CMS-R-153 MCO Annual Surveys

FFY 2024 MEDICAID MANAGED CARE ORGANIZATION (MCO) DRUG UTILIZATION REVIEW (DUR) ANNUAL 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 prospective and retrospective DUR programs; a summary of the interventions used in retrospective DUR and an assessment of the education program; a description of DUR Board activities; and an assessment of the DUR program’s impact on quality of 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. 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.

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.

If you have any questions regarding the DUR Annual Report, please contact your state’s Medicaid Pharmacy Program.

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 Fee-for-Service (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 :

Program Type :

(See Appendix A)

If “Other”, please specify.

Medicaid MCO Information

Identify the MCO person responsible for DUR Annual Report preparation.

First Name:

Last Name:

Email Address:

Position Title:

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

Beneficiaries

2. PROSPECTIVE DUR (ProDUR)

1. Indicate the type of your pharmacy point of service (POS) vendor and identify by name.

• State-operated

• Contractor

• Other organization

If “Contractor” or “Other organization”, please identify by name your pharmacy POS vendor.

If “Other”, please specify.

2. Identify ProDUR table driven criteria source. This would be initial ratings such as drug to drug interactions, dose limits based on age, etc…. Check all that apply:

• First Data Bank

• Medi-Span

• Micromedex

• Other, please specify. ______________________________________________________

3. When the pharmacist receives a ProDUR alert message that requires a pharmacist’s review, does your system allow the pharmacist to override the alert using the “National Council for Prescription Drug Program (NCPDP) drug use evaluation codes” (reason for service, professional service and resolution)?

   • Yes

   • Varies by Alert Type

   • No

If “Yes” or “Varies by Alert Type”, check all that apply:

• Alerts can be overridden ahead of time

• Alerts can be overridden with standard professional codes

• Alerts need prior authorization (PA) to be overridden

• Other, please explain.

4. Does your MCO receive periodic reports providing individua l pharmacy providers DUR alert override activity in summary and/or in detail?

• Yes

• No

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

1. If “Yes,” how often does your MCO receive reports? Check all that apply:

   • Monthly

   • Quarterly

   • Annually

   • Ad hoc (on request)

   • Other, please explain.

2. If “Yes,” does your MCO follow up with those providers who routinely override with interventions?

• Yes

If “Yes,” by what method does your MCO follow up? Check all that apply:

• Contact Pharmacy

• Refer to Program Integrity (PI) for Review

• Other, please explain.

• No, please explain.

5. Early Refill

1. At what percent threshold does your MCO set your system to edit?

   1. Non-controlled drugs:

%

2. Schedule II controlled drugs:

%

3. Schedule III through V controlled drugs:

%

2. For non-controlled drugs:

When an early refill message occurs, does your MCO require PA?

• Yes

• No

• Dependent on the medication or situation

If “Yes” or “Dependent on medication or situation”, who obtains authorization?

• Pharmacist

• Prescriber

• Pharmacist or Prescriber

If “No”, can the pharmacist override at the point of service?

• Yes

• No

3. For controlled drugs:

When an early refill message occurs, does your MCO require PA?

• Yes

• No

If “Yes”, who obtains authorization?

• Pharmacist

• Prescriber

• Pharmacist or Prescriber

If “No”, can the pharmacist override at the point of service?

• Yes

• No

6. When the pharmacist receives an early refill DUR alert message that requires the pharmacist’s review, does your policy allow the pharmacist to override for situations such as (check all that apply):

   • Lost/stolen RX

   • Vacation

   • Overrides are only allowed by a pharmacist through a PA

   • Other, please explain.

7. Does your system have an accumulation edit to prevent patients from continuously filling prescriptions early?

   • Yes

   • No

If “Yes”, please explain your edits.

If “No”, does your MCO plan to implement this edit?

• Yes

• No

8. Does your MCO have any policy prohibiting the auto-refill process that occurs at the POS (i.e. must obtain beneficiary’s consent prior to enrolling in the auto-refill program)?

• Yes

• No

9. Does your system have a diagnosis edit that can be utilized when processing a prescription?

_¡ Yes, please explain.

_¡ No

10. Does your MCO have a documented process (i.e. PA) in place, so that the Medicaid beneficiary or the Medicaid beneficiary’s prescriber may access any rebate participating manufacturer covered outpatient drug when medically necessary?

    • Yes

Please check all that apply:

• Automatic PA based on diagnosis codes or systematic review

• Trial and failure of first or second-line therapies to support Preferred Drug List

• Pharmacist or technician reviews

• Direct involvement with Pharmacy and/or Medical Director

• Other, please explain.

• No, please explain why not.

1. How does your MCO ensure PA criteria is no more restrictive than the FFS criteria and review? Please describe the process.

2. Does your program provide for the dispensing of at least a 72-hour supply of a covered outpatient drug (CODs) in an emergency situation? Please check all that apply.

   • Real time automated process

   • Retrospective PA

   • Other process, please explain.

11. Please list the requested data in each category in Table 1: Top Drug Claims Data Reviewed by the DUR Board below.

Column 1 – Top 10 PA Requests by Drug Name, report at generic ingredient level Column 2 – Top 10 PA Requests by Drug Class

Column 3 – Top 5 Claim Denial Reasons (i.e. Quantity Limits (QL), Early Refill (ER), PA, Therapeutic Duplications (TD), and Age Edits (AE))

Column 4 – Top 10 Drug Names by Amount Paid, report at generic ingredient level Column 5 – From Data in column 4, determine the Percentage of Total Drug Spend Column 6 – Top 10 Drug Names by Claim Count, report at generic ingredient level Column 7 – From Data in Column 6, determine the Percentage of Total Claims

Table 1: Top Drug Claims Data Reviewed by the DUR Board

NOTE: If an entry is not included in the drop-down box list, please select ‘other’ at end of the list and enter a free form response in the box below.

