Rate reductions FY 2012: Support services for adults with intellectual 9 States reduced primary care disabilities: 2010 reimbursement Nursing facilities: 7/1/10 14 States reduced specialist Rehab & community support services for children reimbursement with cognitive impairments/physical limitations: 13 states reduced dental 6/1/11 retro to 9/1/10 reimbursement Developmental & behavioral clinic services: 7/1/10 Behavioral health services: 7/1/10 Transportation: 8/1/10 Occupational & physical therapy: 4/1/12 (pending) Podiatrist: 4/1/12 Private non-medical services: 10/1/10 Family planning: 7/1/11 Community support services: 7/1/10 Behavioral Health (Methadone): 4/1/12, 1/1/13 (pending) Group homes: 7/1/12 Pharmacy targeted PDLs & PA Rebates for crossover claims reforms MAC Rates Blood Factor Supplemental rebate agreements – pricing Restrictions on narcotics use to begin 1/1/2013 Supplemental rebates PAs for more costly drugs to begin 1/1/2013 Changes to ingredient cost & Tried & failed requirements dispending fee reimbursement Additional step therapy Increased use of generics & Restrictions on scripts to begin 1/1/2013 mail-order Suboxone 2 year limit to begin 1/1/2013 Enhanced management for Average Wholesale Price 16%: 4/1/12 – high cost & overprescribed (pending) drugs Mandatory generic substitution (pending) HIT to encourage appropriate Smoking cessation 50% reduction (pending) prescribing Medication Management Initiative Cost sharing incentives No coverage for: 340b payment at cost Anorexic or certain weight loss drugs Specialty drug vendors Most vitamins and herbal products Monitoring use of Hexachlorophene (for nursing facility patients) Products listed as part of the per diem rate of Pharmacy TPL cost – reimbursement for Nursing Facility Services avoidance Discontinued or recalled drugs Less than Effective Drugs (defined by FDA) TB drugs OTC drugs (unless designated otherwise) Fertility drugs Etc. (listed in MaineCare manual)
Rate reductions FY 2012: 9 States reduced primary care reimbursement 14 States reduced specialist reimbursement 13 states reduced dental reimbursement Support services for adults with intellectual disabilities: 2010 Nursing facilities: 7/1/10 Rehab & community support services for children with cognitive impairments/physical limitations: 6/1/11 retro to 9/1/10 Developmental & behavioral clinic services: 7/1/10 Behavioral health services: 7/1/10 Transportation: 8/1/10 Occupational & physical therapy: 4/1/12 (pending) Podiatrist: 4/1/12 Private non-medical services: 10/1/10 Family planning: 7/1/11 Community support services: 7/1/10 Behavioral Health (Methadone): 4/1/12, 1/1/13 (pending) Group homes: 7/1/12 Pharmacy targeted reforms PDLs & PA MAC Rates – Blood Factor pricing Supplemental rebates Changes to ingredient cost & dispending fee reimbursement Increased use of generics & mail-order Enhanced management for high cost & overprescribed drugs HIT to encourage appropriate prescribing Cost sharing incentives 340b payment at cost Specialty drug vendors Monitoring use of Pharmacy TPL – cost avoidance Rebates for crossover claims Supplemental rebate agreements Restrictions on narcotics use to begin 1/1/2013 PAs for more costly drugs to begin 1/1/2013 Tried & failed requirements Additional step therapy Restrictions on scripts to begin 1/1/2013 Suboxone 2 year limit to begin 1/1/2013 Average Wholesale Price – 16%: 4/1/12 (pending) Mandatory generic substitution (pending) Smoking cessation 50% reduction (pending) Medication Management Initiative No coverage for: Anorexic or certain weight loss drugs Most vitamins and herbal products Hexachlorophene (for nursing facility patients) Products listed as part of the per diem rate of reimbursement for Nursing Facility Services Discontinued or recalled drugs Less than Effective Drugs (defined by FDA) TB drugs OTC drugs (unless designated otherwise) Fertility drugs Etc. (listed in MaineCare manual)