WSR 98-05-054

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES

(Medical Assistance Administration)

[Filed February 13, 1998, 4:04 p.m.]

Original Notice.

Preproposal statement of inquiry was filed as WSR 97-24-013.

Title of Rule: WAC 388-530-1600 Unit dose pharmacy billing requirements.

Purpose: This rule has been rewritten to comply with the principles of the Governor's Executive Order 97-02. It also allows pharmacies to bill more than once per month for unit dose services to nursing facilities, if they choose to do so.

Statutory Authority for Adoption: RCW 74.08.090 and 74.04.050.

Statute Being Implemented: 42 CFR 447.333 and Attachment 4.19-B, Page 2-b of the State Plan under Title XIX of the Social Security Act.

Summary: See Purpose above.

Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Joanie Scotson, Medical Assistance Administration, 617 8th S.E., Olympia, WA, (360) 753-7462.

Name of Proponent: Department of Social and Health Services, governmental.

Rule is necessary because of federal law, 42 CFR 447.333.

Explanation of Rule, its Purpose, and Anticipated Effects: See Purpose above.

Proposal Changes the Following Existing Rules: WAC 388-530-1600 has been rewritten to comply with the principles of the Governor's Executive Order 97-02, and reflects that pharmacists have the option of billing more than once per month for unit dose delivery.

No small business economic impact statement has been prepared under chapter 19.85 RCW. This proposed rule does not have an economic impact on small businesses. It allows pharmacies to bill unit doses as dispensed if the pharmacy chooses to do so voluntarily.

RCW 34.05.328 does not apply to this rule adoption. This amendment is exempt according to RCW 34.05.328 (5)(c)(ii) because it is not a significant legislative rule as it does not submit a person to a penalty or sanction. The only change is minor and merely provides a billing option for pharmacies.

Hearing Location: Lacey Government Center (behind Tokyo Bento Restaurant), 1009 College Street S.E., Room 104-B, Lacey, WA 98503, on March 24, 1998, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Paige Wall by March 13, 1998, TTY (360) 902-8324, VOICE (360) 902-7540.

Submit Written Comments to: Paige Wall, Rules Coordinator, Rules and Policies Assistance Unit, P.O Box 45850, Olympia, WA 98504-5850, FAX (360) 902-7540, by March 24, 1998.

Date of Intended Adoption: No sooner than March 25, 1998.

February 12, 1998

Edith M. Rice, Chief

Office of Legal Affairs

AMENDATORY SECTION (Amending WSR 96-21-031, filed 10/9/96, effective 11/9/96)

WAC 388-530-1600 Unit dose pharmacy billing requirements. (1) To be eligible for a unit dose dispensing fee, a pharmacy shall:

(a) Notify MAA in writing of its intent to provide unit dose service;

(b) ((Ask for a unit dose provider number;

(c))) Specify the type of unit dose service to be provided;

(((d))) (c) Identify the nursing facility to be served; ((and

(e))) (d) Indicate the approximate date unit dose service to the facility will commence((.

(2) The pharmacy shall)); and

(e) Sign an agreement to follow department ((abide by specific)) requirements for unit dose reimbursement.

(((3))) (2) Under a true or modified unit dose delivery system, a pharmacy ((shall)) may bill MAA ((only)) for the ((actual)) number of drug units ((used by a client during the billing period)) dispensed.

(((4) Under a modified unit dose delivery system, a pharmacy:

(a) May bill MAA for the number of drug units dispensed to a client during the billing period;

(b) Shall deduct the cost of unused drugs returned to the pharmacy on or before the last day of the billing period from charge to MAA, except as provided in subsection (6) of this section.

(5))) (3) The pharmacy shall ((deduct from)) submit an adjustment form or claims reversal of the charge to MAA for the cost of unused drugs returned to the pharmacy on or before the ((last)) sixtieth day ((of the billing period immediately)) following the ((period in which)) date the drug was dispensed, except as provided in subsection (((6))) (4) of this section. Such adjustment shall conform to the nursing facility's monthly log as described in subsection (6).

(((6) Controlled substances returned to the pharmacy do not have to be credited to MAA. According to federal regulations, pharmacists shall destroy))

(4) Modified unit dose providers do not have to credit MAA for controlled substances which are returned to the pharmacy.

(((7) Pharmacies shall bill MAA only once per month for all clients residing in a nursing facility served under a unit dose system. The monthly billing period shall be the same for all clients in the nursing facility.

(8) The billing period for:

(a) A true unit dose pharmacy shall be the calendar month;

(b) A modified unit dose pharmacy may be the calendar month or a monthly period starting on a specified date which shall be carried over to succeeding months. Once the modified unit dose pharmacy establishes the billing period for a nursing facility, the pharmacy shall not change the billing period without the department's approval.

(9) The pharmacy shall wait at least thirty days from the commencement of unit dose service to a nursing facility before submitting the first claims for drugs dispensed under unit dose to clients residing in that facility. This billing lag shall apply to both true and modified unit dose providers.

(10))) (5) Pharmacies ((may)) shall not charge ((the)) clients or MAA a fee for repackaging a client's bulk medications in unit dose form ((a client's bulk medications supplied by another pharmacy,)). The costs of repackaging shall be the responsibility of the nursing facility when the repackaging is done:

(a) To conform with a nursing facility's delivery system ((and)); or

(b) For the nursing facility's convenience. ((The costs of repackaging in such instances shall be the responsibility of the nursing facility.

(11))) (6) The pharmacy shall maintain detailed records of medications dispensed under unit dose delivery systems. The pharmacy shall keep a monthly log for each nursing facility served, including but not limited to the following information:

(a) Facility name and address;

(b) Client's name and patient identification code (PIC);

(c) Drug name/strength;

(d) NDC or labeler information;

(e) Quantity and date dispensed;

(f) Quantity and date returned;

(g) Value of returned drugs or amount credited;

(h) Explanation for no credit given or nonreusable returns; and

(i) Prescription number.

(((12))) (7) Upon MAA's request, the pharmacy shall submit ((to MAA)) copies of the ((monthly)) logs referred to in subsection (((11) of this section. MAA shall decide whether a unit dose pharmacy should maintain)) (6) on a monthly, quarterly, or annual ((reports)) basis.

(((13))) (8) The pharmacy shall submit annually with the completed prescription volume survey to MAA:

(a) An updated list of nursing facilities served under unit dose systems; and

(b) The nursing facilities' respective billing period start dates. ((The pharmacy shall submit this update with the pharmacy's completed prescription volume survey.))