Column 1 Top 10 PA Requests by Drug Name, report at generic ingredient level	Column 2 Top 10 PA Requests by Drug Class	Column 3 Top 5 Claim Denial Reasons (i.e. Quantity Limits (QL), Early Refill (ER), PA, Therapeutic Duplications (TD), and Age Edits (AE))	Column 4 Top 10 Drug Names by Amount Paid, report at generic ingredient level	Column 5 % of Total Spent for Drugs by Amount Paid (From data in Column 4, determine the % of total drug spend)	Column 6 Top 10 Drug Names by Claim Count, report at generic ingredient level	Column 7 Drugs by Claim Count % of Total Claims (From data in Column 6, determine the % of total claims)
				%		%
				%		%
				%		%
				%		%
				%		%
				%		%
				%		%
				%		%
				%		%
				%		%

12. Section 1927(g)(A) of the Act requires that the pharmacist offer patient counseling at the time of dispensing. Who in your program has responsibility for monitoring compliance with the oral counseling requirement? Check all that apply.

• State Medicaid Program

• State Board of Pharmacy

• Other, please explain.

1. Please explain the steps taken to monitor compliance by pharmacies with the prospective DUR counseling requirements contained in federal and state laws and regulations.

3. RETROSPECTIVE DUR (RetroDUR)

1. Please indicate how your MCO operates and oversees RetroDUR reviews.

• State-operated interventions

• Managed Care executes its own RetroDUR activities

• Pharmacy Benefit Manager (PBM) performs RetroDUR activities

• Combination of MCO RetroDUR interventions and state interventions are performed

• Other, please explain.

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

2. Identify the vendor, by name and type that performed your RetroDUR activities during the time period covered by this report.

• Vendor

• Academic Institution, please identify by name and type.

• Other Institution, please identify by name and type.

1. Is the RetroDUR vendor the developer/supplier of your retrospective DUR criteria?

   • Yes, please explain.

• No, please explain.

2. Does your MCO customize your RetroDUR vendor criteria?

   • Yes

   • No

   • Ad hoc based on state-specific needs

3. Who reviews and approves your MCO RetroDUR criteria?

• State DUR Board

• MCO DUR Board

• PBM performs RetroDUR and has a RetroDUR Board

• PBM Pharmacy and Therapeutics (P&T) Board also functions as a DUR Board

• State Pharmacy Director

• Other, please explain.

4. How often does your MCO perform retrospective practitioner-based education?

• Monthly

• Bi-monthly

• Quarterly

• Other, please specify:

1. How often does your MCO perform retrospective reviews that involves communication of client specific information to healthcare practitioners (through messaging, fax, or mail)? Check all that apply:

   • Monthly

   • Bi-monthly

   • Quarterly

   • Other, please specify:

2. What is the preferred mode of communication when performing RetroDUR initiative s? Check all that apply:

   • Mailed letters

   • Provider phone calls

   • Near real time fax

   • Near real time messaging

   • Other new technologies such as apps or Quick Response (QR) codes

   • Focused workshops, case management or Webex training

   • Newsletters or other non-direct provider communications

   • Other, please specify: __________________________________

5. Summary 1: RetroDUR Educational Outreach

RetroDUR Educational Outreach Summary should be a year-end summary report on retrospective screening and educational interventions. The summary 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.

4. DUR BOARD ACTIVITY

1. Does your MCO utilize the same DUR Board as the state FFS Medicaid program or does your MCO have its own DUR Board?

• Same DUR Board as FFS agency

• MCO has its own DUR Board

• Other, please explain.

2. Does your MCO have a separate advisory board for your PDL?

• ^Yes

• ^No

3. Does your MCO have a Medication Therapy Management (MTM) Program?

• Yes

• No

4. Summary 2: DUR Board Activities

DUR Board Activities Summary should include a brief descriptive report on DUR activities during the fiscal year reported. This summary should:

• Indicate the number of DUR Board meetings held

• List additions/deletions to DUR Board approved criteria

  1. For ProDUR, list problem type/drug combinations added or deleted

  2. For RetroDUR, list therapeutic categories added or deleted

• Describe Board policies that establish whether and how results of ProDUR screening are used to adjust RetroDUR screens

• Describe policies that establish whether and how results of RetroDUR screening are used to adjust ProDUR screens

• Describe DUR Board involvement in the DUR education program (i.e. newsletters, continuing education, etc.)

• Describe policies adopted to determine mix of patient or provider specific intervention types (i.e. letters, face-to-face visits, increased monitoring)

5. PHYSICIAN ADMINISTERED DRUGS (PAD)

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 pharmacy system been designed to incorporate this data into your DUR criteria for:

1. ProDUR?

• Yes

• No

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

• Yes

• No

2. RetroDUR?

• Yes

• No

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

• Yes

• No

6. GENERIC POLICY AND UTILIZATION DATA

1. Summary 3: Generic Drug Substitution Policies

Generic Drug Substitution Policies should summarize factors that could affect your generic utilization percentage. In describing these factors, please explain any formulary management or cost containment measures, preferred drug list (PDL) policies, educational initiatives, technology or promotional factors, or other state specific factors that affects your generic utilization rate.

2. In addition to the requirement that the prescriber write in his own handwriting "Brand Medically Necessary" for a brand name drug to be dispensed in lieu of the generic equivalent, does your MCO have a more restrictive requirement?

