Baton Rouge: On November 1, 2012, pharmacy becomes a benefit of three Medicaid Bayou Health Plans, with those plans assuming responsibility for helping members access pharmacy services, encouraging compliance with medication and driving use of the most clinically effective, least expensive drug available.
"The first phase of Bayou Health implementation has given Medicaid recipients a greatly improved level of care coordination, and we are pleased these same benefits will now exist for pharmacy services," said Louisiana Department of Health and Hospitals Secretary Bruce D. Greenstein. "Through the past six months, we've worked closely with pharmacists, other providers, advocates and stakeholders to determine the best way to integrate pharmacy into Bayou Health. We're grateful for their assistance, and we look forwarded to continuing to work with them as we enhance the value of the care we provide in Medicaid."
Bayou Health is the State's coordinated care model for most Medicaid and LaCHIP recipients. In Bayou Health, five Health Plans - Amerigroup RealSolutions, Community Health Solutions, LaCare, Louisiana Healthcare Connections and UnitedHealthcare Community Plan -- are responsible for coordinating health care for recipients and working with them to address issues and empower them to take a more active role in owning their own health. Bayou Health was implemented for eligible Medicaid and LaCHIP recipients around Louisiana by June 1.
During this implementation phase, pharmacy was one of several services that were "carved out," meaning Medicaid recipients got prescriptions filled and received other pharmacy services through the legacy Medicaid fee-for-service program. Effective Nov. 1, pharmacy becomes an integrated benefit for recipients in the three plans that are a prepaid model, meaning they operate as traditional, MCO-style health care networks with a capitated rate -- Amerigroup, LaCare and Louisiana Healthcare Connections.
At this time, each health plan has an extensive network of pharmacies in Louisiana currently under contract, with nearly the same number or more pharmacies than participate in the Medicaid program today. At the request of pharmacists in Louisiana, DHH is requiring that the health plans receive proactive agreement by each pharmacy to participate in their Medicaid network. However, to ensure a smooth transition for recipients, DHH is allowing a 30-day window where pharmacies with existing commercial contracts with the plans will still be able to bill and be paid for services at the plan's Medicaid rate, even if they have not yet fully executed the addendum for Medicaid services to their current contract.
Additionally, the plans have protocols in place to reimburse providers for out-of-network services if contracts are still being negotiated. Pharmacy providers are strongly encouraged to visit www.MakingMedicaidBetter.com and see the Informational Bulletin (IB-30) that details how they can treat patients and receive payment for services if they are still working out contracts with a health plan.
Pharmacists can determine which Bayou Health plan their Medicaid clients belong to through the Medicaid eligibility verification system, eMEVS. This information will also let providers know which Plan to bill for services or obtain authorizations as needed. Providers should consider eMEVS the ultimate source of information. A recipient may think he is in a different plan or have a card from another plan, but providers should defer to what is listed in eMEVS. A sample view of the eMEVS screen and where a recipient's Bayou Health coverage would be listed is available at www.MakingMedicaidBetter.com/Providers.
The other two Bayou Health plans, Community Health Solutions and United Healthcare Community Plan, are enhanced primary care case management networks. These Plans process and pay claims using the Medicaid fiscal intermediary, and pharmacy benefits for recipients in these networks will continue through the legacy Medicaid fee-for-service program. Membership in these two Plans, combined with those individuals remaining in legacy Medicaid, account for more than half of Medicaid recipients.
Secretary Greenstein and DHH Medicaid leadership originally announced plans in June to incorporate pharmacy into Bayou Health. DHH issued a concept paper, held a series of statewide forums - most of which took place after business hours so more providers would have an opportunity to attend - and held numerous meetings with stakeholders to discuss this transition. Based on feedback received from these efforts, DHH issued its final pharmacy reform concept in late August, with plans for the pharmacy benefit integration to occur Nov. 1. DHH then held 19 pharmacy-focused provider outreach sessions across the state and published a comprehensive provider resource guide to help pharmacy providers prepare for the transition. These materials are all available online at www.MakingMedicaidBetter.com under the "Pharmacy" section.
DHH Offers Resources to Assist Providers During Pharmacy Integration
Medicaid leadership have established resources in place to assist pharmacists and prescribing providers during the Bayou Health pharmacy integration.
