Medicaid Drug Rebate Program – Billing Guidance for Practitioner-Administered Drugs
IMPACTED PLANS: Medicaid, SNP, and HARP
TO: All Providers
Dear Valued MetroPlusHealth Provider,
MetroPlusHealth is committed to keeping our provider network informed of important Department of Health policies. This notice serves as a reminder for important guidance regarding billing for practitioner-administered drugs under the New York State Medicaid Drug Rebate Program (MDRP). The rebate program is intended to offset Medicaid costs and reduces federal and state spending on drugs.
To participate in the Medicaid Drug Rebate Program, established in 1990 under the Omnibus Reconciliation Act (OBRA ’90); drug manufacturers must sign a National Drug Rebate Agreement (NDRA) with the Centers for Medicare & Medicaid Services (CMS) to report pricing data and pay rebates to state Medicaid Programs. Under this program, reimbursement of practitioner-administered drugs is allowable only if the drug qualifies for a rebate pursuant to 42 USC Section1396r-8.
Providers are encouraged to use the referenced tools below to determine if a practitioner-administered drug will be reimbursable in MetroPlusHealth Medicaid, SNP, and HARP Plans. As a reminder, National Drug Code (NDC) must be reported for practitioner-administered drugs. Claims with a missing, invalid, incomplete NDC information or with an NDC not listed on the MDRP, will be denied.
Category of drugs exempt from the MDRP include vaccines, radiopharmaceuticals and contrast media, as well as certain service-related exceptions. For example, a drug is not considered a Covered Outpatient Drug (COD) if it is provided as part of or bundled in an all-inclusive payment in the same setting.
The Practitioner Administered Drug (PAD) Search Tool is a list of practitioner-administered drugs which includes Healthcare Common Procedure Coding System (HCPCS) code and National Drug Code (NDC) information. Practitioner-administered drugs (PAD) are drugs, other than vaccines, that are covered under section 1927(k)(2) of the Social Security Act and are typically administered by a medical professional in a practitioner’s office or other outpatient clinical setting. Due to the frequency of updates to this tool, it should not be used to determine NYS Medicaid coverage exclusion.
Providers can identify product data for drugs, including labelers/vendors that participate in the Medicaid Drug Rebate Program, here.
If you have any questions regarding this memo, please contact MetroPlusHealth at: [email protected].