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Medicaid & State Issues

Medicaid Audits - Program Integrity

January 8th, 2013

Click here for documents to assist with Medicaid Audits provided by Program Integrity

NC Medicaid Diabetes Update:

Roche ACCU-CHEK Diabetic Supplies Program Extension

May 9th, 2012

Attention: DME and Pharmacy Providers

Prodigy diabetic supplies coverage extended until July 31, 2012. Roche and Prodigy diabetic supplies will be covered until July 31, 2012. Overrides will not be required. This applies to the durable medical equipment (DME) and pharmacy point-of-sale claims processing systems. Effective August 1, 2012 ONLY ACCU- CHEK diabetic supplies will be covered.

NC Medicaid Diabetic Update

December 1, 2011

Click here for Roche Document

Tax Code G.S. 105-164.13(12)d

October 3, 2011

Tax Code - NC Department of Revenue G.S. 105-164.13(12)d. exempts from sales and use tax “durable medical supplies sold on prescription.”  Please click here for the document.

URGENT UPDATE: NC Medicaid Incontinence Update

September 2, 2011

Members from the NCAMES Board were invited and did attend a specially called meeting by Medicaid yesterday regarding the incontinence program. As you know, NCAMES has been involved in this debate with the state for nearly a year and a half – offering ways to protect the benefit, protect patient access, protect the provider network and preserve fair reimbursement rates. We are still working with the Department regarding the rates they revealed yesterday which seem fair for the majority of the fee schedule but there are a few codes that need to be adjusted and the Department is open to this discussion. There is a push to begin the new pricing (including pull up codes) on October 1st. NCAMES is also working with the Department regarding this date and some adjustments that can be made to make a quick implementation more palatable.

Stay tuned for more information and Medicaid will release the fee schedule once is is approved and finalized.

August 24, 2011

NCAMES will participate in a meeting at the Division of Medical Assistance on September 1st regarding the incontinence program for Medicaid. NCAMES will be there along with other stakeholders invited by DMA. We have been told that the fee schedule and the implementation schedule will be released at that time. Our efforts to get any information prior to the meeting regarding the details have been unsuccessful. NCAMES never waivered in our desire to lobby for for fair rates and appropriate implementation time table that would ensure patient access to the benefit.

However, current rates you are using now are in still in place until further notice

May 24, 2011

To be fair, this isn't really much of an update other than late yesterday I heard from my contacts at the Division of Medical Assistance and for now, it's business as usual. This means the current fee schedule is still in place and there have not been any changes. The Department recognizes that NCAMES is ready to assist as those changes are made and pledged to talk with us before any changes are made. I currently have no schedule for these meetings but they discussed looking toward "some time in June". I'm sorry that we have no more detail than that, but as of today, that's all we know.

As you know, NCAMES stands ready to help with not only this benefit but there will without a doubt be more cuts down the road with the current budget needs for North Carolina. Stay tuned and thank you for your support. I must say that hearing from membership who understands this difficult situation is quite a lift to those who work tirelessly for NCAMES. Rest assured that your Board, task forces and your lobbyists are hard at work at the Legislature and within HHS to protect our industry.
 

April 20th, 2011

As you know the new rates have been released from Medicaid for the incontinence program and while NCAMES made huge efforts to influence those numbers...Click here for the rest of the update.

Medicaid Update

March 25th, 2011

For more information regarding Incontinence, Rehab, Prodigy, NPI-Carolina Access, CMN/PA Click Here.

Diabetic Supplies RFP

 

 
 

Office of Procurement and Contract Services
Attn: Sherri Garte
801 Ruggles Drive, Hoey Building
Raleigh, NC 27603
Telephone:     (919) 855-4086
Facsimile :      (919) 733-5957
e-mail :            sherri.garte@dhhs.nc.gov

  

Additional Information on the Medicaid Incontinence Bid Award 

 

March 4th, 2011

Click here for DHHS Press Release

March 1st, 2011

In an effort to obtain more information from the Department, NCAMES pressed for more details. We were notified that a press release is pending but due to our positive working relationship with DMA, they conferenced me in on a call to provide what information that they can for now. Many details are still being ironed out and after reading the information below, I'm certain you will still have questions.


