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New MA Reimbursement Rate Now in Effect

Friday, July 26, 2019   (0 Comments)
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From Minnesota Department of Human Services, July 19: Important changes were made to state law regarding the reimbursement rate for outpatient drugs covered by the fee-for-service (FFS) Medical Assistance (MA) program during the 2019 legislative session. See the Office of the Revisor Statutes SF 12 Bill Text Versions webpage for statutory references. DHS will reprocess claims for dates of service from July 1-18, 2019 on Aug. 29, 2019, and they will appear on pharmacies’ remittance advice on Sept. 17, 2019. Effective for claims with a date of service on or after July 1, 2019, the following changes will be incorporated into the MA reimbursement for outpatient drugs:

Drug reimbursement (ingredient cost, for example)

  • The reimbursement rate for drugs is the same for all pharmacies. The differential rate paid to rural independently owned pharmacies was eliminated.
  • The reimbursement rate for drugs is the lesser of the National Average Drug Acquisition Cost (brand or generic), the state maximum allowable cost or specialty maximum allowable cost, or the usual and customary charge submitted. If a drug does not have a National Average Drug Acquisition Cost, state maximum allowable cost and specialty maximum allowable cost, then the reimbursement rate is the lesser of the wholesale acquisition cost minus 2 percent or the usual and customary charge submitted.

Dispensing fee

  • The dispensing fee for “covered outpatient drugs”, as defined by federal law, will be increased to $10.48 from $3.65.
  • The dispensing fee for covered drugs that don’t meet the federal definition of a “covered outpatient drug” will remain $3.65. An example of a covered drug that doesn’t meet the definition of a “covered outpatient drug” is a covered over-the-counter (OTC) multivitamin.
  • The dispensing fee for all compounded intravenous solutions was changed to $10.48 per bag. All other dispensing fees for compounded intravenous products were eliminated.
  • The dispensing fee for covered OTC drugs will be prorated if a claim is for less than the manufacturer’s original package size.
  • The retrospective billing pharmacy OTC drug dispensing fee was eliminated.
  • The ong-term care blister card system dispensing fee was eliminated.

For full information, including details on 340B reimbursement, OTC drugs, MinnesotaCare tax, and additional changes, visit the Minnesota Health Care Programs website.

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