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Ohio Medicaid Starts Paying Pharmacists for COVID-19 Testing & Pilots Focus on Direct Care from Pharmacists

Two significant announcements were made by Ohio’s Department of Medicaid recently. Both announcements provide greater access to healthcare services for Medicaid beneficiaries in Ohio and by utilizing the expertise of pharmacists and providing reimbursement for their services related to COVID-19 testing.

Ohio Medicaid Starts Paying Pharmacists for COVID-19 Testing

On June 15, Ohio’s Department of Medicaid announced that it will begin to pay all pharmacies for the administration of COVID-19 tests.[1] Before this announcement, about 2,000 community pharmacies in Ohio were unable to conduct tests because there was no plan in place for reimbursement. Large chain pharmacies like CVS and Kroger were the only locations that offered testing because they have in-store clinics with credentials from the state allowing them to be paid for the service.[2] With this expansion, Medicaid beneficiaries now have greater access to COVID-19 tests.

Pharmacies serving both Medicaid fee-for-service waiver recipients and managed care plan members will be reimbursed for collection or swabbing for COVID-19 testing at a rate of $23.46.[3] Pharmacies serving Medicaid managed care members will bill through the plan’s Pharmacy Benefit Management systems. It is advised that Medicaid recipients contact their local pharmacy to confirm their participation in this program and to schedule testing. Additionally, pharmacies should contact each managed care plan to verify billing codes and claims processing.

Ohio’s Department of Medicaid noted this is one of the several initiatives it has implemented since the pandemic began. Other initiatives include waiving member co-pays regardless of a medication’s relation to COVID-19, authorizing reimbursement to pharmacists who dispense emergency refills without prescription, and enabling Medicaid members to shop at any pharmacy, regardless of provider network status, without jeopardizing pharmacy reimbursements.

Medicaid Pilots Focus on Direct Care from Pharmacists

In early 2019, Governor John Kasich signed SB 265 which formally recognized pharmacists as direct care providers in Ohio. The legislation permits health insurers to provide payment or reimbursement for direct services performed by a pharmacist within the pharmacist’s scope of practice.[4] These changes elevate the role of the pharmacist and improve patient access to pharmacist services in Ohio.[5]

In response to the passage of SB 265, Medicaid managed care plans started to implement pilot programs in Ohio. These pilot programs designate pharmacists as direct care providers and allow them to receive reimbursement for providing services. A main goal of the programs is to increase collaboration between hospitals and healthcare teams with pharmacists and to better utilize the expertise of pharmacists. Currently, there are three plans with pilot programs: Buckeye Health Plan, CareSource, and UnitedHealthcare.

Buckeye Health Plan launched the first phase of its program in June 2020. During this phase, participating pharmacists and physicians will work closely with patients living with chronic conditions such as diabetes, depression, and cardiovascular disease. Pharmacists will provide consultations, monitor medications, demonstrate medical equipment, order lab tests, and provide preventative care.[6] Steve Province, President and CEO of Buckeye Health Plan, stated, “[t]his offers more access, more help and more support to those who often need it the most. We believe in the added value this program provides to our members so much that we’re reimbursing pharmacists participating in the program for this expanded role."[7] This program has been implemented at Northeast Ohio Neighborhood Health Services, Primary Health Solutions in Cincinnati and The Christ Hospital also located in Cincinnati.

UnitedHealthcare’s Pharmacy Care Extension pilot program launched in April 2020. Franklin Pharmacy in Warren and Brewster Family Pharmacy in Brewster are the first independent Ohio pharmacies to join this program, which aims to leverage the expertise of pharmacists to work with physicians to manage chronic diseases and prevent unnecessary rehospitalizations.[8] Using their medication expertise, pharmacists will be able to prevent adverse reactions to medications and collaborate with other health care providers to provide a new level of care to patients.[9]

Information about CareSource’s pilot program will be announced soon. Their program will also reimburse pharmacists for clinical services. The participating pharmacists will focus on diabetes, asthma, opioid use, and smoking cessation. More pilot programs are expected to launch following SB 265 and the Ohio Pharmacists Association have a website dedicated to announcing on-going efforts to improve patient access to pharmacist care in Ohio. 

For more information, contact your primary BMD Health Care & Hospital Law attorney.