The high volume of calls and emails that this has generated leads me to request that you please direct questions to beth@ncames.org with the Subject "NC Medicaid Incontinence Award" or reply to this email. Those questions will be accumulated and taken to the Department for answers.

This is all the information I have at this time:
 

  • Neil Medical was awarded the contract that has a May 1st implementation date. Their primary role is as a supplier and providers can order products through Neil. Neil's role as a provider would be as a back-up only.
  • The Department selected Option 1 on the RFP that allows for the provider community to stay in place, purchase products from the supplier and provide products to the patients they serve.
  • The Department is in the process of getting provider notifications sent out.
  • The policy will now be finalized to allow for these products on the DME fee schedule.
  • Rate setting is currently computing the Medicaid reimbursement rate for the fee schedule to provide for a "reasonable markup" as set forth in the RFP. NCAMES does NOT know what this rate is or what the margins are at this time.
  • At this time, I am not clear on what the protocol is for purchasing from another supplier or purchasing other products or the reimbursement tied to that.


PLEASE direct any questions to email and NCAMES will continue to work with the Department in the coming days and weeks. As information is made available, you will be notified immediately. Thank you for your interest.

January 28, 2011

NCAMES met with Secretary Cansler and the RFP results are not yet known but the Secretary understands NCAMES cost saving proposal and the need to protect jobs in North Carolina.  Once the RFP evaluates the results, the Department isn't tied to those results in any way and they have heard from us the many problems that can come from sole-sourcing!

October 2010

The latest on Incontinence - The RFP for incontinence products in still in play, however, NCAMES is still discussing our cost-saving proposal with the Department.

August 10th, 2010

The latest on Incontinence - to date the Department does not have a policy on these products though they remain on the fee schedule.  NCAMES is working with the Department to prevent sole-sourcing as we have offered a proposal to save the needed money in the budget.  NCAMES is waiting on word from the department.

February 25th, 2010

Incontinence Update:
The policy allowing durable medical equipment (DME) providers to seek reimbursement for medically necessary incontinence, ostomy, and urological supplies has been placed on temporary hold. The policy is under budgetary review.

Note: Any recipient needing these supplies should be referred to a home health agency in their area to obtain these items. A home care agency that is enrolled with Medicaid to provide Private Duty Nursing (PDN) services can also provide incontinence, osotomy and urological supplies to Medicaid recipients and there will no reimbursement to DME providers of the supplies effective 3/1/2010.

Prodigy Rebate Update
Per Prodigy the rebate checks are being sent out, NCAMES is verifying with Prodigy the exact date of mailing and hopes to share that with our membership tomorrow, but no later then Friday February 26, 2010
 

 

Update on Urological, Diapers, Ostomy Supplies

 

 

 

Prior Approval Items Removed:

During the NCAMES winter meeting Mary Lou Fleming (NCAMES Medicaid Chair) updated the attendees on the last Medicaid committee meeting. One issue discussed was a change in some items in regard to prior approval requirements that we wanted to make sure you knew about.

*The following items no longer require prior approval:


1. E0982
2. E0990
3. E0992
4. E0202
5. E0935
6. E0966
7. E0967
8. E2602
9. K0046
10. K0047
11. K0052
12. K0056
13. A9284


*These apply to all dates of service.
  

Medicaid Diabetes Contract with Prodigy - Q&A

 

December 15th, 2009

Question:
SUPPLIES: Prodigy is out of ½ cc syringes until Jan 1, 2010 and DMA is verifying availability on the quantity and at which wholesalers these syringes are still available? What is the phone and fax # at Prodigy where folks can send their MD prescription to when a Pediatric patient need a second meter?

