Reimbursement : Amounts

Acceptance of Payment

The amounts allowed as payment for covered services must be accepted as payment in full. Therefore, total payment for the service (i.e., any amount paid by other health insurance sources, any BadgerCare Plus or Medicaid copayment or spenddown amounts paid by the member, and any amount paid by BadgerCare Plus, Medicaid, or ADAP) may not exceed the allowed amount. As a result, providers may not collect payment from a member, or authorized person acting on behalf of the member, for the difference between their usual and customary charge and the allowed amount for a service (i.e., balance billing).

Other health insurance payments may exceed the allowed amount if no additional payment is received from the member or BadgerCare Plus, Medicaid, or ADAP.

Billing Service and Clearinghouse Contracts

According to Wis. Admin. Code § DHS 106.03(5)(c)2, contracts with outside billing services or clearinghouses may not be based on commission in which compensation for the service is dependent on reimbursement from BadgerCare Plus. This means compensation must be unrelated, directly or indirectly, to the amount of reimbursement or the number of claims and is not dependent upon the actual collection of payment.

Brand or Generic Status of a National Drug Code

ForwardHealth uses the following information to determine the brand or generic status of an NDC:

• NADAC Classification for Rate Setting
• Manufacturer's label name of the product

Brand Status of a National Drug Code

An NDC's brand status is assigned using the Classification for Rate setting field on the NADAC file. The federal CMS provides the NADAC file, which is available on the Medicaid website. An NDC with a value of "B" or "B-ANDA" is assigned a brand status. If an NDC is not on the NADAC file, brand status is determined by the market or label name. If the NDC market or label name is different than the active ingredient(s), the NDC is considered a brand; e.g., Adderall (active ingredients amphetamine and dextroamphetamine) and Norco (active ingredients acetaminophen and hydrocodone) have a brand status.

Generic Status of a National Drug Code

An NDC's generic status is assigned using the Classification for Rate Setting field on the NADAC file. An NDC with a value of "G" will be assigned a generic status. If an NDC is not on the NADAC file, generic status is determined by the market or label name. If the NDC market or label name is based on the active ingredient(s), the NDC will be considered a generic; e.g., digoxin and omeprazole have a generic status.

Covered Outpatient Drug Reimbursement

Definition of Covered Outpatient Drugs

Covered outpatient drugs are drugs that are treated as prescribed drugs for the purposes of § 1905(a)(12) of the Social Security Act (42 U.S.C. § 1396d[a][12]) and meet the definition of a covered outpatient drug as found in 42 C.F.R. § 447.502. The AAC reimbursement requirements for covered outpatient drugs set forth in the Code of Federal Regulations do not include, in part, diabetic supplies, physician-administered drugs, or specialty drugs not purchased through the federal 340B Program.

Ingredient Cost

ForwardHealth reimburses covered outpatient drugs according to a separate ingredient cost and a professional dispensing fee. Ingredient cost reimbursement is based on AAC; as defined by 42 C.F.R. § 447.502, AAC is "the agency's determination of the pharmacy providers' actual prices paid to acquire drug products marketed or sold by specific manufacturers."

ForwardHealth uses the NADAC to reimburse ingredient cost for covered outpatient drugs, excluding drugs purchased through the federal 340B Program. CMS has stated the NADAC is an appropriate benchmark to establish AAC reimbursement. The NADAC is provided by CMS and calculated by a CMS vendor, Myers and Stauffer LC, a national certified public accounting firm. Myers and Stauffer LC conducts surveys of retail community pharmacy prices, including drug ingredient costs, to develop the NADAC pricing benchmark. NADAC pricing is available on the Medicaid website. The NADAC prices are updated on a weekly basis.

NADAC pricing review requests or notifications of recent drug price changes that may not be reflected in the posted NADAC file should be directed to the NADAC Help Desk. The NADAC Help Desk may be contacted through the following means:

• Telephone (toll-free): 855-457-5264
• Email: info@mslcrps.com
• Fax: 844-860-0236

ForwardHealth will not accept drug price review requests, disputes, or notifications of recent drug price changes for NADAC pricing.

Providers will be reimbursed at the lesser of the covered outpatient drug's NADAC rate, plus a professional dispensing fee, or the billed amount. If a covered outpatient drug does not have a NADAC rate available, then the provider will be reimbursed at the lesser of the drug's WAC or SMAC, if available, plus a professional dispensing fee, or the billed amount.

Providers will receive an informational EOB code on each detail on pharmacy noncompound and compound claims identifying the pricing benchmark used.

If an NDC does not have a NADAC, WAC or SMAC rate on file, the claim will be denied.

