BEFORE THE DEPARTMENT OF PUBLIC
HEALTH AND HUMAN SERVICES OF THE
STATE OF MONTANA
In the matter of the amendment of ARM 37.85.105 and 37.86.1105 pertaining to Medicaid pharmacy unit dose prescription fee
NOTICE OF PUBLIC HEARING ON PROPOSED AMENDMENT
TO: All Concerned Persons
1. On September 25, 2013, at 3:00 p.m., the Department of Public Health and Human Services will hold a public hearing in Room 207 of the Department of Public Health and Human Services Building, 111 North Sanders, Helena, Montana, to consider the proposed amendment of the above-stated rules.
2. The Department of Public Health and Human Services will make reasonable accommodations for persons with disabilities who wish to participate in this rulemaking process or need an alternative accessible format of this notice. If you require an accommodation, contact Department of Public Health and Human Services no later than 5:00 p.m. on September 18, 2013, to advise us of the nature of the accommodation that you need. Please contact Kenneth Mordan, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena, Montana, 59604-4210; telephone (406) 444-4094; fax (406) 444-9744; or e-mail email@example.com.
3. The rules as proposed to be amended provide as follows, new matter underlined, deleted matter interlined:
37.85.105 Effective dates, CONVERSION FACTORS, POLICY ADJUSTERS, AND COST-TO-CHARGE RATIOS of Montana Medicaid Provider Fee Schedules (1) and (2) remain the same.
(3) The department adopts and incorporates by reference, the fee schedule for the following programs within the Health Resources Division, on the date stated.
Iinpatient hospital services fee schedule and inpatient hospital base fee schedule rates includ eing:
(i) remains the same.
(ii) the Montana Medicaid APR-DRG relative weight values, average national length of stay (ALOS), outlier thresholds, and APR grouper version 29
are contained in the APR-DRG Table of Weights and Thresholds effective July 1, 2013. The department adopts and incorporates by reference the APR-DRG Table of Weights and Thresholds effective July 1, 2013.
Ooutpatient hospital services fee schedules includ eing:
(i) the Outpatient Prospective Payment System (OPPS) fee schedule as published by the Centers for Medicare and Medicaid Services (CMS) in 71 Federal Register 226, effective January 1, 2007, and reviewed annually by CMS as required in 42 CFR 419.5
and as updated quarterly by the department;
(ii) through (c) remain the same.
(d) The Relative Values for Dentists, as provided in ARM 37.86.1004, reference published in 2013 resulting in a dental conversion factor of $31.89 and fee schedule is effective July 1, 2013.
The dental services covered procedures, the Dental and Denturist Program Provider Manual, as provided in ARM 37.86.1006, is effective July 1, 2013.
(e) The dental services covered procedures, the Dental and Denturist Program Provider Manual, as provided in ARM 37.86.1006, is effective July 1, 2013.
(e) remains the same but is renumbered (f).
(i) remains the same.
(ii) a minimum of $2.00 and a maximum of $6.52 for preferred brand-name and generic drugs and generic drugs not identified on the preferred list
(iii) (g) The outpatient drugs reimbursement, compound drug dispensing fee range as provided in ARM 37.86.1105(4), the dispensing fee for each compounded drug will be $12.50, $17.50, or $22.50 based on the level of effort required by the pharmacist, is effective July 1, 2013 ;.
(iv) (h) The outpatient drugs reimbursement, vaccine administration fee as provided in ARM 37.86.1105(5), the vaccine administration fee will be $21.32 for the first vaccine and $13.38 for each additional administered vaccine, effective July 1, 2013 ; and.
(v) (i) The out-of-state providers will be assigned a $3.50 dispensing fee.
(j) The outpatient drugs reimbursement, unit dose prescriptions fee as provided in ARM 37.86.1105(9), will be $0.75 per pharmacy-packaged unit dose medication, effective November 1, 2013.
(f) through (k) remain the same but are renumbered (k) through (p).
(4) through (6) remain the same.
