N.J. Admin. Code § 10:51-2.7

Current through Register Vol. 56, No. 24, December 18, 2024

Section 10:51-2.7 - Prescription dispensing fee (capitation)

(a) The New Jersey Medicaid and NJ FamilyCare programs capitate the dispensing fee for each prescription for beneficiaries in Medicaid approved nursing facilities in accordance with the total number of Medicaid and NJ FamilyCare fee-for-service beneficiary days in the facility(ies) serviced by the pharmacy. Additional dispensing fees (add-ons) per prescription shall be given to pharmacy providers who provide the following levels of services: Pharmacies with institutional permits shall be reimbursed as defined in (a) above, except that the daily per beneficiary capitation fee shall be 75 percent of the fee for pharmacies with retail permits.

1. Twenty-Four Hour Unit Dose Service: Pharmacies with retail permits dispensing medication in a dispensing system in which a 24-hour supply of unit dose oral medication, both solid (for example, tablets, capsules) and liquid formulations, is delivered for each beneficiary daily, shall be reimbursed the cost of all reimbursable legend medication plus a fee of $ 0.656 per beneficiary day.

i. Exception: Certain liquid medications that are supplied in concentrate form only and are administered by drop dosage cannot be supplied in a 24-hour dose.

2. Modified Unit Dose Service: Pharmacies with a retail permit dispensing medication in a dispensing system in which up to a one-month supply of oral unit dose solid medication is delivered for each beneficiary (for example, unit dose solids, "bingo" card), shall be reimbursed the cost of all reimbursable legend medication plus a fee of $ 0.544 per beneficiary day.

3. Traditional Service: Pharmacies with a retail permit dispensing medication in a dispensing system in which a maximum one-month supply of medication is delivered monthly for each beneficiary shall be reimbursed the cost of legend medication plus a fee of $ 0.487 per beneficiary day.

4. Computerized Service: Pharmacies which provide ancillary computerized services, such as, but not limited to, continuously updated computerized beneficiary profiles, clinical records (med sheets and physicians' orders on at least a monthly basis), etc., receive an added increment of $ 0.05 per beneficiary day, thereby making the total fee $ 0.706, $ 0.594 or $ 0.537 depending upon the dispensing system used.

(b) Price information is supplied from a reference drug file subcontracted for this purpose by the fiscal agent and accepted by the Division as the primary source of pricing information for the New Jersey Medicaid Management Information System. The calculated price shall not exceed the lower of the average wholesale price (AWP) or the Federal Fund Participation Upper Limit (FFPUL) as supplied by the reference drug file contractor.

(c) In order to receive any or all of the above increments, the provider shall certify annually to the Division on Form FD-70, that the services(s) as defined in (a) above, are being provided and/or that the provider is entitled to the impact increment as defined in (a) above.

1. Each claimed increment is subject to audit and retroactive recovery with appropriate penalties, if warranted, if the New Jersey Medicaid or NJ FamilyCare program determines that the provider was not entitled to reimbursement for them.

(d) When a nursing facility changes its servicing pharmacy provider, the new pharmacy provider must notify the fiscal agent so that the provider file of the New Jersey Medicaid Management Information System (NJMMIS) may be updated. The following information is required in writing:

1. A copy of the agreement between the servicing pharmacy provider and the nursing facility (Appendix G, incorporated herein by reference);

2. The provider number of the servicing pharmacy;

3. The effective date of the change in servicing pharmacy provider if not clearly indicated in the agreement between the servicing pharmacy provider and the nursing facility;

4. The name and address of the previous servicing pharmacy provider for the nursing facility;

5. The level of service to be provided (for example: traditional, modified unit dose, or 24-hour unit dose); and

6. A statement indicating the provision of ancillary computerized services or recordkeeping for the nursing facility.

N.J. Admin. Code § 10:51-2.7

Amended by R.1998 d.488, effective 9/21/1998.
See: 30 N.J.R. 2169(b), 30 N.J.R. 3538(a).
In (a), inserted a reference to NJ KidCare and a reference to NJ KidCare fee-for-service in the introductory paragraph; in (c)1, inserted a reference to NJ KidCare; and in (d)1, inserted a reference to Appendix G.
Amended by R.2004 d.26, effective 1/20/2004.
See: 35 N.J.R. 3788(a), 36 N.J.R. 558(a).
Substituted "NJ FamilyCare" for "NJ KidCare" throughout.