State Maximum Allowed Cost Policy

Under Wisconsin's State Medicaid Plan approved by CMS, Wisconsin Medicaid and WCDP may assign SMACs to establish an upper limit for payment of brand or generic versions of the same drug (federal legend or OTC drugs), regardless of manufacturer. SMAC rates are set by using best estimates of prices currently in the marketplace in comparison to NADAC and WAC as stated in the approved Wisconsin State Plan.

Covered Outpatient Drug Reimbursement: 340B Drug Pricing Program

Definition of the 340B Drug Pricing Program

The 340B Program is a federal program that requires drug manufacturers to provide outpatient drugs to eligible covered entities at significantly reduced prices. Section 340B(a)(4) of the Public Health Services Act specifies which covered entities are eligible to participate in the 340B Program. The 340B Program enables covered entities to fully utilize federal resources, reaching more eligible patients and providing more comprehensive services.

Providers may determine if they are an eligible organization/covered entity to participate in the 340B Program, and if so, may register with the 340B Program through the HRSA website. Upon enrollment in the 340B Program, covered entities must determine whether they will use drugs purchased through the 340B Program for their Medicaid members (carve-in) or purchase drugs for their Medicaid members through other mechanisms (carve-out). Covered entities who carve-in must be listed on the HRSA 340B MEF, which is used to assist states and manufacturers in determining which drugs are not subject to Medicaid rebates. Covered entity providers who carve-in are subject to 340B Program reimbursement.

340B Ingredient Cost Reimbursement

The Covered Outpatient Drugs Final Rule, 42 C.F.R. § 447.502, requires state Medicaid programs to reimburse drugs acquired through the 340B Program at their AAC. Because NADAC pricing is not applicable for covered outpatient drugs purchased through the 340B Program, ForwardHealth uses calculated 340B ceiling prices to determine a maximum ingredient cost of drugs purchased through the 340B Program, including specialty drugs purchased through the 340B Program, and to comply with the 340B AAC requirements in the rule. The federal CMS has stated that ceiling price is an appropriate AAC benchmark for drugs purchased through the 340B Program.

The 340B ceiling price refers to the maximum amount a manufacturer can charge a covered entity for the purchase of a covered outpatient drug through the 340B Program. The 340B ceiling price is statutorily defined as the AMP reduced by the rebate percentage, which is commonly referred to as the URA. HRSA maintains the official 340B ceiling prices, which are not available to state Medicaid programs or the public due to confidentiality protections. However, CMS performs the URA calculations based on manufacturer-reported pricing data and specific methodology determined by law. CMS provides the URA and pricing data to states quarterly. ForwardHealth uses this information to determine the calculated 340B ceiling price. ForwardHealth does not adjust claims if manufacturers retroactively change AMP or URA.

Providers are required to submit their AAC when they dispense drugs purchased through the 340B Program to ForwardHealth members. Providers who dispense 340B inventory to ForwardHealth members will be reimbursed at the lesser of the calculated 340B ceiling price or the provider-submitted 340B AAC.

When a calculated 340B ceiling price is not available for a drug, ForwardHealth will reimburse at the lesser of WAC minus 50 percent or the provider-submitted 340B AAC.

Contract Pharmacies

Drugs acquired through the federal 340B Program and dispensed by 340B contract pharmacies are not covered by ForwardHealth. A 340B contract pharmacy must carve-out ForwardHealth from its 340B operation and purchase all drugs billed to ForwardHealth outside of the 340B Program.

Covered Outpatient Drug Reimbursement: Professional Dispensing Fees

Per 42 C.F.R. § 447.502, the professional dispensing fee is designed to reflect professional services and costs associated with delivering a covered outpatient drug to a ForwardHealth member. BadgerCare Plus, Medicaid, SeniorCare, ADAP, and WCDP reimburse the same professional dispensing fee reimbursement rates, based on a dispensing provider's annual prescription volume for all prescriptions dispensed, for services provided. These fees include the following:

• Professional dispensing fee (Services covered under the professional dispensing fee include record keeping, patient profile preparation, prospective DUR, and counseling.)
• A compound drug add-on of $7.79

Additionally, BadgerCare Plus, Medicaid, and SeniorCare reimburse a repackaging allowance of $0.015 per unit billed to the professional dispensing fee for oral drugs in a solid form that are not considered unit dose.

Professional Dispensing Fee Reimbursement Rates

A professional dispensing fee is usually paid once per member, per service, per month, per provider, depending on the prescriber's prescription.