[1] Ohio Department Of Medicaid Advances Access To Statewide COVID-19 Testing, Ohio Department of Medicaid, June 29, 2020, https://medicaid.ohio.gov/Portals/0/Press%20Releases/COVID-Testing-Pharmacy-Reimbursement-Media-Advisory.pdf

[2] Catherine Candisky, Ohio’s community pharmacies can now offer COVID-19 tests, The Columbus Dispatch, June 15, 2020, https://www.dispatch.com/news/20200615/ohiorsquos-community-pharmacies-can-now-offer-covid-19-tests

[3] Ohio Department Of Medicaid Advances Access To Statewide COVID-19 Testing, Ohio Department of Medicaid, June 29, 2020, https://medicaid.ohio.gov/Portals/0/Press%20Releases/COVID-Testing-Pharmacy-Reimbursement-Media-Advisory.pdf

[4] Senate Bill 265 Summary, The Ohio Legislature, https://www.legislature.ohio.gov/legislation/legislation-summary?id=GA132-SB-265

[5] Provider Status: Expanding Patient Access to Pharmacist Services, Ohio Pharmacists Association, https://www.ohiopharmacists.org/aws/OPA/pt/sp/provider-status#:~:text=On%20January%204%2C%202019%2C%20Governor,growing%20role%20of%20the%20pharmacist.

[6] Buckeye Health Plan launches new program that expands pharmacist’s role in patient care, Ohio Pharmacists Association, https://ohiopharmacists.org/aws/OPA/pt/sd/news_article/308342/_PARENT/layout_interior_details/false

[7] Id.

[8] Pharmacists tapped by UnitedHealthcare to expand access to care and help improve health outcomes in Ohio, Ohio Pharmacists Association, https://ohiopharmacists.org/aws/OPA/pt/sd/news_article/293763/_blank/layout_interior_details/false

[9] Id.

Investment Training for the Second and Third Generations

Consider this scenario. Mom and Dad started the business from the ground up. Over the decades it has expanded into a money-making machine. They are able to sell the business and it results in a multimillion-dollar payday for their labors. The excess money has allowed Mom and Dad to invest with various financial advising firms, several fund management groups, and directly with new startups and joint ventures. Their experience has made them savvy investors, with a detailed understanding of how much to invest, when, and where. They cannot justify formation of a full family office with dedicated investors to manage the funds, but Mom and Dad have set up a trust fund for the children to allow these investments to continue to grow over the years. Eventually, Mom and Dad pass. Their children enjoy the fruits of their labors, and, by the time the grandchildren are adults, Mom and Dad's savvy investments are gone.

Provider Relief Funds – Continued Confusion Regarding Reporting Requirements and Lost Revenues

In Fall 2020, HHS issued multiple rounds of guidance and FAQs regarding the reporting requirements for the Provider Relief Funds, the most recently published notice being November 2, 2020 and December 11, 2020. Specifically, the reporting portal for the use of the funds in 2020 was scheduled to open on January 15, 2021. Although there was much speculation as to whether this would occur. And, as of the date of this article, the portal was not opened.

Ohio S.B. 310 Loosens Practice Barrier for Advanced Practice Providers

S.B. 310, signed by Ohio Governor DeWine and effective from December 29, 2020 until May 1, 2021, provides flexibility regarding the regulatorily mandated supervision and collaboration agreements for physician assistants, certified nurse-midwives, clinical nurse specialists and certified nurse practitioners working in a hospital or other health care facility. Originally drafted as a bill to distribute federal COVID funding to local subdivisions, the healthcare related provisions were added to help relieve some of the stresses hospitals and other healthcare facilities are facing during the COVID-19 pandemic.

HHS Issues Opinion Regarding Illegal Attempts by Drug Manufacturers to Deny 340B Discounts under Contract Pharmacy Arrangements

The federal 340B discount drug program is a safety net for many federally qualified health centers, disproportionate share hospitals, and other covered entities. This program allows these providers to obtain discount pricing on drugs which in turn allows the providers to better serve their patient populations and provide their patients with access to vital health care services. Over the years, the 340B program has undergone intense scrutiny, particularly by drug manufacturers who are required by federal law to provide the discounted pricing.

S.B. 263 Protects 340B Covered Entities from Predatory Practices in Ohio

Just before the end of calendar year 2020 and at the end of its two-year legislative session, the Ohio General Assembly passed Senate Bill 263, which prohibits insurance companies and pharmacy benefit managers (“PBMs”) from imposing on 340B Covered Entities discriminatory pricing and other contract terms. This is a win for safety net providers and the people they serve, as 340B savings are crucial to their ability to provide high quality, affordable programs and services to patients.