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Medi-Cal Claw Back / Special Session on Medi-Cal
The claw back for pharmacies is still slated to begin on August 28th. Some important points;
- Applies to pharmacy providers but in addition to drugs does include enteral formula. It applies to any items billed by a pharmacy using the electronic NCPDP standard or, any item billed using a similar paper billing process such as the Pharmacy Claim Form (30-1) and (30-4) where an NDC is used. In general, Medical Supplies are not included; however, there are exceptions. Below are some examples of non-drug items that are traditionally billed by pharmacies using the NCPDP format and therefore, subject to the reduction.
Diabetic Supplies: Strips, Lancets
Condoms
Heparin flush
Aerochambers (for asthma inhalers)
- The process will start with a notice to the provider indicating the total amount of the claw back. DHCS will then begin to claw back on check writes 2 to 3 weeks later at a rate of no more than 5% of the total check write amount. The process will begin with the larger chain pharmacies so some pharmacies may not get letters or start the process on that date.
- CAMPS continues to participate in meetings and conversations with DHCS on numerous issues. For example, we are still awaiting clarification from DHCS on how the claw back applies to CCS claims and crossover claims.
- The effected claims will in essence be reprocessed so the provider will see the claim with paid amount and the adjustment.
- There is no word yet on the timing to initiate the claw back on DME or medical supplies
Meanwhile the Legislature continues to meet in the Special Session on Medi-Cal that is running concurrently with the regular Session that will adjourn on September 11th. The focus has been on the current Managed Care Organization (MCO) Tax that CMS has determined to need adjustment to be more broad based, i.e. currently the MCO tax only applies to Medi-Cal managed care enrollees. The MCO tax provides $1.1B for the Medi-Cal program and will expire or need to be fixed by July 1, 2016. Republicans have been adverse to any tax increases and the broadening of the MCO tax to other insurance premiums is being met with resistance. The fact that end date is not until July 2016 also leads many observers to include that there will not be action in the short term.
The Special Session is seeing more support for an increase in the cigarette tax that could be used to increase Medi-Cal funding. A coalition of healthcare providers and SEIU are pushing for an initiative in 2016 that would raise the tax and dedicate part of that new revenue to increasing Medi-Cal provider rates. It may be that the Legislature does not take immediate action on Medi-Cal in the Special Session and the issue heads to the ballot in 2016. We will know more in the coming weeks.
SAVE THE DATE
CAMPS 2nd Annual Fall Conference
Thursday, November 5, 2015
8:30 am - 4:30 pm
Long Beach Yacht Club
Long Beach, CA 90803
CAMPS is hosting a one-day educational event discussing vital CA-specific healthcare provider issues with nationally known consultants and leaders with public agencies. Industry providers to have informational booths and be a part of discussion. Schedule finalized soon. Member and non-member registration rates include continental breakfast and lunch. More information here.
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One Capitol Mall, Suite 800
Sacramento, CA 95814 t: (916) 443-2115 f: (916) 444-7462 |
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