• Yes

• No

If “Yes”, check all that apply:

• Require that a MedWatch Form be submitted

• Require the medical reason(s) for override accompany the prescription(s)

• PA is required

• Other, please explain

Complete Table 2: Generic Drug Utilization Data using the following Computation Instructions.

Computation Instructions KEY

Single Source (S) – Drugs having an FDA New Drug Application (NDA), and there are no generic alternatives available on the market.

Non-Innovator Multiple -Source (N) – Drugs that have an FDA Abbreviated New Drug Application (ANDA), and generic alternatives exist on the market.

Innovator Multiple -Source (I) – Drugs which have an NDA and no longer have patent exclusivity.

1. Generic Utilization Percentage: To determine the generic utilization percentage of all covered outpatient drugs paid during this reporting period, use the following formula:

N ÷ (S + N + I) × 100 = Generic Utilization Percentage

2. Generic Expenditure s Percentage of Total Drug Expenditures: To determine the generic expenditure percentage (rounded to the nearest $1000) for all covered outpatient drugs for this reporting period use the following formula:

$N ÷ ($S + $N + $I) × 100 = Generic Expenditure Percentage

CMS has developed an extract file from the Medicaid Drug Rebate Program Drug Product Data File identifying each NDC along with sourcing status of each drug: S, N, or I, which can be found at Medicaid.gov (Click on the link “National Drug Code and Drug Category file [ZIP],” then open the Medicaid Drug Product File 4^th Qtr. Excel file).

Please provide the following utilization data for this DUR reporting period for all covered outpatient drugs paid. Exclude Third Party Liability (TPL).

Table 2: Generic Drug Utilization Data

	Single Source (S) Drugs	Non-Innovator (N) Drugs	Innovator Multi- Source (I) Drugs
Total Number of Claims
Total Reimbursement Amount Less Co-Pay

3. Indicate the generic utilization percentage for all CODs paid during this reporting period, using the computation instructions in Table 2: Generic Utilization Drug Data.

Number of Generic Claims:

Total Number of Claims:

Generic Utilization Percentage: %

4. Does your Medicaid program have a brand over generic program when the brand product nets a lower cost.

• ^Yes

• ^No

5. Indicate the percentage dollars paid for generic CODs in relation to all COD claims paid during this reporting period using the computation instructions in Table 2: Generic Drug Utilization Drug Data.

Generic Dollars: $

Total Dollars: $ Generic Expenditure Percentage: %

6. Does your MCO have any policies related to biosimilars? Please explain.

7. PROGRAM EVALUATION/COST SAVINGS/COST AVOIDANCE

1. Did your program conduct a DUR program evaluation of the estimated cost savings/cost avoidance?

   • ^Yes

   • ^No

If “Yes,” identify, by name and type, the institution that conducted the program evaluation.

Institution Type

• ^Vendor

• ^{Academic Institution}

• ^{Other Institution} Institution Name

2. Please provide your ProDUR and RetroDUR program cost savings/cost avoidance in the chart below.

	Cost in Dollars
ProDUR Total Estimated Avoided Costs
RetroDUR Total Estimated Avoided Costs
Other Cost Avoidance
Grand Total Estimate d Avoided Costs

3. The Estimated Percent Impact was generated by dividing the Grand Total Estimated Avoided Costs from Question 2 above by the Total Dollar Amount provided in Section VI, Question 4, then multiplying this value by 100.

Estimated Percent Impact: %

4. Does your program allow pharmacists to order either prescription or OTC medications through:

• Standing orders

• Collaborative practice agreements

• ^{State Board authorized prescriptive authority}

• ^{Other predetermined protocols, please explain:}

_______________________________________________________________________________________________________________________________________________________________________________________

What categories of drugs are dispensed through these types of agreements?

_________________________________________________________________________________________________________________________________________________________________________________________________________

5. Summary 4 – Cost Savings/Cost Avoidance Methodology

Cost Savings/Cost Avoidance Methodology Summary should include program evaluations/cost savings estimates prepared by the state or contractor. Please provide detailed summary below.

8. FRAUD, WASTE AND ABUSE DETECTION (FWA)

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 why not.

________________________________________________________________________

________________________________________________________________________

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 Review (SUR) Unit for audit/investigation

• Refer to Office of Inspector General (OIG)

• Other, please explain.

2. Does your MCO have a Lock-In Program for beneficiaries with potential misuse or abuse of controlled substances?

   • Yes

   • No

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

1. What criteria does your MCO use to identify candidates for Lock-in? Check All that apply:

   • Number of controlled substances (CS)

   • Different prescribers of CS

   • Multiple pharmacies

   • Days’ supply of CS

   • 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.

2. Does your MCO have the capability to restrict the beneficiary to:

1. Prescriber only

   • Yes

   • No

2. Pharmacy only

   • Yes

   • No

3. Prescriber and pharmacy

   • Yes

   • No

3. What is the usual Lock-in time period?

• 12 months

• 18 months

• 24 months

• As determined by the State/MCO on a case by case basis

• Lock-in time period is based on number of offenses

• Other, please explain.

4. On average, what percentage of your Medicaid MCO population is in Lock-in status annually?

%

5. Please provide an estimate of the savings attributed to the Lock-In Program for the fiscal year under review or N/A if your MCO does not estimate savings.

• ^{$_________________}

• ^N/A

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

   • 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.

• No, please explain why not.

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

   • 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.

• No, please explain why not.

