CMS-R-153 Abbreviated MCO Surveys

FFY 2024 MEDICAID MANAGED CARE ORGANIZATION (MCO) DRUG UTILIZATION REVIEW (DUR) ANNUAL ABBREVIATED SURVEY

ABOUT THE SURVEY

42 C.F.R. § 438.3 (s)(4) and (5) require that each Medicaid managed care organization (MCO) must operate a drug utilization review (DUR) program that complies with the requirements described in Section 1927(g) of the Social Security Act (the Act) and submit an annual report on the operation of its DUR program activities. Such reports are to include descriptions of the nature and scope of the DUR programs; a summary of the interventions used in retrospective DUR (RetroDUR) and an assessment of the education program; and an assessment of the DUR program’s impact on quality of care. While states have the ability to exclude (or “carve out”) subsets of Medicaid benefits from their MCO contracts, it is typical that an MCO that does not cover the pharmacy benefit (that is, pay for covered outpatient drugs (CODs) dispensed from a pharmacy) will still be responsible for covering CODs administered in a doctor’s office and/or outpatient hospital or clinic. If medication is associated with a prescription and the medication is dispensed, the expectation is prospective and retrospective requirements are to be applicable. If medications are clinically administered, the expectation is only for retrospective reviews. If traditional drug benefits are not part of the benefit package, then the MCO would not be required to have a prospective program unless they review a Healthcare Common Procedure Coding System (HCPCS) request for clinical appropriateness and have a DUR component engrained in that process. It is expected that if the drug benefit is handled separately there are file transfers of the drug claim file so MCOs can coordinate that aspect of the care. Covered Outpatient Drugs (COD) are referenced throughout this survey and refers to participating labelers in the Medicaid Drug Rebate Program (MDRP).

This report covers the period October 1, 2023 to September 30, 2024 and is due for submission to Centers for Medicare & Medicaid Services (CMS) Central Office by no later than June 30, 2025. This abbreviated version of the MCO survey is for MCOs that have pharmacy benefits covered through the Fee -For-Service (FFS) program, but the MCOs still have some portion of benefits for covered outpatient drugs.

Answering the attached questions and returning the requested materials as attachments to the report will constitute compliance with the above-mentioned statutory and regulatory requirements. If you have any questions regarding the DUR Annual Report, please contact your state’s Medicaid Pharmacy Program.

CMS does not edit state responses; therefore, what is submitted will be what is

posted on Medicaid.gov. This material is also utilized for composing the annual report to Congress.

Pursuant to 42 C.F.R. § 438.3 (s), Medicaid managed care programs must submit to CMS an annual report on the operation of its DUR program activities for that Federal Fiscal Year (FFY). Individual managed care plan’s survey results will be published online and will be publicly available similar to the FFS surveys which have been published on Medicaid.gov since 2012. Please confirm and acknowledge there is no proprietary or confidential information submitted in this report by checking the box below:

I confirm I am aware this survey will be posted online. Confidential and proprietary information has been removed from this survey.

PRA DISCLOSURE STATEMENT (CMS-R-153)

This mandatory information collection (section 4401 of the Omnibus Budget Reconciliation Act of 1990 and section 1927(g) of the Social Security Act) is necessary to establish patient profiles in pharmacies, identify problems in prescribing and/or dispensing, determine each program’s ability to meet minimum standards required for Federal financial participation, and ensure quality pharmaceutical care for Medicaid patients. State Medicaid agencies that have prescription drug programs are required to perform prospective and retrospective DUR in order to identify aberrations in prescribing, dispensing and/or patient behavior. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The control number for this information collection request is 0938-0659 (Expires: XX/XX/XXXX). Public burden for all of the collection of information requirements under this control number is estimated at 65 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CMS, 7500 Security Boulevard, Attn: Paperwork Reduction Act Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244- 1850.

1. DEMOGRAPHIC INFORMATION

State Abbreviation:

MCO Name :

Please Note: Name above must match name entered in Medicaid Drug Program (MDP) DUR system

Medicaid MCO Information

Identify the MCO person responsible for DUR Annual Report Preparation. First Name:

Last Name: Email Address:

Position Title:

1. On average, how many Medicaid beneficiaries are enrolled monthly in your MCO for this Federal Fiscal Year?

Beneficiaries

2. Are all Section 1927(g) of the Act covered outpatient drugs (CODs) included in Fee-for-Service (FFS) pharmacy benefits (CODs include drugs dispensed in a pharmacy, administered in a doctor’s office, outpatient hospital or clinic. Drugs reimbursed at bundled/global rate are not considered outpatient drugs)?

