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Pharmacy Provider Self-Attestation FAQs

Background

  1. Why is Medi-Cal changing its fee-for-service pharmacy dispensing fee structure?
    The Department of Health Care Services (DHCS) is implementing a new fee-for-service pharmacy reimbursement methodology to comply with the 2016 Centers for Medicare & Medicaid Services (CMS) Final Rule for Covered Outpatient Drugs (CMS-2345-FC). The rule not only mandates that state Medicaid agencies transition to an acquisition cost-based reimbursement for drug ingredient costs, but also ensures that the professional dispensing fee adequately reimburses providers for their costs of dispensing.

  2. What are the two possible dispensing fees, and how do I know if I am eligible to receive the higher of the two fees?
    Pursuant to California Welfare and Institutions Code (W&I Code), Section 14105.45, the professional dispensing fee is based on a pharmacy's total (Medicaid and non-Medicaid) annual prescription volume from the previous year as follows:

    a) Less than 90,000 claims equals $13.20
    b) 90,000 or more claims equals $10.05

    DHCS policy is that a claim is equivalent to a dispensed prescription.

  3. Why does the fee-for-service professional dispensing fee change at a total annual claim volume threshold of 90,000?
    Survey results demonstrated that the decrease in the cost of dispensing flattened out for pharmacies filling more than 90,000 dispensed prescriptions each year, thus providing a natural demarcation point for dispensing fees. Please note that DHCS policy equates a claim to a prescription dispensed.
  4. If I dispense 90,000 or more prescriptions during a reporting period, do I still need to complete an attestation?
    No.
  5. What happens if I dispense less than 90,000 prescriptions during a reporting period but do not complete this self-attestation?
    If you dispense less than 90,000 prescriptions and do not complete the attestation then the dispensing fee you receive will default to the lower tier ($10.05).

  6. Why is there no longer a unique Long Term Care (LTC) dispensing fee?
    DHCS engaged a vendor to conduct a study of pharmacy providers' costs of dispensing in the summer of 2016. The survey data reported by LTC pharmacies did not result in an average dispensing cost statistically different from the results of the two-tier professional dispensing fee structure.

  7. What are the expectations with regards to the claim volume attestation? Is that per company? Location? What will the total claim volume be reported by?
    The total claim volume attestation shall be based upon each National Provider Identifier (NPI) approved as a Medi-Cal fee-for-service pharmacy provider.

  8. How long will DHCS keep this new dispensing fee structure?
    There is no predetermined duration identified with this new methodology. Code of Federal Regulations, Title 42, Part 447.518(d), mandates that when a state changes its reimbursement methodology for the ingredient cost of drugs, it also examine, and if necessary, revise its professional dispensing fee to ensure that overall reimbursement to pharmacy providers is in accordance with the requirements of Section 1902(a)(30)(A) of the Social Security Act.

  9. Why weren't specialty pharmacies given their own unique dispensing fee?
    The survey results for costs of dispensing did not justify the creation of professional dispensing fees unique to specialty pharmacies. Therefore, specialty pharmacies will be reimbursed based upon the two-tier professional dispensing fee model.

  10. Timelines

  11. When is the attestation period?
    The attestation period is from January 15 through February 28 (February 29 in a leap year) each year.
  12. What is the relationship between a calendar year attestation and its resulting professional dispensing fee in terms of claim submission dates?
    The attestation for each calendar year reporting period will determine the fee-for-service professional dispensing fee component of the pharmacy claim reimbursement for claims with dates of service within the state's following fiscal year. As an example, a 2017 calendar year claim volume attestation will determine the professional dispensing fee for claims within the State's 2018 – 2019 fiscal year (dates of service of July 1, 2018, through June 30, 2019).

    Note: Because the effective date of the reimbursement methodology is April 1, 2017, the first attestation collection period in early 2018 will require an attestation of both calendar years 2016 and 2017 reporting periods.

