Transition (Carve-Out) of Pharmacy Benefit from Managed Care to Fee-For-Service (FFS)
All Stakeholder: Implementation Update
- Presentation also available in Portable Document Format (PDF)
November 16, 2020
Overview
Project Overview
- Transitioning pharmacy services from Managed Care to fee-for-service (FFS) will, among other things, do the following:
- Provide the State with full visibility into prescription drug costs.
- Centralize and leverage negotiation power.
- Provide a single drug formulary with standardized utilization management protocols.
- Address the growth of the 340B program and associated reductions in State rebate revenue.
Stakeholder Engagement Update
All Stakeholders: Monthly
Purpose:
NYS DOH will lead and provide all interest stakeholders with updates, facilitate a Q&A session, and incorporate feedback into the workplan as needed.Status:
- Monthly meetings ongoing starting with July 13 session
- Remaining meetings scheduled for third Monday of each month
Technical Workgroup: Bi-weekly
Purpose:
NYS DOH is leading working sessions with Medicaid Managed Care Plans (and other subject matter experts as needed) to address transition topics and incorporate feedback into the workplan as needed.Status:
- Sessions 1-7 complete covering Roles & Responsibilities, Scope of Benefits, Data Sharing, Transition Strategy, Member & Provider Communication, Value-Based Payments, QARR Measures, Program Integrity, DME Supplies
- Next two sessions will address Transition & Communication Activities and Model Contract
340B Advisory Group: Four Meetings
Purpose:
Provide non-binding recommendations by October 1, 2020 regarding the reimbursement of 340B claims.Status:
- Three meetings held on 8/5, 8/26, 9/16.
- No formal recommendations have been submitted by the Advisory Group to date.
- A fourth meeting will be scheduled with the Advisory Group in the coming weeks.
Key Deliverables and Timeline Update
Key Deliverables and Timeline Update
Deliverable(s) | Target Date |
---|---|
Complete Work Plan and Establish State Transition Team and 340B Advisory Group | June 2020 ✔️ |
Recurring Workgroup Calls with Health Plans and All Stakeholders begin | July 2020 ✔️ |
Frequently Asked Questions Posted to the NYS DOH Website | August 2020* ✔️ |
Finalize NYS DOH/Managed Care Plan Roles and Scope of Benefits | September 2020 ✔️ |
Consensus between the state and plans on data sharing concept | October 2020 ✔️ |
Deliver file formats, data dictionary, and process for daily claim file | November 2020 |
Transition Analysis Conducted (e.g., Formulary, DME, OTC Comparisons), Changes Made To Smooth Transition and Transition Strategy Finalized | November 2020 |
Identify Sections of the Model Contract that Require Changes | December 2020 |
Notice of 1115 Waiver Amendment | December 2020 |
Required System Changes Identified and Implemented | December 2020 |
340B Related State Plan Amendment (SPA) Submitted (if necessary) | December 2020 |
Initial Special Edition Medicaid Update Published | December 2020 |
Systems Stress Testing Performed | January 2021 |
Member and Provider Notifications Sent and Second Special Edition Medicaid Update Published | February 2021 |
Customer Service Staff Hired and Trained | February 2021 |
Make Required Changes to Common Benefit Identification Card (CBIC), Carrier or Notice | February 2021 |
1115 Waiver Amendment and SPA Approved by CMS | March 2021 |
Go Live: Daily Calls with Stakeholders (through 4/30/2021 or Beyond as Needed) | April 2021 |
* Initial FAQs posted and will be regularly updated as project progresses.
Updates
- Transition & Communications Timeline
- Scope of Benefits
- Durable Medical Equipment (DME)/Supplies
- FAQs Updated on October 23 & November 5, 2020 - DME Supplies Focus
Medicaid Update - Provider Enrollment
- October 2020 Medicaid Update - Provider Enrollment
Article: Pharmacies, Durable Medical Equipment, Prosthetics, Orthotics and Supply Providers, and Prescribers That are Not Enrolled in Medicaid Fee-for-Service (p. 10)
Communications & Resources
Website Updates
- The following content has been added to the website since the last meeting:
- All Stakeholder October 19 Presentation
- Scope of Benefits Updated October 21, 2020
- FAQ Update - November 5, 2020
- Transition & Communication Activities Timeline - November 10, 2020
- Website updates will continue to be communicated via the MRT listserv.
Resources
Website: www.health.ny.gov/health_care/Medicaid/redesign/mrt2/
Information regarding the transition of the pharmacy benefit from Managed Care to FFS will be posted at the above website.
Email: PPNO@health.ny.gov – Please write Carve-Out in the subject line
MRT LISTSERV: /health_care/medicaid/redesign/listserv.htm
Q&A
Questions?
Please enter your question within the chat feature of the WebEx Event meeting.
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