^No

^{Yes, FFS covers all 1927(g) covered outpatient drugs.}

---------------------If ye s, completion of the remaining survey is voluntary--------------------------

3. Please list what CODs are included in the benefits by your MCO (i.e. physician administered drugs (PAD), medication assisted treatment (MAT) at outpatient treatment programs (OTPs), and outpatient hospital drugs)?

• Drugs administered in a clinic or physician’s office

• Drugs administered during an outpatient hospital stay

• Emergency Departments (ER)

• OTPs

• 
  Other, please explain.

4. What practices and policies do you have in place to share information between providers? NOTE: It is expected that if the drug benefit is handled separately there are file transfers of the drug claim file so MCOs can coordinate that aspect of the care.

Please explain.

1. Please explain the process for coordination of clinical outcomes between medical providers and pharmacy?

2. How is quality of care for prescriptions ensured? Please explain.

5. Does your MCO have a documented process (i.e. prior authorization (PA), pharmacist or technician reviews, etc.) in place, so that the Medicaid beneficiary or the Medicaid beneficiary’s prescriber may access any COD covered under your benefit plan when medically necessary?

• Yes, what is the PA process?

• 
  

No, please explain why there is not a process for the beneficiary to access a COD when it is medically necessary.

2. RETROSPECTIVE DUR (RetroDUR)

   1. Who reviews and approves the RetroDUR criteria?

MCO DUR Board MCO P&T Board

^{MCO pharmacy manager State pharmacy director}

Combination of medical and pharmacy directors ^{State DUR Board}

Outside entities

Other, please explain.

2. Summary 1 – RetroDUR Educational Outreach

RetroDUR Educational Outreach Summary is a report on retrospective profile screening and educational opportunities during the fiscal year reported. This report should be limited to the most prominent problems with the largest number of exceptions. The results of RetroDUR screening and interventions should be included and detailed below.

3. PHYSICIAN ADMINISTERED DRUGS (PAD)

   1. The Deficit Reduction Act requires collection of national drug code (NDC) numbers for covered outpatient physician administered drugs. These drugs are paid through the medical benefit. Has your claims processing system been designed to evaluate the drug data supplied by the state into your RetroDUR criteria or PA reviews?

Yes No

If “No”, does your MCO have a plan to include this information in your DUR criteria in the future?

Yes No

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4. FRAUD, WASTE, AND ABUSE (FWA) DETECTION

1. LOCK-IN or PATIENT REVIEW and RESTRICTION PROGRAMS

   1. Does your MCO have a documented process in place that identifies potential FWA of controlled drugs by beneficiaries?

Yes

• 
  ^{No, please explain}

If “Yes”, what actions does this process initiate? Check all that apply: Deny claims

Require prior authorization (PA) Refer to Lock-In Program

Refer to Program Integrity Unit (PIU) and/or Surveillance Utilization Revie w (SUR) Unit

Refer to Office of Inspector General (OIG) Other, please explain.

2. Does your MCO have a coordinated process in place, such as a lock-in program, for beneficiaries with potential use or abuse of controlled substances?

Yes No

If “No”, skip to question 3. If “Yes”, please continue.

1. What criteria is used to identify beneficiaries with potential FWA of controlled

substances? Check all that apply.

Number of controlled substances Different prescribers of controlled substances

Multiple pharmacies Days’ supply

Exclusivity of short acting opioids Multiple emergency room (ER) visits

Prescription Drug Monitoring Program (PDMP) data Same FFS state criteria is applied

Other, please explain.

Does your MCO have the capability to restrict the beneficiary to a prescriber only?

Yes No N/A

3. Does your MCO have a documented process in place that identifies possible FWA of controlled drugs by prescribers?

^{Yes No}

If “No”, please explain why not.

If “Yes”, what actions does this process initiate? Check all that apply.

Deny claims written by this prescriber

Refer to Program Integrity Unit (PIU) and/or Surveillance Utilization Review (SUR) Unit for audit/investigation

Refer to the appropriate Medical Board Other, please explain.

