The purpose of the amendment to Rule 59G-4.251, Florida Administrative Code, is to establish the reimbursement methodology for prescribed drug claims in the Florida Medicaid program. The amendment also revises the rule title to Prescribed Drugs ...

 

AGENCY FOR HEALTH CARE ADMINISTRATION

Medicaid

RULE NO.:RULE TITLE:

59G-4.251Florida Medicaid Prescribed Drugs Reimbursement Methodology

PURPOSE AND EFFECT: The purpose of the amendment to Rule 59G-4.251, F.A.C., is to establish the reimbursement methodology for prescribed drug claims in the Florida Medicaid program. The amendment also revises the rule title to Prescribed Drugs Reimbursement Methodology.

SUMMARY: The rule amendment specifies who the rule applies to, revises the definition of estimated acquisition cost, makes technical edits throughout the rule text, and updates the name of the rule.

SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS AND LEGISLATIVE RATIFICATION: The Agency has determined that this will not have an adverse impact on small business or likely increase directly or indirectly regulatory costs in excess of $200,000 in the aggregate within one year after the implementation of the rule. A SERC has not been prepared by the Agency.

The Agency has determined that the proposed rule is not expected to require legislative ratification based on the statement of estimated regulatory costs or if no SERC is required, the information expressly relied upon and described herein: A checklist was prepared by the Agency to determine the need for a SERC. Based on this information at the time of the analysis and pursuant to section 120.541, Florida Statutes, the rule will not require legislative ratification.

Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.

RULEMAKING AUTHORITY: 409.919 FS.

LAW IMPLEMENTED: 409.906, 409.908, 409.912 FS.

A HEARING WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:

DATE AND TIME: April 5, 2015, 11:00 a.m. – 12:00 p.m.

PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Conference Room D, Tallahassee, Florida 32308-5407

Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 48 hours before the workshop/meeting by contacting: Arlene Elliott. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).

THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Arlene Elliott, Bureau of Medicaid Policy, 2727 Mahan Drive, Mail Stop 20, Tallahassee, Florida 32308-5407, telephone: [phone], email: [e-mail]

 

THE FULL TEXT OF THE PROPOSED RULE IS:

 

59G-4.251 Florida Medicaid Prescribed Drugs Reimbursement Methodology.

(1) This rule applies to all prescribed drug service providers enrolled in the Florida Medicaid program that provide services under the fee-for-service delivery system in accordance with Rule 59G-4.250, Florida Administrative Code.

(2) Definitions. Usual and customary charge - The average charge to all other customers in any quarter for the same drug, quantity, and strength.

(3) Reimbursement Methodology. Florida Medicaid reimburses Reimbursement for services prescribed drug claims is made in accordance with the provisions of Title 42, Code of Federal Regulations, sSections 447.512-.516. Reimbursement amounts for covered drugs dispensed by a licensed pharmacy, approved as a Medicaid provider, by an enrolled dispensing physician filling his own prescriptions, or by a medical professional administering injectable medications, shall not exceed the lesser lower of:

(a) The estimated acquisition cost, defined as the lower of:

(a)1. Average Wholesale Price (AWP) minus 16.4%, or The wWholesaler aAcquisition cCost (WAC) plus 1.5%, plus a dispensing fee of $3.73.;

(b)2. The fFederal uUpper lLimit (FUL) established by the Centers for Medicare and Medicaid Services, plus a dispensing fee of $3.73.; or

(c)(b) The sState mMaximum aAllowable cCost (SMAC), plus a dispensing fee of $3.73.; or

(d)(c) The provider’s uUsual and cCustomary (U&C) charge, including inclusive the of dispensing fee.

(e)(2) For drugs purchased by qualified entities under Section 340B of the Public Health Service Act:

The actual acquisition cost, plus a dispensing fee of $7.50. This provision only applies to cCovered entities, and fFederally qQualified hHealth cCenters or their contracted agents, that dispense or administer fill Medicaid patient prescriptions with drugs purchased at prices authorized under sSection 340B of the Public Health Service Act must bill Medicaid for reimbursement at the actual acquisition cost plus a dispensing fee of $7.50 for these drugs.

Rulemaking Authority 409.919 FS. Law Implemented 409.906(20), 409.908, 409.912(39)(a) FS. History–New 1-28-09, Amended 8-23-09, 5-20-12,________.

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Arlene Elliott

NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: Elizabeth Dudek

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: February 17, 2016

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: May 28, 2015