TennCare Drug Utilization Review (DUR) Board Minutes - Magellan ...

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o o o o the level 1 (approximately $27) reimbursement TennCare proposed. Next year reimbursement will be between $27 and $50 using non-recurring funds. In FY 2014 the reimbursement rate will be re-evaluated. Supplemental grants to the Med/ Metro/ Jellico were restored. TNAAP contract was restored for FY2013 with $100,000 nonrecurring funds. Proposed reductions not in the Governor’s budget that will not be implemented include: • Eliminate hospice support services for adults • 1.25% provider rate reduction • Eliminate adult allergy medication coverage • Mental health provider rate reduction • Co-pay for non-pregnant adults for some services Other changes that are forms of reductions • Currently TennCare has low requirements to be eligible for long term care requiring only 1 Activities of Daily Living (ADL) deficiency. This is more generous than most states in the country. • Tennessee is proposing to change that to 3 groups. The change requirements for nursing facility care include: • Deficiencies in 3-4 ADLs to qualify for nursing home ‣ Choices Group 1 - Nursing Home Care Recipients ‣ Choices Group 2 – Home care recipients (HCBS) Adults 65 years of age and older OR adults 21 years of age and older who have physical disabilities ‣ New Group: Choices Group 3 Deficiency in 1-3 ADLs Not eligible for residential care but will be eligible for HCBS program • This will allow TennCare to provide services to those in need without being too liberal regarding nursing home services. • HBCS providers are going to see some reduction in their rates. It’s a blended rate of homemaker and personal assistant. • Limit Retroactive Eligibility payments to MCO: Currently if a member is approved for retroactive eligibility TennCare will pay 2 years full capitation rate to the MCO. It’s proposed that TennCare pay the full capitation rate for no more than 12 months of retroactive eligibility and pay only for claims received for services rendered prior to the 12 months. • TennCare is going to follow CMS policy to not pay for hospital acquired conditions that could be preventable. • TennCare Standard Spend Down o The new enrollment opened February 21, 2012. o There were approximately 2,500 calls in just over an hour. • EHR Provider Incentive Program o As of February 17, 2012, $37,242,756.58 has been paid out to 1,011 eligible professionals and 19 eligible hospitals. • John B Lawsuit 2
o John B lawsuit addresses the adequacy of EPSDT services provided by TennCare for children under the age of 21. On 2/14/2012, Judge Wiseman issued a ruling stating that the State is in substantial compliance with all the binding provisions of the consent decree. He vacated the consent decree, dissolved all injunctive relief and dismissed the case. The plaintiffs have said they intend to appeal to the 6 th circuit court. • ICD -10 Implementation o ICD – 10 was scheduled for October 1, 2013. However, CMS has indicated it’s considering a delay due to concerns from the AMA (American Medical Association) regarding the burden on physicians to meet the deadline. There is no information on whether the delay will be granted at this time. Until further notice, TennCare continues to work toward the deadline requirements for the ICD- 10 implementation that was previously set. Dr. Woods gave an update on the TennCare Pharmacy Program: • New NCPDP D.0 Claim Standard format o o o January 1 st , 2012 the new NCPDP D.0 format went into effect replacing the previously accepted 5.1 claim format. The transition to the new format went smoothly. Pharmacies were allowed a transition period during the month of December in which both the 5.1 and D.0 formats were accepted, so pharmacies could properly convert to the new format. During that time they were encouraged pharmacies to contact SXC to work out any problems. Pharmacies that wanted to test submission of claims in the new format were advised to contact SXC to arrange a testing time. There will be future guidance going out to the pharmacies regarding a couple new fields required to properly identify 340B claims. The federal government has put forth some guidance stating that states must have a way of documenting methodology, how 340B claims are identified and ensure providers that are identified as 340B providers are submitting their claims with 340B pricing. Any provider who qualifies as a 340B provider gets the discount up front so those claims are not eligible for federal rebates. There will be some future guidance going out as to specifically what fields will be required and what values need to be put in those fields to properly identify 340B claims. • Pharmacy Budget Reductions o In FY2013 the proposed budget item regarding implementing a more aggressive MAC (maximum allowable cost) on certain generic drugs was postponed due to non-recurring funds. If no additional funds are available this will go in after FY 2013. • Proposed Budget Reductions for FY 2013 o Enhanced Third Party Liability (TPL) - In July 2011, a POS (point of sale) coordination of benefits (COB) edit was implemented. This COB edit identified members who were known to have primary insurance and required that the pharmacy submit the claim to the primary insurance first, with TennCare being the payor of last resort. It’s anticipated that this edit will continue into the next budget year and will continue to provide savings for the State. This is a great edit to make sure we are the payor of last resort. 3
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TennCare Drug Utilization Review (DUR) Board Minutes - Magellan ...

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