Public Notices

The written comments will be available for public review between the hours of 7:45 a.m. and 4:30 p.m. daily in Room 418 of the State Office Building, 1 West Wilson Street, Madison, Wisconsin.

Health and Family Services

(Medical Assistance Reimbursement of Physician Administered Drugs)

The State of Wisconsin reimburses providers for services provided to Medical Assistance recipients under the authority of Title XIX of the Social Security Act and ss. 49.43 to 49.47, Wisconsin Statutes. This program, administered by the State's Department of Health and Family Services, is called Medical Assistance (MA) or Medicaid. Federal statutes and regulations require that a state plan be developed that provides the methods and standards for reimbursement of covered services. A plan that describes the reimbursement system for the services (methods and standards for reimbursement) is now in effect.

Proposed Change

The Wisconsin Department of Health and Family Services is proposing to modify the reimbursement methodology for physician administered injectable drugs. This change will utilize new sources of drug pricing and clinical drug indication information in order to establish payment rates and requirements for these services. Additional sources of information include wholesale prices, average sale prices and other information available in the marketplace. The Department is based on a provision of the pending 2005-07 state budget bill. The proposal involves no change in services and the benefits remain the same.

The proposed will be effective for dates of service on and after July 1, 2005. If enacted the fiscal effect of the budget bill proposal will be savings of $740,400 GPR and $1,058,900 FED for a total of $1,799,300 all funds (AF) in SFY 2005-06.

Copies of the Proposed Change:

A copy of the proposed change may be obtained free of charge by calling or writing as follows:

Regular Mail

Pharmacy Policy Unit

Bureau of Fee-for-Service Health Care Benefits

Division of Health Care Financing

P.O. Box 309

Madison, WI 53701-0309

FAX

[phone]

Attention: Pharmacy Policy Unit

Written Comments:

Written comments are welcome. Written comments on the proposed changes may be sent by FAX, e-mail, or regular mail to the Department. The FAX number is [phone]. The e-mail address is [e-mail]. Regular mail can be sent to the above address. All written comments will be reviewed and considered.

The written comments will be available for public review between the hours of 7:45 a.m. and 4:30 p.m. daily in Room 350 of the State Office Building, 1 West Wilson Street, Madison, Wisconsin. Revisions may be made in the proposed changed methodology based on comments received.

Health and Family Services

(Medical Assistance Reimbursement of Hospitals)

The state of Wisconsin covers legend and non-legend drugs and drug products and reimburses pharmacies for services provided to low-income persons under the authority of Title XIX of the Federal Social Security Act and sections 49.43 to 49.47 and 49.688, Wisconsin Statutes. The Wisconsin Department of Health and Family Services administers this program, which is called Medical Assistance or Medicaid.

Federal statutes and regulations require a state plan that indicates Medicaid covered services and limits to coverage.

A state plan is in effect that indicates coverage of drugs and drug products for medically needy and categorically needy Medicaid recipients and reimbursement policy for pharmacy services. The Department is proposing to make changes in the provisions contained in the state plan that apply to coverage of drugs and drug products and reimbursement policies.

Multi-State Preferred Drug List - Supplemental Rebates and Prior Authorization

The Federal government has clarified that states may enter into multi-state supplemental rebate agreements with pharmaceutical manufacturers and that states may impose prior authorization requirements related to supplemental rebate agreements for covered outpatient drugs.

The State will extend prior authorization to drugs as allowed under state law.

In addition, the State will enter into negotiations for multi-state supplemental rebates from manufacturers for drugs and drug products covered under Medicaid and SeniorCare. Expected savings are indeterminate at this time.

Copies of Proposed Changes

When available, a copy of the proposed state plan changes may be obtained free of charge by calling or writing as follows:

Mail:

James J. Vavra, Director

Bureau of Fee-for-Service Health Care Benefits

Division of Health Care Financing

P.O. Box 309

Madison, WI 53701-0309

Written Comments

Written comments are welcome. Written comments on the proposed changes may be sent by FAX, e-mail, or regular mail to the Division of Health Care Financing. The FAX number is [phone]. The e-mail address is [e-mail]. Regular mail can be sent to the above address. All written comments will be reviewed and considered.

The written comments will be available for public review between the hours of 7:45 a.m. and 4:30 p.m. daily in Room 350 of the State Office Building, 1 West Wilson Street, Madison, Wisconsin. Revisions may be made in the proposed changed methodology based on comments received.

Health and Family Services

(Medical Drug Coverage and Reimbursement)

The State of Wisconsin reimburses hospitals for medical services provided to low-income persons under the authority of Title XIX of the Federal Social Security Act and Chapter 49.43 to 49.47, Wisconsin Statutes. The Wisconsin Department of Health and Family Services administers this program that is called Medicaid or Medical Assistance (MA). Federal statutes and regulations require state plans, one for outpatient services and one for inpatient services, that provide the methods and standards for paying for hospital outpatient and inpatient services.

State plans are now in effect for the reimbursement of outpatient hospital services and inpatient hospital services. The Department is proposing to make changes to the provisions contained in the Medicaid inpatient and outpatient hospital state plans effective July 1, 2005 to implement proposed provisions pending the approval of the 2005-2007 Wisconsin state budget act, and maintain compliance with federal payment limits, and for administrative efficiencies.

Outpatient Hospital Services

Proposed changes in the state plan for reimbursement for outpatient services may include:

1. Remove the Border Metropolitan Statistical Area Supplement. The hospitals that once qualified for this adjustment are now Critical Access Hospitals. As such, they are paid at cost, which now makes them ineligible for the supplement.

2. Remove the Hold Harmless provision from the rate per visit calculation. Eliminating this provision would result in an equitable allocation of the across-the-board rate increase as all providers would receive the same percentage of Medicaid costs in the outpatient rate.

3. Limit reimbursement for therapy services provided in an outpatient hospital setting from the OP rate per visit to the rates paid to therapy providers.

Implementation of the above changes to the State Plan for outpatient services are expected to reduce payments by an estimated $4,375,000 All Funds ($2,529,625 FED, $1,845,375 GPR) due to reclassification of therapy services claims, and increase payments by an estimated $5,926,600 All Funds ($3,426,600 FED, $2,500,000 GPR) for general outpatient rate increase for state fiscal year 2005-2006.

Inpatient Hospital Services

Proposed changes in the state plan for reimbursement for inpatient services may include:

1. Change the trimpoint for outlier payments. Create one trimpoint for acute care hospitals.

2. Change methodology and maximum amount available for the General Assistance Disproportionate Share Hospital Allowance.

3. Remove the Critical Access Hospitals (CAHs) from the appendix for hospitals qualifying for exemption from capital cost reduction. This calculation does not affect the CAHs.

Implementation of the above changes to the State Plan for inpatient services are expected to decrease expenditures by $200,000 all-funds ($115,640 Fed, and $84,360 GPR).

Copies of Proposed Changes

Copies of the proposed changes will be sent to every county social services or human service department main office where they will be available for public review. For more information, interested persons may fax or write to:

Hospitals, Physicians and Clinics Section

Division of Health Care Financing

P.O. Box 309

Madison, WI 53701-0309

Fax: [phone]

Written Comments

Written comments on the proposed changes are welcome and should be sent to the above address. The comments received on the changes will be available for public review between the hours of 7:45 a.m. and 4:30 p.m. at:

Division of Health Care Financing

Room 350, State Office Building

One West Wilson Street

Madison, WI