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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.

New York, Kansas, Massachusetts, and Delaware Become the latest States to Adopt Full Practice Authority for Nurse Practitioners

While the COVID-19 pandemic certainly created many obstacles and hardships, it also created many opportunities to try doing things differently. This can be seen in the instant rise of remote work opportunities, telehealth visits, and virtual meetings. Many States took the challenges of the pandemic and turned them into an opportunity to adjust the regulations governing licensed professionals, including for advanced practice registered nurses (APRNs).

Explosive Growth in Pot of Gold Opportunity for Bank (and Other) Cannabis Lenders Driving Erosion of the Barriers

Our original article on bank lending to the cannabis industry anticipated that the convergence of interest between banks and the cannabis industry would draw more and larger banks to the industry. Banks were awash in liquidity with limited deployment options, while bankable cannabis businesses had rapidly growing needs for more and lower cost credit. Since then, the pot of gold opportunity for banks to lend into the cannabis industry has grown exponentially due to a combination of market constraints on equity causing a dramatic shift to debt and the ever-increasing capital needs of one of the country’s fastest growing industries. At the same time, hurdles to entry of new banks are being systematically cleared as the yellow brick road to the cannabis industry’s access to the financial markets is being paved, brick by brick, by the progressively increasing number and size of banks that are now entering the market.

2021 EEOC Charge Statistics: Retaliation & Impact of Remote Work

The U.S. Equal Employment Opportunity Commission (EEOC) released its detailed information on workplace discrimination charges it received in 2021. Unsurprisingly, for the second year in a row, the total number of charges decreased as COVID-19 either shut down workplaces or disconnected employees from each other. In 2021, the agency received a total of approximately 61,000 workplace discrimination charges - the fewest in 25 years by a wide margin. For reference, the agency received over 67,000 charges in 2020, and averaged almost 90,000 charges per year over the previous 10 years.

Ohio’s Managed Care Overhaul Delayed – New Implementation Timeline

At the direction of Governor Mike DeWine, the Ohio Department of Medicaid (ODM) launched the Medicaid Managed Care Procurement process in 2019. ODM’s stated vision for the procurement was to focus on people and not just the business of managed care. This is the first structural change to Ohio’s managed care system since the Centers for Medicare & Medicaid Services' (CMS) approval of Ohio’s Medicaid program in 2005. Initially, all of the new managed care programs were supposed to be implemented starting on July 1, 2022. However, ODM Director Maureen Corcoran recently confirmed that this date will be pushed back for several managed care-related programs.

Laboratory Specimen Collection Arrangements with Contract Hospitals - OIG Advisory Opinion 22-09

On April 28, 2022, the Department of Health and Human Services, Office of Inspector General (“OIG”) published an Advisory Opinion[1] in which it evaluated a proposed arrangement where a network of clinical laboratories (the “Requestor”) would compensate hospitals (each a “Contract Hospital”) for specimen collection, processing, and handling services (“Collection Services”) for laboratory tests furnished by the Requestor (the “Proposed Arrangement”). The OIG concluded that the Proposed Arrangement would generate prohibited remuneration under the federal Anti-Kickback Statute (“AKS”) if the requisite intent were present. This is due to both the possibility that the proposed per-patient-encounter fee would be used to induce or reward referrals to Requestor and the associated risk of improperly steering patients to Requestor.