Medicaid

Maryland Medicaid Pharmacy Program changes are effective July 1.  Please see the Preferred Drug List for the latest information.

New Maryland Medicaid ORP Provider

The Medicaid program notified the MPS that it now allows Ordering, Referring, and Prescribing (ORP) provider enrollment 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 the prescriptions they order.  This new option is somewhat similar to opting out of Medicare but, according to Medicaid Provider Services, there is no 2-year minimum requirement, i.e. someone can sign up for ORP one week and then change to a provider the next week.  A signed written agreement with the patient would be best practice.

You must enroll as an ORP (or as one of the rendering provider options) for prescriptions to be paid by Medicaid after October 1, 2019.  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.

[As a reminder, last year Medicaid began rejecting payment for prescriptions if the prescriber was not enrolled as a provider in the Medicaid program.  This practice was put on hold after the MPS raised alarm that some psychiatric patients were no longer able to obtain their medicines.  As a precaution, some non-enrolled psychiatrists referred their patients to other psychiatrists who participate in Medicaid.  Others continued seeing their Medicaid patients during the hiatus to preserve the treatment relationship.]

There is some screening with the ORP enrollment at health.maryland.gov/eprep.  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 first 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.

Public Behavioral Health System Rates Effective July 1

The  rates for community-based behavioral health services in Maryland were increased as of July 1, 2018.  Rates were initially posted incorrectly on the Beacon Health Options website.  New rates are now listed.

Assistance with Medicaid Appeals and Grievances

Beacon Health Options Maryland manages care to people served by the Maryland Department of Health Behavioral Health Administration.  Aspects of the services provided, including medical necessity, service authorization, etc, are described in detail on the Beacon website.  The regulations for grievances and appeals are outlined in COMAR 10.09.36.  For information about the process of how to request a review, submit a grievance or request an appeals hearing, please review Chapter 10 of the Beacon provider manual.

Medicaid and CHIP Scorecard

The Medicaid and Children’s Health Insurance Program (CHIP) Scorecard includes measures voluntarily reported by states, as well as federally reported measures in three areas: state health system performance; state administrative accountability; and federal administrative accountability. Click here to view the Maryland profile.  Of note, Maryland’s Medicaid and CHIP enrollment has increased over 50% since the ACA rollout in October 2013.  For more information, please review the fact sheet.

Medicaid Mail Reminder

In 2018, the Maryland Medicaid program is automatically disenrolling Medicaid enrollees whose mail is returned due to an invalid address, which has been a regulatory requirement by the federal and state government for some time.  A fact sheet describes the new process, identifies specific consumer types who will be excluded from disenrollment, and provides information on how an enrollee can report address changes.  Please inform patients that they must communicate address changes to the state to protect their Medicaid status.

Opioid-Related Changes

In an attempt to block the prescription pathway to substance use disorders, DHMH announced policy changes for both Medicaid fee-for-service and HealthChoice plans.  The changes, which will be in place by July 1, 2017, aim to:

  • Prevent medical and non-medical opioid use, abuse, and substance use disorder from developing;
  • Identify and treat opioid dependence early in the course of the disease;
  • Prevent overdose deaths, medical complications, psychosocial deterioration, transition to injection drug use, and injection-related disease; and
  • Identify and outreach to providers who do not follow standard practice.

All high-dose and long-acting opioids, including fentanyl prescriptions issued to Maryland Medicaid members, are now subject to prior authorization. In addition to these new prior authorization requirements, Maryland Medicaid is also encouraging providers to:

  • Consider non-opioids as first-line treatment for chronic pain;
  • Offer naloxone to patients who meet certain risk factors;
  • Conduct thorough substance use disorder screening prior to prescribing opioids;
  • Refer patients to treatment that are identified as having a substance use disorder; and
  • Use the Department’s Prescription Drug Monitoring Program for all Controlled Dangerous Substance prescriptions.

Parity Rule for Medicaid and CHIP

On March 29, 2016 CMS announced final 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.

Individual  Provider Enrollment with Medicaid

Check Individual Provider Enrollment with Medicaid for the steps needed to be able to deliver behavioral health services to Medicaid recipients under Maryland’s Public Behavioral System.