Kentucky Administrative Regulations › Title 907 - CABINET FOR HEALTH AND FAMILY SERVICES - DEPARTMENT FOR MEDICAID SERVICES › Chapter 23 - Outpatient Pharmacy Program › Section 907 KAR 23:020 - Reimbursement for outpatient drugs

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO:KRS 205.5510 to 205.5520,
				205.560,
				205.561,
				205.5631,
				205.5632,
				205.5634,
				205.5636,
				205.5638,
				205.5639,
				205.622,
				205.6316(4),
				217.015,
				42
				C.F.R. 440.120,
				447.45,
				447.500 -
				447.520,
				42
				U.S.C. 256b,
				1396a
				- 1396d,
				1396r-8
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
				Family Services, Department for Medicaid Services has responsibility to
				administer the Medicaid Program.
				KRS
				205.520(3) authorizes the
				cabinet, by administrative regulation, to comply with any requirement that may
				be imposed or opportunity presented by federal law to qualify for federal
				Medicaid funds.
				KRS
				205.561(2) and
				205.6316(4)
				require the department to promulgate an administrative regulation to establish
				the professional dispensing fee for covered drugs. This administrative
				regulation establishes the Medicaid Program reimbursement requirements,
				including the professional dispensing fee, for covered outpatient drugs
				dispensed to all enrolled Medicaid recipients.
Section 1. Reimbursement. Reimbursement to a
			 pharmacy or medical provider participating in the Medicaid Program for a
			 covered outpatient drug provided to an eligible recipient shall be determined
			 in accordance with the requirements established in this section.
(1) A rebate agreement in accordance with
			 42 U.S.C.
			 1396r-8(a) shall be signed
			 by the drug manufacturer, or the drug shall be provided based on an exemption
			 from the rebate requirement established by
			 907 KAR
			 23:010, Section 5(3).
(2) A pharmacy claim shall meet the point of
			 sale (POS) requirements for services in accordance with
			 907 KAR
			 1:673.
(3)
			 Reimbursement shall not be made for more than one (1) prescription to the same
			 recipient during the same time period for a drug with the same:
(a) National Drug Code (NDC); or
(b) Drug or active ingredient name, strength,
			 and dosage form.
(4) A
			 timely claim payment shall be processed in accordance with
			 42 C.F.R.
			 447.45.
(a)
			 In accordance with
			 42 C.F.R.
			 447.45, a claim shall be submitted to the
			 department within twelve (12) months of the date of service.
(b) The department shall not reimburse for a
			 claim submitted to the department after twelve (12) months from the date of
			 service unless the claim is for a drug dispensed to an individual who was
			 retroactively determined to be eligible for Medicaid.
(c) The department shall not reimburse a
			 claim for a drug dispensed to an individual who was retroactively determined to
			 be eligible for Medicaid after 365 days have lapsed from the date that the
			 department issued the notice of retroactive eligibility.
(5) Reimbursement shall be denied if:
(a) The recipient is ineligible on the date
			 of service;
(b) The drug is
			 excluded from coverage in accordance with
			 907 KAR
			 23:010; or
(c) Prior authorization is required by the
			 department and the request for prior authorization has not been approved prior
			 to dispensing the drug, except in an emergency supply situation.
(6) Pursuant to
			 KRS
			 205.622, prior to billing the department, a
			 provider shall submit a bill to a third party payer if the provider has
			 knowledge that the third party payer may be liable for payment.
(a) If a provider is aware that a Medicaid
			 recipient has additional insurance or if a recipient indicates in any manner
			 that the recipient has additional insurance, the provider shall submit a bill
			 to the third party in accordance with
			 KRS
			 205.622.
(b) A provider who is aware that a recipient
			 may have other insurance, but the other insurance is not identified on the
			 medical assistance identification card or by the recipient, shall notify the
			 department's fiscal agent of the potential third-party liability.
(7) There shall be no copayment or
			 cost-sharing for an outpatient drug.
(8) If a payment is made for a drug that was
			 not administered or dispensed in accordance with
			 907 KAR
			 23:010 or the payment was not appropriately reimbursed
			 as required by this administrative regulation, the provider shall refund the
			 amount of the payment to the department or the department may, at its
			 discretion, recoup the amount of the payment.
(9) Adherence to the requirements established
			 in this section shall be monitored through an on-site audit, post payment
			 review of the claim, a computer audit, or an edit of the claim.