4. ^{Does your MCO have a documented process in place that identifies potential FWA of controlled} drugs by pharmacy providers?

^Yes No

If “No”, please explain why not.

If “Yes”, what actions does this process initiate? Check all that apply.

Deny claims

Refer to Program Integrity Unit (PIU) and/or Surveillance Utilization Review (SUR) Unit for audit/investigation

Refer to the Board of Pharmacy Other, please explain.

5. Does your MCO have a documented process in place that identifies and/or prevents potential fraud or abuse of non-controlled drugs by beneficiaries, pre scribers, and pharmacy providers?

^{Yes, please explain your program for FWA of non-controlled substances.}

No, please explain why not.

6. Briefly explain the MCOs objectives and scope of responsibility between DUR and SUR functions as they relate to FWA. Additionally, explain how the MCO maintains separation between fraud and abuse and educational activities. (Character limit 1000)

2. PRESCRIPTION DRUG MONITORING PROGRAM (PDMP)

1. Does your MCO have the ability to query the state’s PDMP database?

• Yes, for all data files

• Yes, for selective beneficiary and provider searches

• 
  No, please explain.

If “Yes,” please continue.

1. Please check all applicable ways your MCO accesses the PDMP database.

• Receive PDMP data

• Direct access to the database

1. If “Receive PDMP data,” please specify how often. Check all that apply.

• Daily

• Weekly

• Monthly

• Other, please specify. ____________

2. If “Direct access to the database,” please specify how. Check all that apply.

• Can query by client (beneficiary)

• Can query by prescriber

• Can query by dispensing entity

2. Please explain how your MCO applies this information to help control FWA of controlled substances.

c. Does your state also have access to contiguous states’ PDMP information?

• Yes

• No

1. In the state’s PDMP system, which of the following beneficiary information is available to prescribers as close to real-time as possible? Check all that apply.

• PDMP drug history

• The number and type of controlled substances prescribed to and dispensed to the beneficiary during at least the most recent 12-month period

• The name, location, and contact information, or other identifying number, such as a national provider identifier, for previous beneficiary fills

• 
  Other, please explain.

1. Are there barriers that hinder your MCO from fully accessing the PDMP data that prevent the program from being utilized the way it was intended to be to curb FWA?

   • 
     Yes, please explain the barriers (e.g., lag time in prescription data being submitted, prescribers not accessing, pharmacists unable to view prescription history before filling script).

   • No

3. How have you communicated to prescribers who are covered providers that they are required to check the PDMP before prescribing controlled substances to beneficiaries who are covered individuals? Check all that apply.

• Provider bulletin

• Program website

• Provider blast fax

• DUR letter

• Public notice

• Provider manual

• RetroDUR communication

• 
  Other, please explain.

_¡ No, please explain.

1. Has your MCO specified protocols for prescribers checking the PDMP?

   • 
     Yes, please explain.

• No

2. Do providers receive protocols for responses to information from the PDMP that is contradictory to information that the practitioner expects to receive (example: when a provider prescribing pain management medication finds medications for opioid use disorder (OUD) during a PDMP check, when client denies opioid use disorder)?

   • Yes

   • No

3. If a provider is not able to conduct PDMP check, does your state require the prescriber to document a good faith effort, including the reasons why the provider was not able to conduct the check?

   • Yes

   • 
     No, please explain why not.

If “Yes,” does your MCO require the provider to submit, upon request, documentation to the state?

• Yes

• No, please explain.

4. Have any changes occurred to your state’s PDMP during this reporting period that improved or detracted from the Medicaid program’s ability to access PDMP data?

• 
  Yes, please explain.

• No

5. In this reporting period, have there been any data or privacy breaches of the PDMP or PDMP data?

• Yes

• No

3. OPIOIDS

1. Does your MCO coordinate with the entity that provides the drug benefits to monitor opioid prescriptions (duplicate therapy, early refills, quantity limits, etc.)?

Yes No

Please explain above response.

2. Does your MCO have comprehensive automated retrospective claims review process to monitor opioid prescriptions exceeding state defined limitations?

^{Yes, please explain in detail the scope and nature of these retrospective reviews.}

No, please explain.

