In The States – Weekly news about states

Alabama

Mandatory provisions of the Affordable Care Act require the Medicaid Agency (Medicaid) to select and provide oversight for a Medicaid Recovery Audit Contractor (RAC) to perform provider audits. Alivia Analytics, LLC (Alivia) was selected to be Medicaid’s RAC effective October 1, 2024. The RAC program is designed to improve payment accuracy by identifying under and overpayments in Medicaid. The Medicaid RAC program is separate from the Medicare RAC overseen by the Centers for Medicare and Medicaid Services.

Reviews will be conducted by Alivia staff to include a medical director, certified professional coders and experienced clinicians. Audits will be conducted by Alivia using a “top down” approach where data analysis, through data mining, is applied against the universe of paid claims to identify patterns of utilization or billing which look atypical based on Medicaid and/or national standards. Following the high-level claims analysis, Alivia may expand its review by requesting clinical records and/or other documents in accordance with state and federal regulations.

Alivia has been informed of the critical role that all providers play in a successful Medicaid program and requires that auditors be professional, objective and consistent in performing all required audits/reviews.

Providers are reminded that the Alabama Administrative Code, the Provider Manual and their Provider Agreements require compliance with requests for medical records for Medicaid program audits.

Questions regarding the audits should be directed to Jamie Cousins, RAC Program Manager, at (334) 353-8025 or Yulonda Carter, Recipient Review Associate Director, at (334) 242-5161.

Also in Alabama, the State Board of Pharmacy will transition to a new database in October of this year. The new system and the renewal process will look different. The changes will ultimately be positive but require you to create a new account to renew licenses, permits and registrations.

Finally in Alabama, as a reminder, 2024 is a year for pharmacist license renewals and pharmacy permit renewals.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

Michael Silber2024-09-05T10:05:19-04:00September 5, 2024|Alabama|

Alaska

The Board of Pharmacy adopted regulation changes in August related to pharmacy technicians, collaborative practice authorities, sterile pharmaceutical guidelines, manufacturer license requirements, PDMP registration, alternative to probation program and definitions. The regulation changes were reviewed and approved by the Department of Law, signed and filed by the Office of the Lieutenant Governor on August 29, 2024, and are effective on September 28, 2024. The filed version of the regulations will be posted in Register 251, October 2024 of the Alaska Administrative Code.

For more information, contact NACDS’ Mary Staples at 817-442-1155.

Michael Silber2024-09-05T10:04:11-04:00September 5, 2024|Alaska|

California

Last week, the State Assembly passed an amended version of SB 966, PBM Reform legislation, and the State Senate concurred with the amended version. Upon passage, the bill was ordered to “engrossing and enrolling” after which it will be presented to Gov. Gavin Newsom (D) for signature. The governor has until September 30 to act. The bill requires PBMs to apply for a licensure from the California Department of Insurance by January 1, 2027; clarifies the State Attorney General retains all authorities to maintain or restore competitive, fair and honest markets and prosecute state and federal antitrust and unfair competitive violations; prohibits retroactive fees; and would allow a pharmacy that is not owned by the PBM to participate in a PBM network as a preferred provider if the pharmacy is willing to accept the same terms and conditions. NACDS sent a letter to Gov. Gavin Newsom (D) urging him to sign SB 966 to help preserve and expand patient access to pharmacists, pharmacies of all sizes and the Californians they serve.

Also in California, last week, AB 3063 passed the state legislature and was ordered to “engrossing and enrolling” after which it will be presented to Gov. Gavin Newsom (D) who has until September 30 to act. This legislation states the addition of a flavoring agent to a conventionally manufactured product is not considered compounding if certain conditions are met. It also requires the addition of the flavoring agent to be documented in the prescription record.

Also in California, the Department of Health Care Services posted the following alerts and weekly notice and monthly bulletin on the Medi-Cal Rx Web Portal. Please note the MAIC 30-day pharmacy provider notice; rates will be effective October 1, 2024, and were to be posted to the Mercer Medi-Cal Rx website no later than September 1, 2024.

Finally in California, the Board of Pharmacy posted the agenda and meeting materials for the Full Board Meeting on September 12, 2024. Please note the discussion and action related to awarding a contract for medication error reporting.

For more information, contact NACDS’ Sandra Guckian at 703-774-4801.