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, prescribers, 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. ____________

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

• Can query by client

• Can query by prescriber

• Can query by dispensing entity

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

3. Does your MCO 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 the MCO from fully accessing the PDMP that prevent the program from being utilized the way it was intended to be to curb FWA?

• Yes, please explain the barriers (i.e., 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 checks, does your MCO 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 MCO?

• Yes

• No, please explain.

3. Please specify below the following information for the 12-month reporting period for this survey.

1. Does your MCO require pharmacists to check the PDMP prior to dispensing a controlled substance to a covered individual?

• Yes

• No, please explain.

If “Yes,” are there protocols involved for pharmacists in checking the PDMP?

• Yes, please explain.

• No

2. The percentage of covered providers (as determined pursuant to a process established by the state) who checked the prescription drug history of a beneficiary through a PDMP before prescribing a controlled substance to such an individual:

%

1. How was the above calculation obtained?

   • A provider survey

   • A provider attestation

   • A PDMP vendor report

   • Raw PDMP data using the median

   • Other, please explain.

3. For sub questions d., e., f., g. and the Tables 3, 4, 5 and 6 below, please specify the type of data utilized in determining the calculations?

• Raw PDMP data

• MMIS claims

• A PDMP vendor report

• Multiple data sources, please explain which source is used for each question below.

• Other, please explain.

i. Do these calculations include cash payments?

• Yes

• No

d. Total morphine milligram equivalents (MME) dispensed in 12 month reporting period:

_________ MME

e. Total MME dispensed per covered individual:

_________ MME

f. Total MME dispensed per covered individual who received an opioid prescription:

_________ MME

g. Average daily MME dispensed per opioid prescription:

MME

h. Please complete Tables 3, 4, 5 and 6 below. Specify the controlled substances prescribed based on prescriptions dispensed (by generic ingredient(s)) and within each population during this 12-month FFY reporting period.

Table 3: Top Opioid Controlled Substance s by Population.

Population	Column 1 Number of Beneficiaries Within Each Age Group	Column 2 Number of Unique Beneficiaries Within Each Age Group Receiving an Opioid Controlled Substance in the 12 Month Reporting Period	Column 3 Percentage of Unique Beneficiaries Within Each Age Group Receiving an Opioid Controlled Substances in the 12 Month Re porting Period	Column 4 Top 3 Opioid Controlled Substances Received Within Each Age Group (Generic Ingredient) in the 12 Month Reporting Period	Column 5 Number of Unique Beneficiaries Within Each Age Group Receiving the Opioid Controlled Substance (Specified in Column 4) in the 12 Month Reporting Period	Column 6 Percentage of Unique Beneficiaries Within Each Age Group Receiving the Top 3 Opioid Controlled Substance (Specified in Column 4) in the 12 Month Reporting Period
0-18 yrs.
19-29 yrs.
30-39 yrs.
40-49 yrs.
50-59 yrs.
60-69 yrs.
70-79 yrs.
80+ yrs.
Individuals with Disabilities Utilizing State Eligibility Categories

Table 4: Top Se dative /Benzodiazepine s Controlled Substance s by Population - When listing the controlled substances in different drug categories, for the purpose of Table 4 below, please consider long and short acting benzodiazepines to be in the same category.

Population	Column 1 Number of Beneficiaries Within Each Age Group	Column 2 Number of Unique Beneficiaries Within Each Age Receiving a Sedative/ Benzodiazepine in the 12 Month Reporting Period	Column 3 Percentage of Unique Beneficiaries Within Each Age Group Receiving a Sedative/Benzodiazepine in the 12 Month Re porting Period	Column 4 Top 3 Sedative/Benzodiazepine Received Within Each Age Group (Generic Ingredient) in the 12 Month Re porting Period	Column 5 Number of Unique Beneficiaries Within Each Age Group Receiving the Sedative/Benzodiazepine (Specified in Column 4) in the 12 Month Reporting Period	Column 6 Percentage of Unique Beneficiaries Within Each Age Group Receiving the Top 3 Sedative/Benzodiazepine (Specified in Column 4) in the 12 Month Reporting Period
0-18 yrs.
19-29 yrs.
30-39 yrs.
40-49 yrs.
50-59 yrs.
60-69 yrs.
70-79 yrs.
80+ yrs.
Individuals with Disabilities Utilizing State Eligibility Categories

Table 5: Top Stimulant/ADHD Controlled Substance s by Population-When listing the controlled substances in different drug categories,

please consider long and short acting ADHD medications to be in the same category.

Population	Column 1 Number of Beneficiaries Within Each Age Group	Column 2 Number of Unique Beneficiaries Within Each Age Receiving a Stimulant/ ADHD Medication in the 12 Month Reporting Period	Column 3 Percentage of Unique Beneficiaries within Each Age Group Receiving a Stimulant/ADHD Medication in the 12 Month Re porting Period	Column 4 Top 3 Stimulant/ADHD Medication Within Each Age Group (Generic Ingredient) in the 12 Month Re porting Period	Column 5 Number of Unique Beneficiaries Within Each Age Group Receiving a Stimulant/ADHD Medication (Specified in Column 4) in the 12 Month Reporting Period	Column 6 Percentage of Unique Beneficiaries Within Each Age Group Receiving the Top 3 Stimulant/ADHD Medication (Specified in Column 4) in the 12 Month Reporting Period
0-18 yrs.
19-29 yrs.
30-39 yrs.
40-49 yrs.
50-59 yrs.
60-69 yrs.
70-79 yrs.
80+ yrs.
Individuals with Disabilities Utilizing State Eligibility Categories

Table 6: Populations on 2 or more Controlled Substance s in Different Drug Categories When listing the controlled substances in different drug categories, for the purpose of Table 6 below, please consider long and short acting opioids to be in the same category. Please follow this approach for long and short acting ADHD medications and benzodiazepines in this table as well. Please note, Column 2 and Column 4 are requesting an average monthly value based on the 12-month reporting period.

