Medi-Cal Update

Pharmacy | January 2020 | Bulletin 960

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1. Authorization for Incontinence Creams and Washes

The November 2019 Medi-Cal Update notified providers that, effective for dates of service on or after January 1, 2020, incontinence creams and washes require authorization. Effective for dates of service on or after January 1, 2020, products in the List of Contracted Incontinence Creams and Washes billed using HCPCS codes A4335 (incontinence supply; miscellaneous) and A6250 (skin sealants, protectants, moisturizers, ointments, any type, any size) are reimbursable for recipients 5 years of age or older with an approved Treatment Authorization Request (TAR) or Service Authorization Request (SAR). An approved non-product-specific SAR will continue to be reimbursable up to the allowable quantity limits provided in the List of Incontinence Medical Supply Billing Codes.

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2. Medi-Cal Pharmacy Provider Self-Attestation Portal Now Open

On January 15, 2020, the online attestation portal opened for fee-for-service Medi-Cal pharmacy providers seeking the higher of two professional dispensing fees as part of the forthcoming reimbursement changes for covered outpatient drugs. During the second week of January 2020, Medi-Cal pharmacy providers should have received a mailer that includes the URL for the online attestation portal, as well as a unique login ID and password.

As has been published in previous Medi-Cal Updates, the Department of Health Care Services (DHCS) has implemented a new fee-for-service reimbursement methodology for covered outpatient drugs. Part of this methodology is a two-tiered professional dispensing fee based on a pharmacy provider's total (Medi-Cal and non-Medi-Cal) annual pharmacy claim volume ($13.20 if fewer than 90,000 claims per year; $10.05 if 90,000 or more). Reporting the claim volume is a self-attestation process, which must be submitted electronically and must be repeated annually.

Note:

DHCS policy is that a claim is equivalent to a dispensed prescription; therefore, the attestation is for the total dispensed prescription volume.

Only fee-for-service Medi-Cal providers dispensing fewer than 90,000 total prescriptions per calendar year are eligible to receive the higher of the two professional dispensing fees and must complete this attestation in order to receive it.

The attestation portal for the 2019 calendar year reporting period is open from January 15, 2020, to February 29, 2020. The web portal will close at 11:59 p.m. on February 29, 2020, and attestations will not be accepted after that time. The attestation for the 2019 calendar year reporting period will determine the professional dispensing fee component of the pharmacy claim reimbursement for claims with dates of service within the state’s following fiscal year (dates of service from July 1, 2020, through June 30, 2021).

For additional information, providers can refer to the Pharmacy Provider Self-Attestation FAQs or the Pharmacy Reimbursement Project web page on the DHCS website. For inquiries not covered in the FAQs, providers may call the Telephone Service Center at 1-800-541-5555 (outside of California, call [916] 636-1960), and select the following options:

       The caller will be directed to an agent.

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3. Recommencement of Pharmacy Retroactive Claim Adjustments in February 2020

The Centers for Medicare & Medicaid Services (CMS) published its final rule on covered outpatient drugs (CODs) on February 1, 2016. Under the final rule, each state Medicaid agency was required to adopt a methodology based on actual acquisition cost (AAC) for CODs. As has been published in previous Medi-Cal Updates, pursuant to California's State Plan Amendment 17-002, the Department of Health Care Services (DHCS) implemented a new fee-for-service reimbursement methodology for CODs to comply with the final rule. The associated system changes went into effect on February 23, 2019.

CMS requires that DHCS make retroactive adjustments for claims with dates of service beginning with the policy effective date of April 1, 2017, through the implementation date of February 23, 2019. DHCS processed the first iteration of these adjustments (claims with dates of service in the month of April 2017) in May 2019, and then paused further adjustments. In the fall of 2019, DHCS contacted all Medi-Cal pharmacy providers to notify them of an Alternative Payment Arrangement (APA) for remaining adjustments. Providers could register for this option via an on-line application that was available from October 28, 2019, through and including November 22, 2019. Providers approved for the APA have since been notified by DHCS and will have their remaining adjustments processed separately from the previous adjustment process.

For providers that did not choose the APA, DHCS will resume retroactive adjustments beginning with the February 10, 2020, checkwrite date, through February 2021, for the remaining impacted claims with dates of service from May 1, 2017, through February 23, 2019.

If you have questions regarding these adjustments, please call the Telephone Service Center at 1-800-541-5555, option 5, followed by option 6.

If providers want additional information regarding the pharmacy retroactive claim adjustments, they may refer to the Frequently Asked Questions (FAQ) page of the Medi-Cal website. Providers may also refer to the Pharmacy Reimbursement Project page of the DHCS website for additional information regarding this project.

DHCS strongly encourages the Medi-Cal pharmacy fee-for-service provider community to closely monitor Medi-Cal Update pharmacy bulletins for additional information regarding any future updates.

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