3. Does your MCO coordinate with the entity that provides the drug benefits to monitor opioids and benzodiazepines being used concurrently?

• Yes

If “Yes,” please check all that apply.

• Automated retrospective claim reviews

• Educational programs

• Titration programs

• Peer to peer assistance

Please explain above response and detail the scope and nature of these reviews and edits. Additionally, please explain any potential titration processes utilized for those patients chronically on benzodiazepines and how the state justifies pain medications, i.e., Oxycodone/APAP, for breakthrough pain without jeopardizing patient care (i.e., quantity limits/practitioner education titration programs).

No, please explain why not.

4. Does your MCO coordinate with the entity that provides the drug benefits to monitor opioids and sedatives being used concurrently?

Yes

If “Yes,” please check all that apply.

• Automated retrospective claim reviews

• Educational programs

• Titration programs

• Peer to peer assistance

No, please explain why not.

5. Does your MCO coordinate with the entity that provides the drug benefits to monitor opioids and antipsychotics being used concurrently?

Yes

If “Yes,” please check all that apply.

• Automated retrospective claim reviews

• Educational programs

• Titration programs

• Peer to peer assistance

No, please explain why not.

6. Does your MCO perform automated retrospective claim reviews and/or provider education in regard to beneficiaries with a diagnosis history of opioid use disorder (OUD) or opioid poisoning diagnosis?

• ^Yes

• ^{No, please explain why not.}

If “Yes,” please check all that apply.

Automated retrospective claim reviews

Provider education

If “Yes,” automated retrospective reviews and/or provide r education, please continue.

1. Please indicate how often: ^Monthly

Quarterly

Semi-Annually Annually

Ad hoc

Other, please specify.

2. Please explain the nature and scope of reviews and/or provider education reviews performed.

If the answer to question 6 is “No”, does your MCO plan on implementing an automated retrospective claims review and/or provider education in regard to beneficiaries with a diagnosis or history of OUD or opioid poisoning in the future?

Yes, when does your MCO plan on implementing?

No, please explain.

7. Does your program develop and provide prescribers with pain management or opioid prescribing guidelines?

^Yes No

If “Yes”, please check all that apply.

Your prescribers are referred to the Center for Disease Control (CDC) 2022 Clinical Practice Guideline for Prescribing Opioids for Pain.

Other guidelines, please identify.

If “No," please explain why no guidelines are offered.

4. MORPHINE MILLIGRAM EQUIVALENT (MME) DAILY DOSE

   1. Does your MCO coordinate with the entity that provides the drug benefit to monitor MME total daily dose of opioid prescriptions dispensed?

^Yes No

Please explain above response.

5. OPIOID USE DISORDER (OUD) TREATMENT

   1. Does your MCO coordinate with the entity that provides the drug benefit to monitor and manage appropriate use of opioid reversal agents to persons at risk of overdose?

Yes No

Please explain above response.

6. OPIOID TREATMENT PROGRAMS (OTP)

1. Does your program cover medications used for OUD through OTPs? Yes

No

If “Yes,” please explain how MAT drugs are billed through OTPs.

7. PSYCHOTROPIC MEDICATION

ANTIPSYCHOTICS

1. Does your MCO coordinate with the entity that provides the drug benefit to manage and monitor the appropriate use of antipsychotic drugs in children?

• Yes

• No

• Covered through the FFS benefit

If “Yes”, please continue.

If “No” or “Covered through the FFS benefit”, skip to question 1.c.

1. Does your MCO manage and monitor

Only children in foster care under 18 y.o.

All children including foster care under 18 y.o.

Other, please explain.

2. Please briefly explain the specifics of your antipsychotic monitoring program(s).

3. If you do not have a documented antipsychotic monitoring program in place, does your MCO plan on implementing a program in the future?

Yes, please specify when.

No, please explain why your MCO will not be implementing a program to

monitor the appropriate use of antipsychotic drugs in children.

2. Does your MCO have a documented program in place to manage and monitor the appropriate use of antipsychotic drugs in individuals over the age of 18 receiving home and community-based services (as defined in section 9817(a)(2)(B) of Public Law 117–2)?

• ^Yes

• ^No

If “Yes,” please continue.

a. Does your MCO have edits in place to monitor (check all that apply):

• Dosage

• Indication

• Polypharmacy

• 
  Other, please explain.

b. Please briefly explain the specifics of your documented antipsychotic monitoring program(s).

