Author: CSRA
On July 21, 2017, the Centers for Medicare & Medicaid Services (CMS) notified North Carolina Medicaid that its State Plan Amendment (SPA TN17-0003) had been reviewed and was approved effective April 1, 2017. The purpose of the proposed changes is to align the State Plan with changes to CFR 447.512 and 447.518 enacted in the covered outpatient drugs final rule (CMS-2345-FC).
This SPA implements changes to the pharmacy reimbursement methodology for ingredient costs and professional dispensing fees for clotting factor based on a survey of costs for Hemophilia Treatment Centers (HTCs) and non-HTCs. A 340-b and a non-340-b state maximum allowable cost (SMAC) rate will be established based on actual acquisition costs for all clotting factor drugs to determine reimbursement of the ingredient cost and the professional dispensing fees for all clotting factor drugs will be $0.04 per unit for HTCs and $0.025 per unit for non-HTCs
Moreover, the SPA specifies that drugs purchased through 340-B covered entities, Federal Supply Schedule, nominal price, and specialty drugs will be reimbursed at their actual acquisition costs.
The updated reimbursement methodology will be implemented into NCTracks April 29, 2018. Claims for clotting factor submitted after that date will be processed and reimbursed using the updated reimbursement methodology.
Pharmacy providers are reminded that clotting factor claims paid between April 1, 2017 and April 29, 2018, will be reprocessed using the updated reimbursement methodology. A future announcement will be posted in the Medicaid Bulletin and Pharmacy Newsletter when the date for the claim reprocessing has been finalized.
Pharmacy providers are advised that any overpayment determined during the reprocessing of these claims will be recouped against future payments.
CSRA, 1-800-688-6696