Population	Column 1 Total Number of Beneficiaries within Each Age Group	Column 2 Number of Unique Beneficiaries in Each Age Group Receiving 2 or more Controlled Substances in Different Drug Categories per Month Averaged for the 12 Month Reporting Period	Column 3 Percentage of Age Group Receiving 2 or more Controlled Substances Averaged for the 12 Month Reporting Period	Column 4 Number of Unique Beneficiaries in Each Age Group Receiving 3 or more Controlled Substances in Different Drug Categories per Month Averaged for the 12 Month Reporting Period	Column 5 Percentage of Age Group Receiving 3 or more Controlled Substances pe r Month Averaged for the 12 Month Reporting Period
0-18 yrs.
19-29 yrs.
30-39 yrs.
40-49 yrs.
50-59 yrs.
60-69 yrs.
70-79 yrs.
80+ yrs.
Individuals with Disabilities Utilizing State Eligibility Categories

i. If there is additional information you want to provide for the previous 12-month reporting period, please explain below, or specify N/A if not applicable.

j. Has your state exempted certain individuals, (see the definition of Covered Individuals under section 1944(h)(2) of the Act, as added by Section 5042 of the SUPPORT Act), from the associated reporting requirements? Check all that apply.

• Individuals receiving hospice

• Individuals receiving palliative care

• Individuals receiving cancer treatments

• Residents of long-term care facilities or other facility specified in section 1944(g)(2)(B)

• Babies with neonatal abstinence syndrome (also called NAS)

• Other population 1, please explain __________________________

• Other population 2, please explain __________________________

• Other population 3, please explain __________________________

i. If any of the information requested is not being reported above, please explain below, or specify N/A if not applicable.

_______________________________________________________

_______________________________________________________

_______________________________________________________

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

• Yes, please explain.

• No

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

• Yes

• No

If “Yes,” please summarize the breach, the number of individuals impacted, a description of the steps the state has taken to address each such breach, and if law enforcement or the affected individua ls were notified of the breach.

3. OPIOIDS

1. For your program, is this category of medications carved out and handled by the state?

• Yes, please explain the nature and scope of the carve out.

• No

If “Yes,” please skip to the next section.

2. Does your MCO currently have a POS edit in place to limit the days supply dispensed of an initial opioid prescription for opioid naïve patients?

   • Yes, for all opioids

   • Yes, for some opioids

   • No, please explain why not

If the answer to question 2 is “Yes, for all opioids” or “Yes, for some opioids” please continue.

If “No,” skip to question 2.b.

1. What is your maximum number of days allowed for an initial opioid prescription for an opioid naïve patient?

# of days

2. Does your MCO have POS edits in place to limit days’ supply of subsequent opioid prescriptions? If yes, please indicate your days’ supply limit ?

   • 24-day supply

   • 30-day supply

   • 34-day supply

   • 90-day supply

   • Other

   • No, please explain.

3. Does your MCO have POS edits in place to limit the quantity dispensed of opioids?

_¡ Yes

_¡ No, please explain why not.

If “Yes,” please continue.

a. Does your MCO have POS edits in place to limit the quantity dispensed of short-acting (SA) opioids?

• Yes

• No, please explain.

• Other, please explain.

b. Does your MCO currently have POS edits in place to limit the quantity dispensed of long-acting (LA) opioids?

• Yes

• No, please explain.

• Other, please explain.

4. Does your MCO have measures other than restricted quantities and days’ supply in place to either monitor or manage the prescribing of opioids?

   • Yes

   • No

If “Yes,” check all that apply.

• Pharmacist override

• Deny claim and require PA

• Intervention letters

• Morphine Milligram Equivalent (MME) daily dose program

• Step therapy or Clinical criteria

• Requirement that patient has a pain management contract or Patient-Provide r agreement

• Requirement that prescriber has an opioid treatment plan for patients

• Require documentation of urine drug screening results

• Require diagnosis

• Require PDMP checks

• Workgroups to address opioids

• Other, please specify.

Please provide details on these opioid prescribing controls are in place.

If “No,” please explain what you do in lieu of the above or why you do not have measures in place to either manage or monitor the prescribing of opioids.

5. Does your MCO have POS edits to monitor duplicate therapy of opioid prescriptions? This excludes regimens that include a single extended-release product and a breakthrough short acting agent.

   • Yes

   • No, please explain why not.

6. Does your MCO have POS edits to monitor early refills of opioid prescriptions dispensed?

   • Yes, POS edits

   • Yes, both POS edits and automated retrospective claims review process

   • No, please explain why not.

7. Does your MCO have comprehensive automated retrospective claim reviews to monitor opioid prescriptions exceeding state limitations (early refills, duplicate fills, quantity limits and days’ supply)?

   • Yes, please explain in detail the scope, nature, and frequency of these retrospective reviews.

• No, please explain why not.

8. Does your MCO currently have automated retrospective claim reviews to monitor opioids and benzodiazepines being used concurrently?

   • Yes, automated retrospective claim reviews only

   • Yes, both POS edits and automated retrospective claims review process

Please explain the above response and detail the scope and nature of these reviews and/or 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.

9. Does your MCO currently have automated retrospective claim reviews to monitor opioids and sedatives being used concurrently?

• Yes, automated retrospective claim reviews

• Yes, both POS edits and automated retrospective claim reviews

• No, please explain why not.

