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Idaho Medicaid Pharmacy Program and Hospice

IDAHO MEDICAID PHARMACY PROGRAM AND HOSPICE

Effective December 2, 2013, the Pharmacy Program has implemented a new procedure related to Medicaid participants receiving hospice care. Any prescription medication that hospice does not provide under the routine home care prospective (per diem) rate must undergo prior authorization evaluation by a pharmacist. Please see the fax which was sent to statewide pharmacies posted to the right under “Important Information”. There has been no change in IDAPA Rule, but this is a payment methodology change in the Pharmacy Program. Idaho Medicaid does not reimburse for drugs prescribed for participants enrolled in hospice services when the drugs are related to the participant’s terminal illness and related conditions.  Coverage for drugs outside of the hospice payment responsibility requires the submission of a prior authorization request to the Pharmacy Department.  Only drugs approved through the prior authorization process will be paid for by Medicaid. The hospice participant or caregiver/family member, pharmacy, or hospice agency can contact the prescribing physician’s office to inform the physician that non-hospice covered medications must have a prior authorization.

How prior authorization for non-hospice related medication is requested: There are two options available to access authorization. One option is to use the Universal Pharmacy Prior Authorization Form which can be accessed at www.medicaidpharmacy.idaho.gov. There will soon be a “Hospice Prior Authorization Form” posted on the website. The prescribing physician or the physician’s nurse will need to complete the form and fax it to the Idaho Medicaid Pharmacy Unit Call Center at 1(800)327-5541. The second option is for the physician or his/her nurse to call 1(866)827-9967 or 1(208)364-1829 and the determination of “approval” or “denial” may be obtained over the phone. The Call Center is open 8am-5pm Mon.-Fri. MST and is closed on state holidays.  The hospice diagnosis and justification as to why hospice is not responsible for paying for the medication must be provided. It would be helpful if the prescribing physician is made aware of the exact primary ICD Diagnosis Code under which the participant was enrolled to hospice care. Authorizations will be approved for a six month period of time. Medicaid does pay for a 72-hour emergency supply of medication that requires PA if the request has been submitted, but has not been processed. If a voice mail is left it will be answered in a timely way.  There will be no retro-active authorizations.

How to learn if a medication has been approved or denied: If a request has been approved, the prescribing physician and pharmacy receive a fax notification. The participant does not receive a notice of decision, but knows a medication has been approved because it is billed to Idaho Medicaid by the pharmacy. If a request has been denied, the prescribing physician and pharmacy receive a fax notification. The participant receives a mailed notice of decision (NOD). The NOD contains information on how to appeal the decision. Also, Megellan Medicaid Administration can be contacted at 1(800)922-3987 to learn the outcome of a PA Request. A hospice agency may contact the pharmacy, the prescribing physician’s office, the participant/family, or Megellan to learn if a specific medication has been approved or denied.

Additional questions: Please contact the Idaho Medicaid Pharmacy Program at 1(866)827-9967 or 1(208)364-1829 during the hours listed previously.  

Hospice Services

The Medical Care Unit is responsible for reviewing hospice notifications for Medicaid. General instructions and important points are outlined below. Forms, the Provider Handbook, and more information is available through the links to the right.
 
Hospice agencies are required to notify Medicaid for all Medicaid participants electing Hospice services. If Medicare or a commercial insurance is the primary payer, the hospice agency must still notify Medicaid. The Centers for Medicare and Medicaid Services (CMS) require the hospice agency to simultaneously notify both programs regarding election, recertification, discharge, revocation, or transfer between hospices, for participant’s who are dually eligible. Medicaid recertification periods are every eight months, and the hospice is responsible to track the due dates. (Medicare’s certification periods are different).
 
For all status changes related to hospice care, fifteen working days are allowed to obtain physician signatures and fax documents as noted on Hospice Notification Form to Medical Care Unit.
 
To allow processing within the Medicaid system and payment for hospice services please legibly complete the Hospice Notification Form and fax it to (877) 314-8779. Fill in Medicaid Provider Information, Participant Information, and fax the required documents for the eight month Election or Recertification period. Or, note an appropriate change in status on the Hospice Notification Form. Supporting documentation is not needed for notification of death, transfer, discharge (hospice chooses to end care if no longer meets eligibility criteria), or revocation (participant chooses to end care).
 
The Provider Handbook summarizes specific information regarding hospice issues and billing. The primary hospice diagnosis ICD-9 code submitted to Medical Care Unit must match the terminal illness diagnosis code used to bill Medicaid.
 
For more information or questions, please contact (208) 364-1818.