The following table lists the professional dispensing fee reimbursement rates that include overall annual prescription volume and associated professional dispensing fees:

Professional Dispensing Fee Surveys

ForwardHealth periodically conducts mandatory professional dispensing fee surveys as part of an ongoing process to ensure up-to-date professional dispensing fee reimbursement rates that accurately reflect the costs associated with dispensing covered outpatient drugs to ForwardHealth members.

Prescription Volume Attestation

Providers are required to attest to their overall annual prescription volume on a yearly basis. The annual attestation process is mandatory for all providers and organizations that dispense covered outpatient drugs. ForwardHealth uses providers' self-reported annual prescription volumes to assign professional dispensing fee reimbursement rates. If providers do not self-report annual prescription volume, ForwardHealth will automatically assign the lowest professional dispensing fee reimbursement rate. Providers are subject to audit at ForwardHealth's discretion.

Newly Enrolled Providers

ForwardHealth assigns the lowest professional dispensing fee reimbursement rate of $10.51 to newly enrolled providers that:

• Enroll in ForwardHealth from December 1 of the previous year to November 30 of the current year. For example, if a provider enrolls in ForwardHealth during the month of December 2020 they are not eligible to participate in the attestation survey sent January 2021. They would be eligible to participate in the attestation survey the following year in January 2022.
• Have not completed a prescription volume attestation survey.
• Have not billed ForwardHealth for a covered outpatient drug.

Out-of-State Providers and In-State Emergency Providers

ForwardHealth assigns a professional dispensing fee reimbursement rate of $10.51 to out-of-state providers and in-state emergency providers.

Change of Ownership

If a pharmacy location experiences a change of ownership during the year, the location is considered a new location and is assigned a professional dispensing fee reimbursement rate of $10.51, regardless of the previous dispensing fee.

The following events are considered a change of ownership and require the completion of a new provider enrollment application:

• Change from one type of business structure to another type of business structure.
• Change of name and tax identification number associated with the provider's submitted enrollment application.
• Change (addition or removal) of names identified as owners of the provider.

FQHCs

FQHCs are not required to attest to their annual prescription volume and are automatically assigned a provider-specific professional dispensing fee reimbursement rate.

Tribal FQHCs

Tribal FQHCs receive an interim professional dispensing fee reimbursement rate of $24.92, which is reconciled to approved federal encounter rates.

Non-Tribal FQHCs

Non-tribal FQHCs, also known as community health centers, receive an interim professional dispensing fee of $24.92 for SeniorCare members. For non-SeniorCare members, non-tribal FQHCs do not receive an interim professional dispensing fee because the professional dispensing fee is incorporated into the approved rate process.

Multiple Locations

Providers who have multiple locations are required to attest for each location individually.

Disputes

There will be no dispute process for providers who do not agree with their rate assignment because the assignment is based on the prescription volume they have reported.

Compound Drug Add-on

A claim submitted for a compound drug for BadgerCare Plus, Medicaid, and SeniorCare will be reimbursed at the provider's assigned professional dispensing fee reimbursement rate plus a compound add-on of $7.79.

Repackaged Drugs and Repackaging Allowances

The repackaging allowance is limited to oral drugs in a solid form that are not considered unit dose. However, the professional dispensing fee may be allowed for unit dose drugs.

Pharmacy providers can obtain a repackaging allowance for oral drugs in a solid form that are repackaged by the pharmacy by entering the appropriate value in the Special Packaging Indicator field. If this field is present on a pharmacy claim when the drug is defined as unit dose, the repackaging allowance will not be reimbursed. Providers will receive an EOB code for repackaged drugs and repackaging allowances.

The repackaging allowance only applies to drugs dispensed in whole units, such as capsules and tablets. The repackaging allowance is not allowed for liquids and creams.

Repackaged manufacturers' products are not covered by BadgerCare Plus, Medicaid, or SeniorCare.

Electronic Funds Transfer

EFT allows ForwardHealth to directly deposit payments into a provider's designated bank account for a more efficient delivery of payments than the current process of mailing paper checks. EFT is secure, eliminates paper, and reduces the uncertainty of possible delays in mail delivery.

Only in-state and border-status providers who submit claims and MCOs are eligible to receive EFT payments.

Provider Exceptions

EFT payments are not available to the following providers:

• In-state emergency providers
• Out-of-state providers
• Out-of-country providers
• SMV providers during their provisional enrollment period

Enrolling in Electronic Funds Transfer

A ForwardHealth Portal account is required to enroll into EFT as all enrollments must be completed via a secure Provider Portal account or a secure MCO Portal account. Paper enrollments are not accepted. A separate EFT enrollment is required for each financial payer a provider bills.