10. Does your MCO currently have automated retrospective claims review process to monitor opioids and antipsychotics being used concurrently?

• Yes, automated retrospective claims review process

• Yes, both POS edits and automated retrospective claims review process

• No, please explain why not.

11. Does your MCO have POS safety edits or perform automated respective claims review and/or provider education in regard to beneficiaries with a diagnosis or history of opioid use disorder (OUD) or opioid poisoning diagnosis?

• Yes

• No, please explain why not.

If “Yes,” please check all that apply.

• POS edits

• Automated retrospective claim reviews

• Provider education

If “Automated retrospective claim reviews,” and/or “Provider education,” please indicate how often:

• Monthly

• Quarterly

• Semi-Annually

• Annually

• Ad hoc

• Other, please specify.

If “No,” does your MCO plan on implementing POS edits, automated retrospective claim reviews and/or provider education regarding 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 why not.

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

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

    • 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.

• No, please explain why no guidelines are offered.

13. Does your MCO have a drug utilization management strategy that supports abuse deterrent opioid use to prevent opioid misuse and abuse (i.e. presence of an abuse deterrent opioid with preferred status on your preferred drug list)?

    • Yes, please explain.

• No, please explain.

14. Have there been state specific events (unplanned outages, natural disasters, public health emergencies, etc…) that have had ramifications on edits, reviews or prescribing for this reporting period?

    • ^{Yes, please explain.}

• ^No

4. MORPHINE MILLIGRAM EQUIVALENT (MME) DAILY DOSE

1. Have you set recommended maximum MME daily dose measures?

   • Yes

   • No, please explain why not.

If “Yes”, please continue.

1. What is your maximum MME daily dose limit in milligrams?

   • Less than 50 MME, please specify. mg per day

   • 50 MME

   • 70 MME

   • 80 MME

   • 90 MME

   • 100 MME

   • 120 MME

   • 200 MME

   • Greater than 200 MME, please specify. mg per day

   • Other, please specify. mg per day

   • More than 1 MME accessed in State

2. Please explain nature and scope of dose limit (i.e. Who does the edit apply to?, Does it apply to New/Chronic Users?, Does the limit apply to all opioids?, Are you in the process of tapering patients to achieve this limit?).

If “No,” please explain why not.

2. Does your MCO have an edit in your POS system that alerts the pharmacy provider that the MME daily dose prescribed has been exceeded?

   • Yes

   • No, please explain why not.

______________________________________________________

______________________________________________________

If “Yes”, does your MCO require PA if the MME limit is exceeded?

• Yes

• No

3. Does your MCO have automated retrospective claims review to monitor the MME total daily dose of opioid prescriptions dispensed?

   • Yes

• No, please explain why not.

4. Does your MCO provide information to your prescribers on how to calculate the morphine equivalent daily dosage or does your MCO provide a calculator developed elsewhere?

   • Yes

   • No

If “Yes,” please continue.

1. Please name the developer of the calculator.

   • CDC

   • Academic Institution

   • Other, please specify.

__________________________________________________________________________

2. How is the information disseminated? Check all that apply:

• Website

• Provider notice

• Educational seminar

• Other, please explain.

5. OPIOID USE DISORDER (OUD) TREATMENT

1. Does your MCO have utilization controls (i.e. PDL, PA, QL) to either monitor or manage the prescribing of Medication Assisted Treatment (MAT) drugs for OUD?

   • Yes, please explain.

• No, please explain.

___________________________________________________________

______________________________________________________________________

______________________________________________________________________

2. Does your MCO set total mg per day limits on the use of buprenorphine and buprenorphine/naloxone combination drugs?

   • Yes

   • No

If “Yes”, please specify the total mg/day:

• 12 mg

• 16 mg

• 24 mg

• 32 mg

• Other, please explain.

3. What are your limitations on the allowable length of this treatment?

   • No limit

   • 3 months or less

   • 6 months

   • 12 months

   • 24 months

   • Other, please explain.

4. Does your MCO require that the maximum mg per day allowable be reduced after a set period of time?

   • Yes

   • No

If “Yes,” please continue.

1. What is your reduced (maintenance) dosage?

   • 8 mg

   • 12 mg

   • 16 mg

   • Other, please explain.

2. What are your limitations on the allowable length of the reduced dosage treatment?

   • No limit

   • 6 months

   • 12 months

   • Other, please explain.

5. Does your MCO have at least one buprenorphine/naloxone combination product available without PA?

   • Yes

   • No

6. Does your MCO currently have edits in place to monitor opioids being used concurrently with any buprenorphine drug or any form of MAT?

   • Yes

   • No, please explain why not.

If “Yes”, can the POS pharmacist override the edit?

• Yes

• No

7. Is there at least one formulation of naltrexone for OUD available without PA?

   • Yes

   • No

8. Does your MCO have at least one opioid reversal agent available without PA?

   • Yes

   • No

9. Does your MCO monitor and manage appropriate use of opioid reversal agents to persons at risk of overdose?

   • Yes

   • No, please explain why not.

10. Does your MCO allow pharmacists to dispense naloxone prescribed independently or by collaborative practice agreements, or standing orders, or other predetermined protocols?

    • ^{Yes, State Board of Professional Regulations/Board of Pharmacy/Board of} Medicine and/or state Medicaid program under protocol

    • ^{Yes, prescribed independently}

    • ^No

6. OUTPATIENT TREATMENT PROGRAMS (OTP)

1. Does your MCO cover OTPs that provide behavioral health (BH) and MAT through OTPs?

   • Yes

   • No, please explain why not.