To ensure questions are answered quickly and accurately, pharmacists are encouraged to first direct pharmacy integration specific questions to the appropriate plan. Questions can be directed by plan as follows:
- General Provider Issues - Call Provider Relations - 1-800-454-3730
- Pharmacy Contracting Issues - Call CVS/Caremark - 1?480?391?4623
- Amerigroup Member with Issues - Have the Member Call Member Services - 1-800-600-4441
- Claims/Billing Issues - Call CVS/Caremark - 1?800-364-6331
- General Provider Issues - Call Provider Relations - 1-888-922-0007
- Pharmacy Contracting Issues - Call PerformRx - 1?800?555?5690
- LaCare Member with Issues - Have the Member Call PerformRx Member Services - 1-866-452-1040
- Claims/Billing Issues - Call PerformRx - 1-800-684-5502
Louisiana Healthcare Connections
- General Provider Issues - Call Provider Relations -1-866-595-8133
- Pharmacy Contracting Issues - Call USScript - 1?877?690?9330
- Louisiana Healthcare Connections Member with Issues - Have the Member Call Member Services - 1-866-595-8133
- Claims/Billing Issues - Call Provider Relations - 1-866-595-8133
Providers should note that pharmacy services will remain in legacy Medicaid for recipients in the Community Health Solutions and United Healthcare plans, and Molina, the Medicaid fiscal intermediary, will provide pharmacy provider relations support.
Community Health Solutions
- General Provider Issues - Call Provider Relations - 1-855-247-5248
- Pharmacy Contracting Issues - Call Molina Provider Relations - 1?877?690?9330
- Community Health Solutions Member with Issues - Have the Member Call Member Services - 1-855-247-5248
- Claims/Billing Issues - Call Provider Relations 1-855-247-5248
- General Provider Issues - Call Provider Relations - 1-866-675-1607
- Pharmacy Contracting Issues - Call Molina Provider Relations - 1?877?690?9330
- United Healthcare Member with Issues - Have the Member Call Member Services - 1-866-675-1607
- Claims/Billing Issues - Call Provider Relations 1-866-675-1607
Any other pharmacy-related questions can be directed to the Medicaid Pharmacy Program at 1-800-437-9101. Pharmacists seeking clarification on average acquisition costs in the fee-for-service Medicaid program should contact the Myers & Stauffer Pharmacy Reimbursement Help Desk at 1-800-591-1183
As DHH's Bayou Health team finalizes the infrastructure needed for the pharmacy integration to go live, they have engaged a "Readiness Response" mode of operation to quickly answer questions and address concerns. A "Readiness Response Center" at DHH headquarters will be staffed throughout the day to respond to issues as they arise. Bayou Health leaders and staff from the Medicaid pharmacy program will be available to help resolve any concerns or answer questions brought to their attention related to the transition. Providers can call 1-800-437-9101 to contact the Readiness Response Center.
Providers can also submit questions by email to email@example.com, and the appropriate staff will address any issues or concerns. Staff are typically able to respond within one business day.
DHH continues to hold a provider phone call at noon each weekday to address Bayou Health questions, with the Monday, Tuesday and Friday calls focused on pharmacy. Any provider is welcome to call in, and pre-registration is not required. The call in number is 1-888-278-0296, and the access code is 6556479#. The Wednesday call at this number is for hospitals and other provider types.
The Thursday call, administered by Magellan, focuses on specialized behavioral health services offered through the Louisiana Behavioral Health Partnership. The call-in number for Thursday is 1-888-205-5513 and the access code is 827176. Any provider can call in on any day, but priority will be given to questions about that day's topic, and the Medicaid staff who work in a particular area will participate in the calls on that scheduled day.
Pharmacists and prescribing providers are encouraged to review Informational Bulletin #27, Provider Issue Escalation and Resolution, to see how Bayou Health providers are instructed to address issues as they arise. Informational Bulletins are available at www.MakingMedicaidBetter.com under the "Informational Bulletins" tab.
Bayou Health members who have questions about their Bayou Health enrollment or who want to know which plan they are in can call 1-855-BAYOU-4U (1-855-229-6848) or visit www.bayouhealth.com. Questions about the legacy Medicaid program can be directed to the eligibility hotline, 1-888-342-6207.