NCPA: Medicaid Managed Care Proposal Needs Improvements to Ensure Beneficiary Access to Pharmacies Continues


The National Community Pharmacists Association has submitted comments in response to the Medicaid managed care proposed rule from the Centers for Medicare and Medicaid Services.


ALEXANDRIA, Va. (July 29, 2015) ­


National Community Pharmacists Association

(NCPA) has

submitted comments

in response to the Medicaid managed care

proposed rule

from the Centers for Medicare and Medicaid Services (CMS). With the expansion of Medicaid in many states and the increased use of managed care organizations (MCOs) and pharmacy benefit manager (PBM) corporations to assist these new patients, it is important for NCPA to advocate for appropriate oversight of these corporate entities in order to protect these vulnerable patients as well as the pharmacy providers that serve them.

³Independent community pharmacies, often located in underserved and vulnerable population centers, have been indispensable to Medicaid beneficiaries receiving high quality prescription services,² said NCPA CEO B. Douglas Hoey, RPh, MBA. ³Therefore, we want to ensure efforts to make Medicaid more efficient and cost-effective do not have the unintended consequence of discouraging independent community pharmacies¹ continued participation in this vital program. We believe our suggestions are constructive, and we stand ready to work in concert with regulators and legislators to strengthen Medicaid by valuing the concerns of all the stakeholders ­ beneficiaries, taxpayers and health care providers ­ going forward.²

NCPA¹s comments included:

  • Supporting the application of a mandatory Medical Loss Ratio (MLR) on Medicaid managed care plans to ensure that these health plans spend a certain percentage of premiums on actual health care costs as opposed to administrative costs and/or plan profits.
  • Requesting clarification on how fees paid to PBM corporations who own mail order pharmacies are treated in the MLR calculation to ensure that MCOs are not incentivized to drive more beneficiaries to mail order pharmacy programs. The Medicaid patient demographic indicates that many of these patients suffer from more than one chronic disease condition and benefit greatly from actual face-to-face interaction with a community pharmacist.
  • Requiring the same PBM corporations¹ disclosures to plans and government entities that are currently required under the Affordable Care Act (ACA).
  • Suggesting CMS collaborate with stakeholders for policy standards within Medicaid Long-Term Services and Supports (MLTSS) in much the same way as had been done with Medicare Part D.
  • Proposing that CMS establish current TRICARE retail access standards as a minimum threshold for Medicaid managed care.
  • Mandating that CMS require states to stipulate to MCOs that fee-for-service Medicaid pharmacy reimbursement rates should serve as a minimum reimbursement ³floor.²
  • Making sure that pharmacy networks in Medicaid managed care programs include an ³any willing pharmacy² provision.
  • Forcing mandatory maximum allowable cost (MAC) drug pricing updates every seven days‹similar to what will be required in Part D in 2016.
  • Adding the protection of Medicaid beneficiary access to specialty medications by the use of CMS¹ Medicare Part D guidelines and giving Medicaid beneficiaries the option of accessing their prescription drug benefit through a retail pharmacy setting similar to what is currently required under Qualified Health Plans (QHPs) in the exchanges.
  • Stipulating that CMS ensure that pharmacy participation in Medicaid managed care contracts should not be used on a conditional basis or otherwise ³tied² to participation in other networks.

Hoey added, ³Clearly, the elephant in the room when it comes to Medicaid managed care is the manner in which PBM corporations operate, who due to a traditional lack of accountability and transparency, have been able to maximize their profits at the expense of others. When CMS issues its final rule it is our hope the reforms have the proper safeguards in place so the vulnerable populations of Medicaid beneficiaries will be able to continue getting pharmacy services that improve health outcomes and ultimately reduce spending.²

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