Health Home Pharmacy Program
• Each Region/HH maintains a Network Pharmacist/Clinical Pharmacist
• Network Pharmacist: – Attends various Medicaid meetings (DUR, P&T, monthly calls, etc)
– Submits reports, Q/A, etc– Administrative oversight
• Clinical Pharmacist: – Conducts Med Recs– Coordinate with community pharmacists
RCO/HH Pharmacy Quarterly Duties/Reporting
• Perform five (5) Physician educational visits. • Perform five (5) pharmacy educational visits. • Perform one home visit with any Health Home
Program Enrollee. • Provide one in‐service training on various clinical
topics for care managers. • Run report on high utilizers. Review the top ten (10)
by costs and identify any possible recipients to be referred to the Care Coordinator for enrollment into the Health Home Program.
RCO/HH Pharmacy Quarterly Duties/Reporting
(continued)
• Perform and submit Medication Reconciliations for Health Home Program Enrollees within five (5) Business Days after receipt of Medication List.
• Perform and submit Medication Reconciliations for transitional/discharge patients within three (3) Business Days after receipt of Medication List.
• New Duties• Coordinate Pharmacy Controlled Substances Lock
In Recipients • SVR Reporting for Hep C patients
More RCO Info
On the Web: www.Medicaid.Alabama.gov > Newsroom > Regional Care Organization
Questions: [email protected]
HH Pharmacist Contacts• Region A: Alabama Community Care
– Kristian Testerman, PharmD (256) 518‐[email protected]
• Region A: My Care Alabama – Machelle Stiles, RPh (256) 518‐9530
[email protected]• Region B: Alabama Care Plan
– Lauren Ward, PharmD (205) 558‐[email protected]
HH Pharmacist Contacts (continued)
• Region C: Alabama Community Care– Lisa Channell, PharmD (205) 553‐4661
[email protected]• Region D: Care Network of Alabama
– Amy Donaldson, PharmD (334)528‐[email protected]
• Region E: Gulf Coast RCO– Holley Rice, PharmD (251) 476‐5656
Pharmacy Overview
FY15 stats• Approx 636k pharmacy recipients• Approx 7mill claims• $660 mill expenditure (total dollars)• 84% generic/OTC utilization
(87% previous years, 84% last year)
• Avg claim cost $90 (B$400 / G$29)
FAQ: Cash or Medicaid?
Can a Medicaid recipient pay cash for “leftover” meds on the script (controls over #68/month)?
ANSWER:
Yes, ONLY (emphasis added) if a max unit override has been filed and denied….
(MORE NEXT SLIDES)
FAQ: Cash or Medicaid?• If the prescription to be paid by Medicaid exceeds the drug’s
maximum unit limit allowed per month, the prescriber or pharmacist must request an override for the prescribed quantity.
• If the override is denied, then the excess quantity above the maximum unit limit is non‐covered and the recipient can be charged as a cash recipient for that amount in excess of the maximum unit limit.
• A prescriber should not write separate prescriptions, one to be paid by Medicaid and one to be paid as cash, to circumvent the override process.
• A provider's failure or unwillingness to go through the process of obtaining an override does not constitute a non‐covered service.
Provider Billing Manual, Chapter 27, Pharmacy Services, 27.2.3 Quantity Limitations
FAQ: Cash or MedicaidPharmacy Quantity Limitations and Controlled Substances
• The pharmacist or prescriber must request an override when the prescription exceeds Medicaid’s maximum limit allowed per month.
• The prescriber should not write separate prescriptions, one to be paid by Medicaid and one to be paid as cash, to circumvent the override process.
• For further information on pharmacy quantity limitations and prescriptions for controlled substances, refer to Chapter 27, section 27.2.3 “Quantity Limitations”.
Provider Billing Manual, Physician Chapter, 28.2 Benefits and Limitations
Contact InfoHealth Information Designs (PAs)
(800) 748‐0130
Hewlett Packard (HP) Claims Processing (800) 456‐1242
RECIPIENT HOTLINE(800) 362‐1504
FRAUD Hotline(866) 452‐4930
Contact Info
Pharmacy Services (334) 242‐5050
Kelli Littlejohn Newman, Pharm DDirector, Clinical Services and Support
Alabama Medicaid Agency(334) 353‐4525
www.medicaid.alabama.gov
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