  13. What is the effective date of this change in fee-for-service reimbursement methodology?
    The mandated effective date for the new professional dispensing fee policy is for dates of service on or after April 1, 2017.
  14. When will the professional dispensing fee actually be reflected in my reimbursement?
    It is anticipated that the required system changes will be implemented in late 2018, allowing the new professional dispensing fees to be reflected in providers' reimbursements.
  15. How will the change be applied retroactively to claims with dates of service on or after April 1, 2017?
    After implementation, there will be historical claims adjustments for all claims with dates of service between April 1, 2017, and the date of system implementation.
  16. Login and Password

  17. How and when will I receive my login information?
    A mailer with additional information including your login details will be mailed during the first week of the New Year.
  18. I did not receive my login information or, I need to reset my password; whom should I contact?
    Please call the Telephone Service Center at 1-800-541-5555 and select the following options:
    1. Option 1 for English
      Option 2 for Spanish

    2. Option 1 for Provider

    3. Option 4 for Technical Help Desk

    4. Option 2 for Pharmacy

    5. Option 1 for Provider

    6. Option 1 for NPI enter NPI followed by the # sign

    7. Option 2 for Pharmacy

  19. The Attestation Process

  20. What is the web address for the attestation?
    The web address for the attestation portal is: https://dhcspharmacyattestation.checkboxonline.com/signin.aspx. Please note that this website will not be live until January 15, 2018.
  21. How long is the actual attestation expected to take?
    If you are equipped with your total claim volume for the reporting period then the attestation should take approximately five minutes.

  22. Who is authorized to complete the attestation for my pharmacy?
    Only the Medi-Cal provider, or a person authorized by the Medi-Cal provider to bind the provider by signature to the conditions contained in the attestation statement, may complete the attestation.
  23. What is to be included in my total number of prescriptions dispensed?
    All prescriptions dispensed, including cash paid, Medicaid, Medicare and third party payers, are to be included. Prescriptions dispensed includes all products dispensed by the pharmacy during the course of business and verifiable through the pharmacy's prescription records. This may include but is not limited to drugs, supplies, enteral nutrition, equipment etc.

    Note: DHCS policy is that a claim is equivalent to a dispensed prescription.

  24. I was not in operation for the full 12 months of the reporting period. How does this impact my attestation?
    If you were not in operation for the full 12 months of the reporting period then only report the total number of dispensed prescriptions during the months of operation for that reporting period. Partial months of operation will not be used to project an annual volume for the reporting period.
  25. After the Attestation Period

  26. I missed the deadline; can I submit an attestation after the deadline?
    No. The portal will close at 12:00 a.m. on March 1, 2018.
  27. Can I change my attestation once I have completed it if the attestation period is still underway?
    Yes. Your attestation can be modified up until the closure of the portal at 12:00 a.m. on March 1, 2018.
  28. Will I know the result of the attestation right away?
    Yes. Soon after submitting your attestation you will receive an email confirmation receipt and notice of whether or not your NPI will be assigned to the higher of the two dispensing fees.
  29. I can see that my prescription volume for the year will exceed (or drop below) the 90,000 threshold for the calendar year that I previously attested to. Am I required to notify DHCS?
    No. Once the attestation period has closed, the applicable dispensing fee is locked in for the entire subsequent fiscal year regardless of your prescription volume trends.
  30. What are the consequences if I falsify information?
    If a pharmacy provider submits false information as a means to obtain a higher reimbursement, that provider is in violation of the federal False Claims Act (FCA), as well as the California False Claims Act (CFCA), California Government Code, section 12650, et. seq., which is modeled after the federal FCA. In the event a false claim is found to have been made, the CFCA provides for treble damages plus statutory penalties between $5,000 and $10,000 for each false claim (California Government Code, section 12651[a]).
  31. Do I need to keep or maintain supporting documentation that demonstrates my total claim volume for the reported period? Will I be audited?
    All fee-for-service Medi-Cal pharmacies should be prepared to produce supporting documentation upon DHCS request for each submitted attestation.
  32. Future Attestations

  33. Will my previous year's attestation automatically carry over to following years, or do I have to re-attest each year?
    Attestations will not automatically carry over from the previous year. You must attest during the attestation period for each reporting period if you believe you are eligible for the higher of the two dispensing fees. DHCS will provide reminder notices each year to pharmacy providers of the upcoming reporting period attestation.
  34. When will the next attestation period be held after this first period in early 2018?
    The next attestation period will be January 15 through February 28, 2019, and will reoccur each year thereafter.
  35. New Providers

  36. I am a new provider and was notified that my provider enrollment application was approved after the attestation period was closed. Which professional dispensing fee will I receive?
    Newly approved fee-for-service pharmacy providers that are notified of their enrollment approval after the attestation period closes will receive the higher dispensing fee. However, those same providers will have to attest for subsequent reporting periods in order to continue to be eligible for the higher dispensing fee in subsequent fiscal years.


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