If “Yes”, is a referral needed for OUD treatment through OTPs?

• Yes,

• No, please explain.

2. Does your MCO cover buprenorphine or buprenorphine/naloxone for diagnoses of OUD as part of a comprehensive MAT treatment plan through OTPs?

   • Yes

   • No, please explain.

3. Does your MCO cover naltrexone for diagnoses of OUD as part of a comprehensive MAT treatment plan?

   • Yes

   • No, please explain.

7. PSYCHOTROPIC MEDICATION

ANTIPSYCHOTICS

1. Does your MCO currently have restrictions in place to limit the quantity of antipsychotic drugs?

   • Yes

   • No

   • Covered through the FFS benefit

Please explain restrictions or N/A.

2. Does your MCO have a documented program in place to manage and monitor the appropriate use of antipsychotic drugs in children?

   • Yes

   • No

If “No” or “Covered through the FFS benefits”, skip to question 2.d.

If “Yes”, please continue with questions 2.a, 2.b and 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. Does your MCO have edits in place to monitor (check all that apply):

• Child’s Age

• Dosage

• Indication

• Polypharmacy

• Other, please explain.

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

If “No,” please continue.

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

   • Yes, please specify when you plan on implementing a program to monitor the appropriate use of antipsychotic drugs in children.

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

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 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.

4. 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

5. Does your MCO currently have restrictions in place to limit the quantity of stimulant drugs?

   • Yes

   • No

   • Covered through the FFS benefit

6. Do you have a documented program in place to manage and monitor the appropriate use of stimulant drugs in children?

   • Yes

   • No

If “No”, or “Covered through the FFS benefits” skip to question 6.d.

If “Yes”, please continue with questions 6.a, 6.b and 6.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. Do you have edits in place to monitor (check all that apply):

• Child’s Age

• Dosage

• Indication

• Polypharmacy

• Other, please explain.

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

If “No”, please continue.

4. Does your MCO plan on implementing a stimulant monitoring program in the future?

   • Yes, please specify when you plan on implementing a program to monitor the appropriate use of stimulant drugs in children.

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

ANTIDEPRESSANTS

7. Does your MCO have a documented program in place to manage and monitor the appropriate use of antidepressant drugs in children?

   • ^Yes

   • ^No

   • ^{Covered through the FFS benefit}

If “No” or “Covered through the FFS benefit”, skip to question 7.d.

If “Yes,” please continue with questions 7.a, 7.b and 7.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. Does your MCO have edits in place to monitor (check all that apply):

• Child’s age

• Dosage

• Indication

• Polypharmacy

• Other, please explain.

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

If “No,” please continue.

4. Does your MCO plan on implementing an antidepressant monitoring program in the future?

   • Yes, please specify when you plan on implementing a program to monitor the appropriate use of antidepressant drugs in children.

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

MOOD STABILIZERS

8. Does your MCO have a documented program in place to manage and monitor the appropriate use of mood stabilizing drugs in children?

• ^Yes

• ^No

• ^{Covered through the FFS benefit}

If “No” or “Covered through the FFS benefit”, skip to question 8.d.

If “Yes,” please continue with questions 8.a, 8.b and 8.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. Does your MCO have edits in place to monitor (check all that apply):

   • Child’s age

   • Dosage

• Indication

• Polypharmacy

• Other, please explain.

3. Please briefly explain the specifics of your documented mood stabilizer monitoring program(s).

If “No,” please continue.

4. Does your MCO plan on implementing a mood stabilizer monitoring program in the future?

• Yes, please specify when you plan on implementing a program to monitor the appropriate use of mood stabilizing drugs in children.

• No, please explain why you will not be implementing a program to monitor the appropriate use of a mood stabilizing drugs in children.

ANTIANXIETY/SEDATIVES

9. Does your MCO have a documented program in place to manage and monitor the appropriate use of antianxiety/sedative drugs in children?

• ^Yes

• ^No

• Covered through the FFS benefit

If “No” or “Covered through the FFS benefit”, skip to question 9.d.

If “Yes,” please continue with questions 9.a, 9.b and 9.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. Does your MCO have edits in place to monitor (check all that apply):

   • Child’s age

   • Dosage

   • Indication

   • Polypharmacy

   • Other, please explain.

3. Please briefly explain the specifics of your documented antianxiety/sedative monitoring program(s).

If “No,” please continue.

4. Does your MCO plan on implementing an antianxiety/sedative monitoring program in the future?

• Yes, please specify when you plan on implementing a program to monitor the appropriate use of antianxiety/sedative drugs in children.

• No, please explain why you will not be implementing a program to monitor the appropriate use of antianxiety/sedative drugs in children.

9. 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 4: Innovative Practices

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

10. EXECUTIVE SUMMARY

1. Summary 5: Executive Summary

Executive Summary should provide a brief overview of your program. It should describe FFY 2024 highlights of the program, FFS initiatives, improvements, program oversight of managed care partners when applicable, and statewide (FFS and MCO) initiatives.

APPENDIX A: MCO PROGRAM TYPES

DEFINITIONS OF MANAGED CARE PROGRAM TYPES

A managed care program is defined by the set of benefits covered and the type of participating managed care plans (e.g., MCOs, PHPs, PACE, etc.) or providers (e.g., PCCM providers).

