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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.

Ohio Supreme Court Clarifies Medical Statute of Limitations

The Ohio Supreme Court issued a decision in late December that clarifies and finalizes the Ohio law regarding the period of time in which patients can assert claims for medical malpractice. The Court was examining the interplay between three different statutes being the statute of limitations, the statute of repose, and the savings statute.

Ohio Hospitals and Healthcare Clinics: It’s Time to Revisit Your Billing and Collection Practices

According to a recent Cuyahoga County case, certain healthcare entities may not be protected from liability when engaging in unfair or deceptive billing acts. This decision is consistent with the growing trend across the country to encourage price transparency and eliminate unfair surprise billing practices by health care organizations. Now is the time for hospitals and other health care organizations to revisit their billing and collection policies and procedures to confirm that they are legally defensible and consistent with best practices.

HIPAA Business Associate Agreements: Why These Contracts Matter

No one loves drafting, reading or negotiating HIPAA Business Associate Agreements (BAAs). Yet many of us need to do so, and some of us do so daily. They are often boring, dense and technical, but BAAs are important from both a legal and a business perspective, and they deserve our attention. Failure to enter a BAA when one is required can constitute a HIPAA violation that results in substantial liability, as demonstrated by certain recent Department of Health & Human Services (HHS) settlements.1 A business associate who makes a disclosure that is not authorized by the applicable BAA or required by law can be subject to civil and, in some cases, criminal penalties. Further, parties are often presented with BAAs that contain onerous one-sided indemnification and other provisions that can be devasting to an organization in the event of a HIPAA breach. The significance of a BAA is often not fully understood by the parties until something goes wrong (e.g., a HIPAA security incident or breach, an Office of Civil Rights (OCR) audit or a fracture in the relationship between the parties) and, at that point, there is limited opportunity to mitigate legal and business risk. Ideally, attention should be given at the commencement of the business associate relationship, when the parties are able, to thoughtfully addressing regulatory requirements, planning and preparing for potential adverse events and appropriately allocating risk among the parties. As with most healthcare regulatory compliance initiatives, a proactive approach with respect to BAAs is preferable. This article provides a broad overview of certain BAA requirements and some practical negotiating tips for the parties involved.

“I’m Out Of Here!” Now What?

We all know that the healthcare industry is experiencing a wave of integration. This trend has been evident for many years. Fewer physicians are willing to assume the legal, financial and other business risks associated with owning their own practices. More and more physicians, including anesthesiologists, are becoming employed by large physician groups, health systems and national providers. This shift necessarily involves not only entry into new employment arrangements but also the termination of existing relationships. And those terminations are often governed by written employment agreements, state and federal healthcare laws and employer benefit plans and other policies and procedures. Before pursuing their next opportunity, physicians should pause for a moment and first attend to the arrangement that they are leaving. Departing physicians need to understand their legal rights and obligations when leaving their current employment relationships in order to avoid unintended consequences and detrimental missteps along the way. Here are a few words of practical advice for physicians contemplating an exit from their current employment arrangements.

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.