Michael Silber2024-09-05T10:03:41-04:00September 5, 2024|California|

Colorado

Gov. Jared Polis (D) announced his new chief of staff, David Oppenheim, replacing Alec Garnett, who has been in that role since January 1, 2023. Garnett has accepted the position of vice president for government and regulatory affairs for the University of Colorado Health.

For more information, contact NACDS’ Mary Staples at 817-442-1155.

Michael Silber2024-09-05T10:03:09-04:00September 5, 2024|Colorado|

Florida

The purpose of this alert is to provide an update to the previous provider alert issued on August 4, 2024, regarding Hurricane Debby.

The following flexibilities/waivers offered to providers in the alert issued on August 4, 2024, expired at 11:59 pm on September 3, 2024:

Waiver of prior authorization requirements for critical Medicaid services
- The lifting of early prescription refill edits will remain in place in accordance with Gov. Ron DeSantis’ emergency executive orders issued for Hurricane Debby
Waiver of service limitations to ensure a recipient requiring critical Medicaid services during the storm receives such care
Temporary postponement of the Preadmission Screening and Resident Review processes

Additional questions from providers may be directed to the Florida Medicaid Contact Center at 1-877-254-1055

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

Michael Silber2024-09-05T10:01:42-04:00September 5, 2024|Florida|

Illinois

The Department of Healthcare and Family Services’ (HFS) Pharmacy Benefit Management System (PBMS) for the fee-for-service program, Change Healthcare, experienced a nationwide system outage as noted in the provider notice dated February 22, 2024. During the system outage, HFS was unable to add new National Drug Codes (NDCs) to the formulary. Providers were asked to hold fee-for-service (FFS) claims until the issue was resolved.

The new NDCs are now available and have been added to the formulary; therefore, providers may release all FFS claims that have been held pending the update.

Questions regarding this notice may be directed to a pharmacy consultant in the Bureau of Professional and Ancillary Services at 877-782-5565.

For more information, contact NACDS’ Leigh Knotts at 803-243-7207.

Michael Silber2024-09-05T10:01:10-04:00September 5, 2024|Illinois|

Indiana

The Family and Social Services Administration (FSSA) Office of Medicaid Policy and Planning (OMPP) is hosting an informational online seminar on the PathWays for Aging program on September 12 at 9:00 am. The presentation by OMPP staff will provide a post-implementation update of the PathWays program which launched on July 1, 2024. The online seminar will be recorded and posted on the PathWays stakeholder engagement website. You can view the online seminar on Zoom or the FSSA YouTube page at the time of the event.

Also in Indiana, FFSA pharmacy updates were approved by Drug Utilization Review Board at the August 2024 meeting.

Finally in Indiana, the Health Coverage Programs (IHCP) posted a bulletin reminding providers of administrative review requirements for fee-for-service prior authorization.

For more information, contact NACDS’ Mary Staples at 817-442-1155.

Michael Silber2024-09-05T10:00:42-04:00September 5, 2024|Indiana|

Iowa

The Department of Health and Human Services (HHS) announced the intent to award a Managed Care Organization (MCO) contract to Iowa Total Care. The new Iowa Medicaid contract period begins July 1, 2025, with no change in operations. This RFP and resulting contract aligns all three MCO contracts (Iowa Total Care, Molina, and Wellpoint Iowa, Inc.) to provide health care services to Iowans to the same contract cycle. All three MCO contracts will have a final contract end date of June 30, 2031.

For more information, contact NACDS’ Sandra Guckian at 703-774-4801.

Michael Silber2024-09-05T10:00:05-04:00September 5, 2024|Iowa|

Louisiana

Medicaid issued a bulletin revising the launch date for its Medicaid Provider Enrollment Rebaseline, which means new managed care organization (MCO) credentialed providers that have not enrolled with Medicaid will receive an invitation letter to enroll through the web portal. The invitation letter will provide specific provider information along with detailed instructions needed for the enrollment process.

Also in Louisiana, Medicaid issued a revised bulletin with contact information outlining the available options to providers for pursuing resolution of issues with Medicaid managed care organizations (MCOs) and the state’s fee-for-service claims processor, Gainwell Technologies. Unless explicitly notated, providers should first seek resolution with the MCO or Gainwell directly, prior to engaging the Department of Health or other third parties.

For more information, contact NACDS’ Mary Staples at 817-442-1155.

Michael Silber2024-09-05T09:59:35-04:00September 5, 2024|Louisiana|