LTC Advocacy and Updates

LTC Division Priorities

Ensuring CMS recognition of medical at home and ALF services

NCPDP patient residence codes exist for medical at home, but are not currently being recognized/utilized. NCPA asks that CMS recognize and promote medical at home pharmacy services at the same level as pharmacy services that are provided to skilled nursing patients, which would ultimately increase the value of patient care and decrease costs. NCPA is engaged in reoccurring discussions with CMS’ Medicare Part D team to further this ask, including a letter NCPA sent to CMS earlier this year.

Assisted living facility (ALF) patients receive a high level of care similar to skilled nursing facility (SNF) patients; however LTC pharmacists are often not appropriately recognized when providing these valuable services. CMS recognition of residence in ALF and the benefits of services LTC pharmacists provide to ALF patients could lead to improved patient care. NCPA is in contact with CMS to see how we can improve recognition of ALF residence.

Keeping DIR fees out of LTC

Part D plan sponsors and pharmacy benefit managers extract direct and indirect remuneration (DIR) fees from community pharmacies, usually months after a transaction, rather than deducting them from claims on a real-time basis. Those retroactive clawbacks make it extremely difficult for community pharmacists to operate their small businesses when they have no idea whether they'll break-even on a transaction until months later. NCPA is committed to advocating on CMS and PBM reimbursement issues, including keeping DIR fees out of LTC pharmacies, as well as, addressing low reimbursements, anticompetitive behavior, and exclusionary preferred networks.

Appropriately defining mail order pharmacy

CMS proposed to define mail order pharmacy in the 2019 Medicare Part D Rule, but did not finalize the definition. NCPA asserted that Part D plans/PBMs require LTC pharmacies that are mailing some prescription refills to patients to register as a mail order pharmacy and pursue state licensure in all 50 states otherwise they would need to stop mailing prescriptions to their patients. A definition of mail-order pharmacy would help distinguish between pharmacies who offer some mail delivery from "true mail order pharmacies," which would prevent PBMs from applying their own arbitrary standards for mail services. NCPA submitted comments advocating for a mail-order definition and will continue to support a definition when discussing with CMS.