If “No,” please continue.

c. Does your MCO plan on implementing an antipsychotic monitoring program in the future?

• Yes, please specify when you plan on implementing a program.

• 
  No, please explain why you will not be implementing a program.

3. Does your MCO have a documented program in place to manage and monitor the appropriate use of antipsychotic drugs in individuals over the age of 18 residing in institutional care settings (including nursing facilities, intermediate care facilities for individuals with intellectual disabilities, institutions for mental diseases, inpatient psychiatric hospitals, and other such institutional care settings)?

• ^Yes

• ^No

If “Yes,” please continue.

a. Does your MCO monitor (check all that apply):

• individuals over the age of 18 residing in nursing facilities

• individuals over the age of 18 residing in intermediate care facilities for individuals with intellectual disabilities

• individuals over the age of 18 residing in institutions for mental diseases

• individuals over the age of 18 residing in patient psychiatric hospitals

• individuals over the age of 18 residing in other such institutional care settings. Please explain.

If your MCO does not monitor all of the above, please explain why not.

b. Does your MCO have edits in place to monitor (check all that apply):

• Dosage

• Indication

• Polypharmacy

• Other, please explain.

c. Please briefly explain the specifics of your documented antipsychotic monitoring program(s).

If “No,” please continue.

d. Does your MCO plan on implementing an antipsychotic monitoring program in the future?

• 
  Yes, please specify when you plan on implementing a program.

• No, please explain why you will not be implementing a program.

STIMULANTS

4. Does your MCO coordinate with the entity that provides the drug benefit to manage and monitor the appropriate use of stimulant drugs in children?

• Yes

• No

• Covered through the FFS benefit

If “Yes”, please continue.

If “No” or “Covered through the FFS benefit”, skip to question 2.c.

1. Does your MCO manage and monitor

^{Only children in foster care under 18 y.o.}

^{All children including foster care under 18 y.o.}

Other, please explain.

2. Please briefly explain the specifics of your documented stimulant monitoring program(s).

3. If you do not have a documented stimulant monitoring program in place, does your MCO plan on implementing a program in the future?

Yes, please specify when.

No, please explain why your MCO will not be implementing a program to monitor the appropriate use of stimulant drugs in children.

ANTIDEPRESSANTS/MOOD STABILIZERS/ANTIAXIETY/SEDATIVES

5. Does your MCO coordinate with the entity that provides the drug benefit to manage and monitor the appropriate use of other psychotropic medication (antidepressants, mood stabilizers, antianxiety/sedative) drugs in children?

Yes (check all that apply)

• Antidepressants

• Mood stabilizers

• Antianxiety/sedative drugs

• 
  Other, please explain.

No

• Covered through the FFS benefit

If “Yes”, please continue with questions 3.a and 3.b.

If “No” or “Covered through the FFS benefit”, skip to question 3.c.

1. Does your MCO manage and monitor

Only children in foster care under 18 y.o.

All children including foster care under 18 y.o.

Other, please explain.

b. Please briefly explain the specifics of your documented monitoring program(s).

3. If you do not have a documented monitoring program in place, does your MCO plan on implementing a program in the future?

Yes, please specify when.

No, please explain why your MCO will not be implementing a program to monitor the appropriate use of drugs in children.

5. INNOVATIVE PRACTICES

1. Does your MCO participate in any demonstrations or have any waivers to allow importation of certain drugs from Canada or other countries that are versions of FDA-approved drugs for dispensing to Medicaid beneficiaries?

Yes, please explain.

No

2. Summary 2 – Innovative Practice s

Has your MCO developed any innovative practices during the past year (i.e. Substance Use Disorder, Hepatitis C, Cystic Fibrosis, MMEs, Value Based Purchasing)? Please describe in a detailed narrative below any innovative practices that you believe have improved the administration of your DUR program, the appropriateness of drug use and/or have helped to control costs (i.e. disease management, academic detailing, automated PA, continuing education programs).

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File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	FFY 2021 MEDICAID MANAGED CARE ORGANIZATION (MCO)
Author	MICHAEL FORMAN
File Modified	0000-00-00
File Created	2024-09-06