Providers who do not have a Portal account may Request Portal Access online. Providers may also call the Portal Helpdesk for assistance in requesting a Portal account.

The following guidelines apply to EFT enrollment:

• Only a Portal Administrator or a clerk that has been assigned the "EFT" role on the Portal may complete the EFT enrollment information.
• Organizations can revert back to receiving paper checks by disenrolling in EFT.
• Organizations may change their EFT information at any time.
• Organizations will continue to receive their Remittance Advice as they do currently.

Refer to the Electronic Funds Transfer User Guide on the User Guides page of the Portal for instructions and more information about EFT enrollment.

Providers will continue to receive payment via paper check until the enrollment process moves into "Active" status and the provider's ForwardHealth EFT enrollment is considered complete.

Recoupment and Reversals

Enrollment in EFT does not change the current process of recouping funds. Overpayments and recoupment of funds will continue to be conducted through the reduction of payments.

Note: Enrolling in EFT does not authorize ForwardHealth to make unauthorized debits to the provider's EFT account; however, in some instances an EFT reversal of payment may be necessary. For example, if the system generates a payment twice or the amount entered manually consists of an incorrect value (e.g., a decimal point is omitted creating a $50,000 keyed value for a $500 claim), a reversal will take place to correct the error and resend the correct transaction value. ForwardHealth will notify the designated EFT contact person of an EFT reversal if a payment is made in error due to a system processing or manual data entry error.

Problem Resolution

If payment is not deposited into the designated EFT account according to the ForwardHealth payment cycle, providers should first check with their financial institution to confirm the payment was received. If the payment was not received, providers should then call Provider Services to resolve the issue and payment by paper check will be reinstated until the matter has been resolved.

Fee Schedules

Maximum allowable fee information is available on the Max Fee Schedules page of the ForwardHealth Portal in the following forms:

• An interactive maximum allowable fee schedule
• Downloadable fee schedules by service area only in TXT or CSV files

Policy information is not displayed in the fee schedules. Providers should refer to their specific service area in the Online Handbook for more information about coverage policy related to a specific procedure code.

Certain fee schedules are interactive. On the interactive fee schedule, providers have more search options for looking up some coverage information, as well as the maximum allowable fees, as appropriate, for reimbursable HCPCS, CPT, or CDT procedure codes for most services.

Providers have the ability to independently search by:

• A single HCPCS, CPT, or CDT procedure code
• Multiple HCPCS, CPT, or CDT procedure codes
• A pre-populated code range
• A service area (Service areas listed in the interactive fee schedule more closely align with the provider service areas listed in the Online Handbook, including the WCDP programs and WWWP.)

The downloadable fee schedules, which are updated monthly, provide basic maximum allowable fee information by provider service area.

Through the interactive fee schedule, providers can export their search results for a single code, multiple codes, a code range, or by service area. The export function of the interactive fee schedule will return a zip file that includes seven CSV files containing the results.

Note: The interactive fee schedule will export all associated information related to the provider's search criteria except the procedure code descriptions.

Providers may call Provider Services in the following cases:

• The ForwardHealth Portal is not available.
• There is uncertainty as to which fee schedule should be used.
• The appropriate fee schedule cannot be found on the Portal.
• To determine coverage or maximum allowable fee of procedure codes not appearing on a fee schedule.

Drug Search Tool

The Drug Search Tool is designed to help users to identify and calculate ingredient reimbursement rates of drugs covered by BadgerCare Plus, Medicaid, SeniorCare, and WCDP. Covered drugs and reimbursement rate information is updated regularly.

Wisconsin Medicaid-enrolled pharmacies and other health care providers can use the drug search tool to help identify and calculate ingredient rates of drugs. Information provided through the drug search tool does not guarantee coverage or payment. Instructions for using the Drug Search Tool can be found in the Max Fee User Guide.

ForwardHealth will periodically update the information on the drug search tool.

Information Included in the Drug Search Tool

For each NDC and label name listed on the Drug Search Tool, the following information is available:

• Age restrictions associated with the NDC
• Copayment amount (brand, generic, compound, or not applicable)
• Diagnosis code restrictions
• Effective date of the listed ingredient rate
• Indicator for whether the NDC can only be billed as a compound drug ingredient
• Maximum days' supply permitted in one dispensing (34 or 100 days)
• The package size used to derive a unit price (It is the usual labeled quantity from which the pharmacist dispenses, such as 100 tablets, 1,000 capsules, or 20 mL vials.)
• The reimbursement methodology applicable to the prescription
• Unit of measurement, or drug form that indicates the basic drug measurement unit for performing price calculations (This includes valid values are for each [tablets, kits, etc.], milliliters [liquids], or grams [solids].)
• NDC unit rate and package rate
• PA requirements

For drugs included on the PDL, information on the Drug Search Tool will also include:

• The PDL dug class
• A list of all preferred drugs associated with the same PDL drug class as the selected NDC.
• The drug's PDL status (preferred or non-preferred).

