Redetermination Toolkit

Resources are available for providers from Maryland’s Medicaid Check-In Campaign to help avoid disruptions in health insurance coverage following the pandemic. A Redetermination Provider Toolkit includes flyers, social media instructions, newsletter blurbs, email, text message and Check-In logo. These resources are available in multiple languages.

PDL Updates Effective July 1, 2023

The Office of Pharmacy Services Advisory 248 alerts prescribers to changes in the Maryland Medicaid Pharmacy Program Preferred Drug List (PDL) effective this month, including anticonvulsants, antidepressants, opioid use disorder treatments, and stimulants.  Please refer to the website for the current PDL and Brand Preferred over Generics List.

The PDL changed effective July 19 for certain Brand name anticonvulsant, OUD treatment and stimulant drugs, which are now preferred over Generic.  Please see Advisory 249 for details.

PMHS Rates Effective July 1, 2023

The updated payment rates for services provided in the Maryland Public Mental Health System are available here.

ATTN: New Buprenorphine Prescribers

On January 12, the DEA announced that the DATA 2000 Waiver (X-Waiver) requirement had been eliminated. All physicians (PT 20) with a DEA registration that includes Schedule III authority can now prescribe buprenorphine for opioid use disorder, as permitted by applicable state law.

The Maryland Department of Health outlined a provider enrollment process to add buprenorphine services to provider records.  Those already enrolled with Maryland Medicaid to prescribe buprenorphine do not need to take any action.

Providers who did not previously have an X-Waiver and are now eligible to prescribe buprenorphine must submit a supplemental application in ePREP and upload these documents to update their provider records and provide that service:

• A copy of the DEA letter announcing the termination of the X-Waiver
• A DEA certificate that includes Schedule III authority

Please see the transmittal for billing and other details.

Medicaid Board Eligibility Policy

A February 22 Optum Maryland alert clarifies the requirements for physicians to have a specialty added to their Medicaid enrollment. Providers select their specialty on their application in ePrep; those who are board certified must upload their board certification. Providers who are board eligible do not need documentation, but must be within the ABMS board eligible period.  Upon receipt of their board certification, providers should submit a supplemental application in ePrep. Providers who do not become board certified by the end of the eligibility period will have the specialization removed from their file. Please contact mdh.bhenrollment@maryland.gov with any questions.

Public Behavioral Health System ASO

Optum Maryland is the administrative service organization (ASO) for Maryland’s public behavioral health system.  Click here for provider alerts.  Click here for Optum Provider Training & Education.  Please see the provider information on the ASO website or call 1-800-888-1965 with questions.

Maryland Medicaid Provider Verification System

The Provider Verification System (PVS) is a public-facing search engine for Maryland Medicaid fee-for-service provider enrollment.  A PVS user can search for a provider to see if the provider was active or inactive on specified date.  For instructions, please see this overview for providers.

Maryland Medicaid ORP Provider

The Medicaid program notified the MPS that Ordering, Referring, and Prescribing (ORP) provider enrollment is available for those who contract privately with patients.  This is instead of enrolling as a rendering provider (and accepting Medicaid contract terms).  The ORP option accommodates psychiatrists who have private pay arrangements with patients while Medicaid pays for prescriptions.  This is somewhat similar to opting out of Medicare but, according to Medicaid Provider Services, there is no 2-year minimum requirement, e.g. someone can sign up as ORP one week and then change to a provider the next.  A signed written agreement with the patient would be best practice.

Providers must enroll as ORP (or as one of the rendering provider options) for prescriptions to be paid by Medicaid.  Once this requirement is fully implemented, if you have not enrolled, payment for prescriptions will be rejected at the pharmacy.  This requirement is due to Section 6401 of the Affordable Care Act and Code of Federal Regulations section 42 CFR § 455.410(b), which prohibits state Medicaid agencies from reimbursing for ordered, referred, or prescribed services when the ORP practitioner is not enrolled in the state Medicaid program.

Begin ORP enrollment at health.maryland.gov/eprep.  There is some screening; for example, a current medical license is required, as for enrolling as a provider, but there is no provider agreement and no contractual relationship with Medicaid.  The ePREP process may be confusing so there are webinars (under “Past Webinars,” see links to slides and recording for “ePREP for Ordering/Referring/Prescribing (ORP) Providers”) and other online resources.  Enrollment instructions help get into the portal on the correct path, but continue as appropriate to your situation.  The rest of the steps depend somewhat how you complete the form.

Please contact mdh.rxenroll@maryland.gov with questions about ORP policies or enrollment.  For many ePREP issues and questions, the call center can get things sorted out quickly. Common issues include password reset requests, user profile setup, and other technical guidance. Try the call center with specific questions or technical issues.  1-844-4MD-PROV (1-844-463-7768) Monday – Friday 7AM- 7PM  but closed on State holidays.

Should that be insufficient, personal assistance with ORP enrollment is available – please email Brenda Logan at blogan@automated-health.com to request an appointment.  A minimum of one hour is recommended, especially if online materials and the webinar have not already been viewed.

After initial enrollment, the provider will need to upload when the medical license renews and revalidate every 5 years.

A third option is available to psychiatrists via ePREP:  they may also enroll as solo practitioners, which is like a rendering provider, except the provider can receive direct payment from Medicaid instead of needing to be affiliated with a reimbursable group.

Please note:  Each year many Marylanders enroll in Medicaid as one of the options on the health insurance exchange established under the Affordable Care Act.  Be sure to ask all private pay patients whether they use Medicaid to cover their medicines.  If so, you must be enrolled as ORP to enable reimbursement.

 Medicaid Mail Reminder

The Maryland Medicaid program automatically disenrolls Medicaid enrollees whose mail is returned due to an invalid address (a regulatory requirement of the federal and state government).  A fact sheet describes the process, identifies specific consumer types who are excluded from disenrollment, and provides information on how an enrollee can report address changes.  Patients must communicate address changes to the state to protect their Medicaid status.

Parity Rule for Medicaid and CHIP

In 2016, CMS finalized regulations to strengthen access to mental health and substance use (MHSU) services for people with Medicaid or Children’s Health Insurance Program (CHIP) coverage, aligning with protections already required of private health plans under the Mental Health Parity and Addiction Equity Act of 2008.  The final rule maintains state flexibility regarding managed care while guaranteeing that Medicaid enrollees can access MHSU services in the same manner as medical benefits.  Plans must disclose information on MHSU disorder benefits upon request, including the criteria for determinations of medical necessity. The final rule also requires the state to disclose the reason for any denial of reimbursement or payment for services with respect to MHSU disorder benefits.  For more information, review the 1425-page final rule or go to the Medicaid Behavioral Health Services webpage.

Clozapine REMS

The FDA Risk Evaluation and Mitigation Strategy (REMS) program can be found at the Clozapine REMS website.  Important: Prescribers need to be certified to participate in the Clozapine REMS program.  To obtain certification, click here.