Answer:
One (A second meter), this is what is posted under the updates link on our NC Provider page. For pediatric patients whose doctors require two meters for optimum patient care, please include a copy of the patient’s prescription with your rebate form and submit by mail or fax to 704-285-6495

Question:
I want to confirm that the ½ cc and 1/3 cc syringes will be in stock at Prodigy Jan 2nd 2010

Answer:
Yes, DMA in response to the temporary supply issue will temporarily lift the 1 time override on syringes (1/2cc and 1/3 cc), effective Friday December 18, 2009 until the supply issues has been resolved (Jan 2, 2010).

Question:
What is the present availability of ½ cc syringes through wholesalers?

Answer:
Cardinal and McKesson.

Question:
Please provide additional information on meters:

Answer:
CMN/PA is required on the voice meter and can only be provided through a DME provider or pharmacy/DME provider. The approved CMN/PA needs to be kept on file for the period of 5 years. With the completed CMN/PA for the voice meter on file, the provider can pursue reimbursement for the meter from Prodigy.  For a broken meter, contact Prodigy directly because all meters carry a lifetime replacement warranty. For a lost or stolen meter or a meter destroyed by fire, please contact DMA Clinical Policy DME section at 919-855-4310 for verification requirements and approval for a replacement meter.


December 11, 2009
DENIALS: DMA is looking into the denials and why certain claims deny. They hope to have more insight in the middle of next week.

 

Comments from DMA:
Pharmacies and DME providers should submit claims according to Medicaid policy. Medicaid recipients are eligible for a meter once every 2 years. If another meter is required, then prior approval may be requested under DME program outside of the limits established. If a Medicaid recipient receives a meter at another pharmacy or DME provider and the current pharmacy or DME provider is unaware of that request then current pharmacy or DME provider will be reimbursed for the meter. However, pharmacies and DME providers should bill for meters according to Medicaid policies and procedures within their individual locations.

Click here for Medicaid Q&A

New Medicaid Diabetes Contract
November 15, 2009

Dear NCAMES Members:

Information will be coming soon from NC Medicaid (DMA) regarding a new program from Prodigy Diabetes Care who will become the state’s sole source for diabetes care products as of November 15th (Target date). NCAMES has a very strong working relationship with the NC Medicaid office and after fighting off the “single source DME” they were still faced with huge budget shortfalls and had to find a way to save more money other than some line items cuts that we negotiated. NC Medicaid wanted to sole source diabetic supplies but NCAMES continued to communicate our desire to move away from this plan. Once DMA initiated the focus on diabetes testing supply costs, NCAMES continued work with them to make sure the patient and the provider were protected, while at the same time, save money. To our state, the most important outcome is the nearly $4 Million they will save over the two-year contract. It was very important to us to keep your reimbursement virtually the same despite the product and reimbursement model changes (lower reimbursement matched by lower cost of goods). Another element is that the reimbursement and costs are the same for all providers in NC, leveling the playing field in the market. The state sees this program as a win-win-win: Win for the state by saving money, win for the provider to keeps costs/payments nearly the same, and a win for the patients as they receive quality products. Soon, you’ll receive an announcement from the Medicaid office through email/fax with some operational and roll-out details. The goal is to make this transition as seamless as possible for all providers and recipients. We met for the last two days with Medicaid and yesterday with Prodigy Diabetes Care who promotes themselves as a high-tech, high-quality cost effective company based in Charlotte. Since the state decided to go forward with this plan, NCAMES assured them that we will continue to work together to implement this change and support our valuable membership base at the same time. We KNOW you will have questions and I can assure you that Medicaid wants to make this program a success. NCAMES will continue to work with them to ensure a transition that works for all. A few more details: Products affected: Glucose monitor, strips, lancets, lancing device, control solution and syringes.
 

Roll out plan:
 

Start date is November 15th, 2010.