Note: Reimbursement information for drugs purchased through the 340B Program is not available on the Drug Search Tool. HRSA maintains the official 340B ceiling prices, which are not available to the public due to confidentiality protections.

Immunizations Covered for Children

Most allowable vaccines provided to members 18 years of age or younger are available through the federal VFC Program at no cost to providers. In order to receive vaccines at no cost, providers are required to enroll in the VFC Program. Refer to the Immunizations: Wisconsin Immunization Program page on the DHS website for contact information about enrolling in the VFC Program.

If an allowable vaccine is available through the VFC Program, ForwardHealth will reimburse only an administration fee to the pharmacy. For allowable vaccines that are not available through the VFC Program, ForwardHealth reimbursement will include an amount for the vaccine plus the administration fee. Providers may refer to the interactive maximum allowable fee schedule for current reimbursement rates.

Maximum Allowable Fees

Maximum allowable fees are established for most covered services. Maximum allowable fees are based on various factors, including a review of usual and customary charges submitted, the Wisconsin State Legislature's Medicaid budgetary constraints, and other relevant economic limitations. Maximum allowable fees may be adjusted to reflect reimbursement limits or limits on the availability of federal funding as specified in federal law.

Providers are reimbursed at the lesser of their billed amount and the maximum allowable fee for the procedure.

State And Specialty Maximum Allowed Cost Drug Pricing Review

To request a review of SMAC and specialty drug pricing, pharmacy providers are required to complete, sign, and submit the State and Specialty Maximum Allowed Cost Drug Pricing Review Request form certifying that the price listed is the AAC of the drug after rebates or discounts from a wholesaler or supplier. The pharmacy must also submit an invoice having a product date of purchase within 60 days of submitting the request. The invoice must include the following:

• Date of purchase
• Purchased price
• Purchaser
• Product NDC (If the NDC is not indicated on the invoice, the provider is required to handwrite the NDC on the invoice.)
• Wholesaler/supplier name

The State and Specialty Maximum Allowed Cost Drug Pricing Review Request form and the supporting documentation must be submitted to the DAPO Center via fax at 608-250-0246 or by mail to the following address:

ForwardHealth
Drug Authorization and Policy Override Center
313 Blettner Blvd
Madison WI 53784

Any action taken by ForwardHealth will be reflected in the State and Specialty Pharmacy Drug Reimbursement Rates data table.

ForwardHealth will return any review requests for products reimbursed using WAC, calculated 340B ceiling price, or NADAC rates.

• Telephone (toll-free): 855-457-5264
• Email: info@mslcrps.com
• Fax: 844-860-0236

Wholesale Acquisition Cost

ForwardHealth diabetic supplies and specialty drugs not purchased through the 340B Program will use the EAC based on WAC reimbursement. As defined by 42 C.F.R. § 447.502, EAC is the state's best estimate of the prices generally and currently paid by providers for a drug marketed or sold by manufacturers or labelers in the package size of the drug most frequently purchased by providers. These products are excluded from the AAC reimbursement requirements for covered outpatient drugs set forth in 42 C.F.R. § 447.502.

Specialty Drug Definition

ForwardHealth defines specialty drugs as drugs requiring comprehensive patient care services, clinical management, and product support services. The definition includes the following criteria:

• Drugs prescribed for complex, chronic, or rare medical conditions
• Drugs not routinely stocked at a majority of retail community pharmacies
• Drugs that require special handling, storage, inventory, or distribution
• Drugs that require complex education and treatment maintenance

ForwardHealth identifies drug classes in which the majority of the drugs do not have an available NADAC as specialty drugs.

Specialty Wholesale Acquisition Cost

An EAC is established for specialty pharmacy drugs by therapeutic class. The EAC is based on the WAC plus or minus a specified percent. The State and Specialty Pharmacy Drug Reimbursement Rates data table provides a list of specialty pharmacy drugs, EAC, and effective dates.

For BadgerCare Plus and Medicaid, specialty drugs purchased through the 340B Program are reimbursed according to 340B ingredient cost reimbursement.

Diabetic Supplies

The EAC for diabetic supplies is WAC plus two percent.