On Tuesday, CVS Health unveiled its plan to overhaul drug pricing at its roughly 9,500 retail pharmacies, of which 466 are PA locations. According to the company, CVS CostVantage “evolves the traditional pharmacy reimbursement model and brings greater transparency and simplicity to the system. CVS CostVantage will define the drug cost and related reimbursement with contracted pharmacy benefit managers (PBMs) and payors, using a transparent formula built on the cost of the drug, a set markup, and a fee that reflects the care and value of pharmacy services.”

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In 2024, the Pennsylvania Office of Medical Assistance Programs (OMAP) will begin enrolling new provider types in the MA program to prepare for upcoming service expansion. Pharmacists will be enrolled as individual practitioners in early 2024. Pharmacies are currently enrolled, but now individual pharmacists will be enrolled too. Enrolled pharmacists will be able to provide services to MA beneficiaries within the scope of their licensure. MCOs will be able to submit encounters to the Department of Human Services for claims paid to pharmacists. Also beginning in early 2024, doulas will be enrolled in the MA Program for the purposes of managed care only. In 2024, doulas are required to be a part of maternity care teams, which MCOs must use to provide perinatal services for at least 25% of their covered births. The doulas may be employed or contracted by the birthing hospital or a physician group, or they may be independent. Like pharmacists, this enrollment will allow MCOs to submit encounters to DHS for any claims paid to doulas. To be enrolled in the MA Program, doulas will need to possess the PA Certification Board’s Certified Perinatal Doula credential. By establishing doula services in the managed care delivery system throughout 2024, OMAP is paving the way for doula services to be added to the State Plan once capacity has been established, hopefully in 2025. Community Health Workers (CHWs) are also going to be enrolled in the MA Program soon and are on track to be added to the State Plan in 2025. MCOs must work with CHWs as part of their Community Based Care Management programs. PACHC is seeking clarification from DHS on if and when each of these providers become eligible to generate an FQHC encounter and will share additional information when available.

The Pennsylvania Department of Human Services (DHS) made available for public review and comment the proposed Federal Section 1115 Demonstration application entitled “Bridges to Success: Keystones of Health for Pennsylvania,” which proposes Medicaid coverage for Health-Related Social Needs (HRSN), reentry supports and multiyear continuous eligibility for young children. The purpose of the proposed demonstration is to further the objectives of Medicaid to expand access to care, improve health outcomes, drive innovation, and engage partners and communities through targeted, time-limited interventions to address HRSNs. The demonstration application is available online at DHS’ website. DHS also announced three virtual public hearings to receive comments about the proposed demonstration, the first from 12:00-1:00 pm on Dec. 11, the second from 6:00-7:00 pm on Dec. 12, and the third from 9:00-10:00 am on Dec. 15. The department’s 30-day public comment period on the proposed demonstration application will be from Dec. 2, 2023, to Jan. 2, 2024. Additional information, including how to register for the public hearings, is available in the Pennsylvania Bulletin.

The Pennsylvania Governor’s Administration is alerting Pennsylvania companies to a new federal requirement. Beginning Jan. 1, many companies in the United States will have to report information about their beneficial owners, individuals who ultimately own or control a company, to the Financial Crimes Enforcement Network (FinCEN), a bureau of the U.S. Department of the Treasury. “While this is a federal requirement and not a Pennsylvania requirement, we are informing our business customers so that they can be prepared to comply,” Secretary of the Commonwealth Al Schmidt said. “The Department’s Bureau of Corporations and Charitable Organizations maintains records of more than three million companies that do business in the commonwealth and serves as the centralized filing office for Uniform Commercial Code financing statements.”

The Centers for Medicare & Medicaid Services (CMS) announced a proposed rule aimed at raising network adequacy standards for state-based exchange plans among other changes for health plans, agents, and brokers. Along with requiring state-based exchanges to have the same network time and distance standards as the federal exchanges, the proposals provide states with greater flexibility to determine financial eligibility policies, which could allow for targeted expansions of Medicaid coverage; allow state-run exchanges to require insurers to cover adult dental care as an essential health benefit; and require a transition period before states can establish a state-based marketplace. The changes are included in the Department of Health & Human Services (HHS) Notice of Benefit and Payment Parameters (Payment Notice) proposed rule for 2025.

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Legislation in the Pennsylvania House could help law enforcement crack down on Medicaid fraud. Last month Acting Attorney General Michelle Henry announced the arrests or convictions of providers accused of illegally billing Medicaid to the tune of $800,000. At the time, Henry touted a “staunch commitment to hold accountable those who steal from Pennsylvania’s most vulnerable residents.” “I could not agree more with the attorney general’s commitment to stop Medicaid fraud in Pennsylvania,” said Rep. Mike Cabell, R-Luzerne, the prime sponsor of House Bill 876, which was introduced earlier this year and would require Medicaid providers to use the National Provider Identifier (NPI) or State Provider Identifier (SPI) when filing a claim.

A recording of the hour-long session for health care employers in rural areas that took place on December 5^th.  The training includes how to share jobs on social media and how to use 3RNet Plus Tools to feature jobs and track candidates.  Watch this space for additional trainings from 3RNet scheduled for January and March.

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The Centers for Disease Control and Prevention (CDC) released an information sheet. The document describes the role of rural public health, rural health disparities, and strategies the CDC’s Office of Rural Health is developing to address inequities in rural health.

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Created for physicians, pediatricians, and other health professionals, the toolkit contains messaging for patients and families who have been disenrolled from Medicaid or the Children’s Health Insurance Program (CHIP), two forms of public health insurance coverage that play a critical role in rural areas.  Among the ready-to-use materials are messages for on-hold phone recordings, e-newsletters and patient portals, and Frequently Asked Questions from patients.  CMS estimates that more than 27 million people are due for renewal in Medicaid or CHIP.  As of August 2023, more than 7 million people were unenrolled, while more than 13 million had their enrollment renewed.

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This newsletter from the Medicare Learning Network provides information for staff involved in billing for services covered by the Medicare Physician Fee Schedule under policies that will take effect on January 1, 2024.

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