  • DMA will mail recipients letters the week of Oct 12-16. All Medicaid staff is prepared for influx of calls.
  • DMA will be sending email blast to physicians and providers. Also you will find this information on DMA’s website.
  • Prodigy will be sending a team out or calling to educate vendors on the product and where to purchase the product.
  • Prodigy will be sending a team out to all endocrinologists, diabetic educators, PCP’s, clinics, and providers to educate and provide a demo meter.
  • Prodigy’s inbound call center will help Medicaid recipients locate a supplier and help with FAQ’s hotline 24/7.
  • Current existing Medicaid recipients requiring special glucose monitors should apply for Prior Approval immediately so there is no break in service.
  • DMA and HP Enterprises are aware of possible increase in PA’s for medical necessity strips or other products. HP Enterprises is the new name for EDS.
  • Prodigy is and has been prepared for the increase in product. They suggest to order TWO weeks prior to the “go live” date.
  • Prodigy has a special packaging with NDC# on the NC Medicaid product that will need to be put on claims and DMA is working on a special SC modifier for the companies that file with HPCS codes.
  • Prodigy has three glucose monitors and all are offered to NC Medicaid program: Autocode, Voice, and Pocket. All are blood plasma.
  • DME providers and Pharmacists will buy Autocode and Pocket meters up front for conversion and Prodigy will rebate full amount for what amounts to a free meter.
  • Prodigy will not provide any rebate on existing vision impaired recipients to get a Voice meter. Resolution: Prior Approval on existing and normal
  • DMA procedures on new Medicaid recipients for Voice meter.
     

Key contacts:
Prodigy Diabetes Care (supply and product questions):
800-366-5901 (main)
www.prodigymeter.com


Recipient Questions:
“careLINK”:
800-662-7030
www.nccarelink.gov


If you have any questions or concerns, please contact NCAMES at info@ncames.org 

February 9th, 2010

NCAMES Executive Director, Beth Bowen, heard from Frake Hunsel from DMA and there is still NO decision by DMA to clarify this issue for DME.

Background:  These items are currently on the DME fee schedule however, there is no policy in place at this time. The delay seems to be due to budget concerns. Frake will continue to update NCAMES. Thank you for your patience on this matter and please direct any concerns to beth@ncames.org and I will forward them to DMA right away!

 

MEDICAID Update

October 21st, 2010

NCAMES continues to work with the Department, and directly with Secretary Cansler to encourage support of NCAMES cost-savings proposal for incontinence products rather than use the results of the RFP.  Using a sole source could harm patient access, patient care, the businesses that serve them AND the North Carolinians they employ!   The Secretary has told NCAMES that the RFP cannot be pulled back but he assured us that the State is not bound to any of the results and can still consider NCAMES' proposal that will save the desired monies required by the budget.   The bid was extended and will be opened at 2pm, October 22nd.

NCAMES sent out the following message to its membership on 09/28/10.  It is vitally important that NCAMES is able to record every member's questions, so that we may discuss these issues with the Department of Medical Assistance.

Please email your questions to beth@ncames.org

September 28th, 2010

NCAMES was notified by the NC Department of Medical Assistance regarding an RFP for Incontinence products. NCAMES worked very hard with the Department, held meetings and offered cost-saving options over the last year hoping to prevent this RFP. However, the Department has chosen to go forward with the RFP. Please read the information below and email beth@ncames.org any questions that you would like NCAMES to pose to DMA by October 4th at 5pm. We will continue to work with DMA to strive to protect your businesses and the patients you serve.
 

INTERNET RFP NOTICE
RFP NUMBER: 30-DMA-263-11



DUE DATE FOR VENDOR QUESTIONS: October 5, 2010, 2:00 PM
DUE DATE FOR PROPOSALS: October 20, 2010, 2:00 PM

RFP 30-DMA-263-11 is available via the Internet.
The RFP can be located at the following address:  https://www.ips.state.nc.us/ips/

Click on Department Listing and scroll down to Department of Health and Human Services Any subsequent addenda will also be available via this website. If you have problems retrieving the document, you may contact Melba McCloud (919) 855-4082 or Jeanette McElroy (919) 855-4081 at the DHHS Office of Procurement and Contract Services.

Questions about anything you have read? Contact beth@ncames.org

DESCRIPTION: Incontinence Products Supplier for Medicaid Program
 

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