Managed Care Program Type	Definition
Comprehensive MCO	Comprehensive Managed Care Organization: A program in which the state contracts with managed care plans to cover all acute and primary medical services; some also cover behavioral health, dental, transportation and long-term care. Entities that qualify as MCOs include Health Maintenance Organizations (HMOs) and Health Insuring Organizations (HIOs in California). If the comprehensive MCO also covers long-term services and supports, the program type should be Comprehensive MCO + MLTSS. When certain benefits, such as behavioral health, dental, or transportation, are carved out of the comprehensive MCO program and covered through a limited benefit program (i.e. a Prepaid Inpatient Health Plan or Prepaid Ambulatory Health Plan), enrollees in such limited benefit plans should be reported in separate programs of the appropriate type (e.g., BHO (PIHP and/or PAHP), Dental PAHP, or Non-Emergency Medical Transportation, or an MLTSS-only program when only LTSS and no other services are covered. Individual beneficiaries can be enrolled in only one comprehensive MCO program (either a comprehensive MCO or a comprehensive MCO+MLTSS) as of the July 1 point in time.
Comprehensive MCO + MLTSS	Comprehensive Managed Care Organization + Managed Long-Term Services and Supports: A program in which plans cover comprehensive acute and outpatient benefits as defined above, where the same plan also covers long- term services and supports (LTSS). Individual beneficiaries can be enrolled in only one comprehensive MCO program (either a comprehensive MCO or a comprehensive MCO+MLTSS).
BHO Only (PIHP and/or PAHP)	Behavior Health Organizations Only (Prepaid Inpatient Health Plan and/or Prepaid Ambulatory Health Plan): A program specializing in behavioral health (mental health and/or substance use disorder) services. Services are covered on a prepaid basis.
Dental only (PAHP)	A Prepaid Ambulatory Health Program (PAHP) that only provides dental services.
MLTSS Only	Managed Long Term Services and Supports Only: A program only covering long term services and supports.
Other PHP	Other Prepaid Health Plan: A program covering a limited set of services through PIHPs or PAHPs not otherwise included above. Examples include disease management and pharmacy benefits.

Managed Care Program Type	Definition
PACE	Programs of All-Inclusive Care for the Elderly: A program that provides prepaid, capitated comprehensive medical and social services in an adult day health center, supplemented by in-home and referral services according to a participant’s needs. To qualify, individuals must: (1) be 55 years of age or older, (2) meet a nursing home level of care, and (3) live in a PACE organization service area.
PCCM	Primary Care Case Management: A managed care arrangement in which primary care providers contract with the state to provide a core set of case management services to the enrollees assigned to them and to serve as the enrollees’ home for medical care, in exchange for a monthly case management fee. All other services are reimbursed on a FFS basis. Primary Care Providers (PCPs) can include primary care physicians, clinics, group practices and nurse practitioners, among others. In general, we would only expect case management and physician services to be covered under capitation for PCCM programs.
PCCM entity	Primary Care Case Management entity: In addition to providing primary care case management services for the state, a PCCM entity is an organization that provides any of the following functions: (1) Provision of intensive telephonic or face-to- face case management, including operation of a nurse triage advice line; (2) Development of enrollee care plans; (3) Execution of contracts with and/or oversight responsibilities for the activities of FFS providers in the FFS program; (4) Provision of payments to FFS providers on behalf of the state; (5) Provision of enrollee outreach and education activities; (6) Operation of a customer service call center; (7) Review of provider claims, utilization and practice patterns to conduct provider profiling and/or practice improvement; (8) Implementation of quality improvement activities including administering enrollee satisfaction surveys or collecting data necessary for performance measurement of providers; (9) Coordination with behavioral health systems/providers; and/or (10) Coordination with long-term services and supports systems/ providers.
Non-Emergency Medical Transportation (NEMT)	A program that covers transportation to and from medically necessary health care services in which these services are paid for on a per capita basis (the state pays the transportation broker based on the number of people served, not the amount of service or trips that each individual receives). Do not report transportation programs in which individual trips are reimbursed on a FFS basis.

MANAGED CARE PLAN CROSSWALK

The table below provides a crosswalk for plan types to program types.

Managed Care Plan Type	Managed Care Program Type
Comprehensive MCO	Comprehensive MCO Comprehensive MCO +MLTSS (if benefits include LTSS)
Traditional PCCM Provider	PCCM
Enhanced PCCM Provider	PCCM
HIO	Comprehensive MCO
Medical-only PIHP (risk or non-risk/non- comprehensive/with inpatient hospital or institutional services)	Other PHP
Medical-only PAHP (risk or non-risk/non- comprehensive/no inpatient hospital or institutional services)	Other PHP
Long Term Care (LTC) PIHP	MLTSS Only
Mental Health (MH) PIHP	BHO (PIHP and/or PAHP)
Mental Health (MH) PAHP	BHO (PIHP and/or PAHP)
Substance Use Disorders (SUD) PIHP	BHO (PIHP and/or PAHP)
Substance Use Disorders (SUD) PAHP	BHO (PIHP and/or PAHP)
Mental Health (MH) and Substance Use Disorders (SUD) PIHP	BHO (PIHP and/or PAHP)
Mental Health (MH) and Substance Use Disorders (SUD) PAHP	BHO (PIHP and/or PAHP)
Dental PAHP	Dental
Transportation PAHP	NEMT
Disease Management PAHP	Other PHP
PACE	PACE
Pharmacy PAHP	Other PHP
Accountable Care Organization	Comprehensive MCO Other PHP PCCM

Managed Care Plan Type	Managed Care Program Type
Health/Medical Home	PCCM
Integrated Care for Dual Eligibles	Comprehensive MCO + MLTSS, MLTSS Only (if benefits cover LTSS)
Unknown – it is not yet known how PCCM entities will be reported in T-MSIS.	PCCM entity

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