North Carolina Medicaid. John Stancil, R.Ph. North Carolina Division of Medical Assistance Associate Director of Pharmacy and DMEPOS

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1 North Carolina Medicaid John Stancil, R.Ph. North Carolina Division of Medical Assistance Associate Director of Pharmacy and DMEPOS

2 North Carolina Medicaid Pharmacy Update North Carolina Division of Medical Assistance Pharmacy Program Statistics Statistic SFY 2013 SFY 2014 SFY 2015 Medicaid Enrollment 1,583,719 1,655,476 1,807,982 Medicaid Expenditures $12,968,605,355 $13,549,540,740 $13,919,524,421 Prescriptions 16,402,375 16,599,494 18,061,358 Prescriptions Per Beneficiary Pharmacy Expenditures (Gross) $1,270,387,859 $1,438,139,251 $1,671,988,842 % of Total Medicaid Expenditures 9.8% 10.6% 12.0% Average Gross Amount Paid Per Prescription $77.45 $87.00 $93.00 Total Average PMPM $66.85 $72.39 $77.07 Drug Rebates $573,782,427 $648,107,690 $809,621,055 % of Gross Pharmacy Expenditures 45.2% 45.1% 48.4% Pharmacy Expenditures (Net) $696,605,432 $790,031,561 $862,367,787 % of Total Medicaid Expenditures 5.4% 5.8% 6.2% Average Net Amount Paid Per Prescription $42.47 $48.00 $47.75 Total Average PMPM Net of Rebates $36.65 $39.77 $39.75 Specialty Drug Utilization $218,132,982 $303,249,147 $434,574,340 Specialty Drug Utilization as a % Paid Amount 17.2% 21.1% 26.0% Generic Dispensing Rate 82.2% 81.4% 80.3% PDL Compliance Rate 96.6% 95.9% 95.2%

3 North Carolina Medicaid Re-credentialing Requirement The Centers for Medicare & Medicaid Services (CMS) requires that all Medicaid providers are revalidated (recredentialed) at least every five years. This is to ensure that provider enrollment information is accurate and current. The provider s credentials and qualifications will be evaluated to ensure that they meet professional requirements and are in good standing.

4 North Carolina Medicaid Re-credentialing Requirement Providers will receive a re-credentialing/reverification letter, or an invitation, through their NCTracks secure portal in-box or when they are scheduled to begin the re-credentialing process. This process is completed in the Status and Management section of the NCTracks Provider Portal under the section titled Reverification. A reverification application will only appear when it is time to reverify. Providers are required to pay a $100 application fee for re-credentialing/reverification.

5 North Carolina Medicaid Re-credentialing Requirement Re-credentialing is not optional. It is crucial that all providers who receive a notice promptly respond and begin the process. Providers will receive a notification letter 45 days before their re-credentialing due date. If the provider does not complete the process within the allotted 45 days, payment will be suspended until the process is completed. The provider will also receive a termination notice. If the provider does not complete the re-credentialing process within 30 days from payment suspension and termination notice, participation in the N.C. Medicaid and Health Choice programs will be terminated. Providers must submit a re-enrollment application to be reinstated.

6 North Carolina Medicaid Re-credentialing Requirement The N.C. Division of Medical Assistance (DMA) has posted Re-Credentialing Due Dates for Calendar Year 2016 on the DMA website. In addition, DMA has posted a spreadsheet listing all active providers who are scheduled for re-credentialing in 2016 (by month). It can also be found under the "Recredentialing" header of the DMA Provider Enrollment web page at

7 In September 2015, North Carolina passed a law to change the way Medicaid services are delivered in our state. This law directed the Department of Health and Human Services to create a "Medicaid Reform" plan that will help doctors and other health care professionals focus even more on quality care and making patients healthier, while controlling costs to taxpayers.

8 Because there are federal rules involved in making changes to a Medicaid plan under the Social Security Act, Medicaid Reform is sometimes called a "waiver application" or a "Section 1115 Demonstration."

9 The NC Department of Health and Human Services presented the draft 1115 waiver and the NC Medicaid reform plan to the Joint Legislative Oversight Committee on Medicaid and NC Health Choice on March 1, Both are available online at the NC Medicaid Reform website The NC 1115 waiver represents and builds upon NC DHHS successes and tradition of developing innovative programs that serve North Carolinians.

10 State Medicaid Reform Proposal Unveiled Time Warner Cable News By Loretta Boniti Tuesday, March 1, 2016 at 04:59 PM EST

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12 The waiver sets forth a plan to improve the access to, quality of, and cost effectiveness of health care for most of our 1.9 million Medicaid and NC Health Choice (Children s Health Insurance Program, or CHIP) beneficiaries by restructuring care delivery using accountable, next-generation prepaid health plans, redesigning payment to reward value rather than volume, and planning toward true personcentered care grounded in increasingly robust patient centered medical homes and wrap-around community support and informatics services.

13 NC s waiver goals not only align fully with the Triple Aim of improving the patient experience of care, improving the health of populations, and containing the per capita cost of health care, but also go one step further by pursuing the Quadruple Aim the Triple Aim plus Improved Provider Engagement and Support.

14 Implementation will be through four broad based initiatives and the corresponding program proposals: 1.Creating Systems of Accountability for Outcomes 2.Creating North Carolina Person-Centered Health Communities (PCHCs) and Connecting Children and Families in the Child Welfare System to Better Health 3.Supporting Providers through Engagement and Innovations 4.Care Transformation through Payment Alignment

15 It is in the creation of North Carolina Person- Centered Health Communities (PCHCs) and Connecting Children and Families in the Child Welfare System to Better Health that the Community Pharmacy Enhanced Services Network (CPESN) pharmacies would be embedded.

16 These pharmacies provide enhanced pharmacy services that go above and beyond conventional prescription dispensing and basic patient education. Enhanced services include interventions such as synchronization of patient s chronic medication fill dates, adherence monitoring and coaching, compliance packaging, and home delivery. Pharmacies additionally offer community pharmacy care management services in close collaboration with the comprehensive medical home and their care management supports to engage in continuous care plan development and reinforcement.

17 North Carolina Medicaid Thank you for the services you provide to the Medicaid beneficiaries of North Carolina