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-2-201, 53-6-101, 53-6-402, MCA
37.86.1105 OUTPATIENT DRUGS, REIMBURSEMENT (1) through (8) remain the same.
(9) The department will reimburse pharmacies a unit dose prescription fee as provided in ARM 37.85.105(3). The unit dose prescription fee will offset the additional cost of packaging supplies and materials which are directly related to filling unit dose prescriptions by the individual pharmacy. This fee is in addition to the regular dispensing fee allowed. The unit dose prescription fee will not be paid for a unit dose prescription packaged by drug manufacturers. Unit dose prescriptions may not exceed the 34-day supply limit. Only one unit dose prescription fee is allowed each month for each prescribed medication.
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-2-201, 53-6-101, 53-6-113, MCA
4. STATEMENT OF REASONABLE NECESSITY
The Department of Public Health and Human Services (department) proposes to amend ARM 37.85.105 and 37.86.1105.
These rule changes are necessary to update the rules to accurately reflect how pharmacy benefits are administered. The unit dose prescription fee has been in place for several years and was inadvertently removed from the rules and needs to be added back for consistency. In 2007, the department was poised to modify ARM 37.86.1102, in regards to outpatient drug reimbursement to comply with provisions of the Deficit Reduction Act of 2005 (DRA). One component of the DRA required the department to remove the enhanced payment for unit dose prescriptions. During the rule amendment process the National Association of Chain Drug Stores (NACDS) and the National Community Pharmacists Association (NCPA) filed suit in federal court against CMS and won an injunction in December 2007, staying certain parts of the regulation relating to pharmacy reimbursement. The department pulled the proposed rule changes and inadvertently did not reinstate the unit dose dispensing fee at that time. As of today, CMS has not changed the dispensing fee rules; therefore, it is essential that the unit dose dispensing fee be returned to the administrative rules since the department has continued to pay them in accordance with the Medicaid State Plan.
The department is proposing to amend this rule by adding the fee associated with pharmacy-packaged unit dose prescriptions. The formatting of this rule is being amended to align the numbering and text with the other text in this rule.
The department is proposing to amend this rule by adding back into the rule the description and limitations for unit dose prescriptions. This language was mistakenly removed in 2007 and is now being corrected.
No fiscal impact is anticipated by the proposed rule amendments. These changes are expected to be budget neutral.
5. The department intends to adopt these rule amendments effective November 1, 2013.
6. Concerned persons may submit their data, views, or arguments either orally or in writing at the hearing. Written data, views, or arguments may also be submitted to: Kenneth Mordan, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena, Montana, 59604-4210; fax (406) 444-9744; or e-mail firstname.lastname@example.org, and must be received no later than 5:00 p.m., October 3, 2013.
7. The Office of Legal Affairs, Department of Public Health and Human Services, has been designated to preside over and conduct this hearing.
8. The department maintains a list of interested persons who wish to receive notices of rulemaking actions proposed by this agency. Persons who wish to have their name added to the list shall make a written request that includes the name, e-mail, and mailing address of the person to receive notices and specifies for which program the person wishes to receive notices. Notices will be sent by e-mail unless a mailing preference is noted in the request. Such written request may be mailed or delivered to the contact person in 6 above or may be made by completing a request form at any rules hearing held by the department.
9. An electronic copy of this proposal notice is available through the Secretary of State's web site at http://sos.mt.gov/ARM/Register. The Secretary of State strives to make the electronic copy of the notice conform to the official version of the notice, as printed in the Montana Administrative Register, but advises all concerned persons that in the event of a discrepancy between the official printed text of the notice and the electronic version of the notice, only the official printed text will be considered. In addition, although the Secretary of State works to keep its web site accessible at all times, concerned persons should be aware that the web site may be unavailable during some periods, due to system maintenance or technical problems.
10. The bill sponsor contact requirements of 2-4-302, MCA, do not apply.
11. With regard to the requirements of Chapter 318, Section 1, Laws of 2013, the department has determined that the amendment of the above-referenced rules will not significantly and directly impact small businesses.
/s/ John C. Koch /s/ Richard H. Opper
John C. Koch Richard H. Opper, Director
Rule Reviewer Public Health and Human Services
Certified to the Secretary of State August 26, 2013.