Pharmacy Provider Dispensing Fee Self-Attestation FAQs
Effective January 1, 2022, many pharmacy services, including covered outpatient drugs, enteral nutrition, some medical supplies and the applicable administrative services (for example, claim submission, processing, appeals, authorization, etc.) related to pharmacy claims, transition to Medi-Cal Rx. Pharmacy providers should submit claims for these products to Medi-Cal Rx. For more information on services covered by Medi-Cal Rx, providers should refer to the Medi-Cal Rx website. For more information on the Pharmacy Provider Dispensing Fee Self-Attestation, providers should refer to the Medi-Cal Rx Attestation page on the Mercer website.
- Why did Medi-Cal change its fee-for-service pharmacy dispensing fee structure?
In February 2019, the Department of Health Care Services (DHCS) implemented a new fee-for-service pharmacy reimbursement methodology, retroactive to April 1, 2017, to comply with the 2016 Centers for Medicare & Medicaid Services (CMS) Final Rule for Covered Outpatient Drugs (CMS-2345-FC). The rule not only mandated that state Medicaid agencies transition to an acquisition cost-based reimbursement for drug ingredient costs, but also ensured that the professional dispensing fee adequately reimburses providers for their costs of dispensing.
- 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:
- Less than 90,000 claims equals $13.20
- 90,000 or more claims equals $10.05
DHCS policy is that a claim is equivalent to a dispensed prescription.
- Why did 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.
- If I dispense 90,000 or more prescriptions during a reporting period, do I still need to complete an attestation?
- 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).
- 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.
- 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.
- 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.
- 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.
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