REDLINE: 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-forService (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.

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I. 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

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II. 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

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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, please explain.

______________________________________________________
______________________________________________________
a) If “Yes,” how often does your MCO receive reports? Check all that apply:

 Monthly
 Quarterly
 Annually
 Ad hoc (on request)
 Other, please explain.

b) 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
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 Other, please explain.

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No, please explain.

5. Early Refill
a) At what percent threshold does your MCO set your system to edit?
i.

Non-controlled drugs:
%

ii.

Schedule II controlled drugs:
%

iii.

Schedule III through V controlled drugs:
%

b) 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

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

 Yes
 No
c) 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.

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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:
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 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.

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

b) 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.

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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

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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)

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

%

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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.

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

III. 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

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 Academic Institution, please identify by name and type.

 Other Institution, please identify by name and type.

a) Is the RetroDUR vendor the developer/supplier of your retrospective DUR criteria?

 Yes, please explain.

 No, please explain.

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b) 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:
a) 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
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 Bi-monthly
 Quarterly
 Other, please specify:
b) 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.

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IV. 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
a) For ProDUR, list problem type/drug combinations added or deleted
b) 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)
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V. 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

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VI. 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

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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 4th Qtr. Excel file).

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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 MultiSource (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.

4.

Number of Generic Claims:

__

Total Number of Claims:

__

Generic Utilization Percentage:

%

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.

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VII.

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:

%

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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.

VIII. FRAUD, WASTE AND ABUSE DETECTION (FWA)
A. 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
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 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.
a) What criteria does your MCO use to
Check All that apply:

identify candidates for Lock-in?

 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.

b) Does your MCO have the capability to restrict the beneficiary to:
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i) Prescriber only

 Yes
 No
ii) Pharmacy only

 Yes
 No
iii) Prescriber and pharmacy

 Yes
 No
c) 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

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 Other, please explain.

d) On average, what percentage of your Medicaid MCO population is in Lock-in status
annually?
%
e) 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 pre scribers?

 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.

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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.

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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)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

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




Receive PDMP data
Direct access to the database

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






Daily
Weekly
Monthly
Other, please specify. ____________

ii. 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

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

c. Does your MCO have access to contiguous States’ PDMP information?
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 Yes
 No


2. 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.

a. 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
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




RetroDUR communication
Other, please explain.

No, please explain.

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

 Yes, please explain.

 No
b. 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
c. 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.

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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.
a. 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

b. 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:
%
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i.







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.

c. For sub questions d., e., f., g. and the Tables 3, 4, 5 and6 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
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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.

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Table 3: Top Opioid Controlled Substance s by Population.

Population

Column 1
Column 2
Number of
Number of Unique
Beneficiaries Within Beneficiaries Within Each
Each Age Group
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
Column 5
Top 3 Opioid Controlled
Number of Unique
Substances Received
Beneficiaries Within Each Age
Within Each Age Group Group Receiving the Opioid
(Generic Ingredient) in the
Controlled Substance
12 Month Reporting Period (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

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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 2
Column 3
Column 1
Number of
Number of Unique
Percentage of Unique
Beneficiaries Within Beneficiaries Within Each
Beneficiaries
Within Each Age Each Age Receiving a Age Group Receiving a
Sedative/
Sedative/Benzodiazepine
Group
in the 12 Month
Benzodiazepine in the
12 Month Reporting
Re porting Period
Period

Column 5
Column 6
Column 4
Number of Unique Beneficiaries
Percentage of Unique Beneficiaries
Top 3
Sedative/Benzodiazepine Within Each Age Group Receiving Within Each Age Group Receiving the
the Sedative/Benzodiazepine
Received Within Each Age
Top 3 Sedative/Benzodiazepine
Group (Generic
(Specified in Column 4) in the 12
(Specified in Column 4) in the 12
Month Reporting Period
Month Reporting Period
Ingredient) in the 12
Month Re porting 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

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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 2
Column 3
Column 1
Number of
Number of Unique
Percentage of Unique
Beneficiaries Within Beneficiaries within Each
Beneficiaries
Within Each Age Each Age Receiving a Age Group Receiving a
Stimulant/ ADHD
Stimulant/ADHD
Group
Medication in the 12
Medication in the 12
Month Re porting Period
Month Reporting
Period

Column 4
Column 5
Column 6
Top 3 Stimulant/ADHD
Number of Unique Beneficiaries
Percentage of Unique Beneficiaries
Medication Within Each Within Each Age Group Receiving a Within Each Age Group Receiving the
Age Group (Generic
Top 3 Stimulant/ADHD Medication
Stimulant/ADHD Medication
Ingredient) in the 12
(Specified in Column 4) in the 12
(Specified in Column 4) in the 12
Month Re porting Period
Month Reporting Period
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

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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
Column 2
Total Number of
Number of Unique
Beneficiaries within Each Beneficiaries in Each Age
Age Group
Group Receiving 2 or more
Controlled Substances in
Different Drug Categories
per Month Averaged for
the 12 Month Reporting
Period

Column 3
Column 4
Percentage of Age
Number of Unique
Group Receiving Beneficiaries in Each Age
2 or more
Group Receiving 3 or more
Controlled
Controlled Substances in
Different Drug Categories
Substances
Averaged for the per Month Averaged for
12 Month
the 12 Month Reporting
Period
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
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 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.
_______________________________________________________
_______________________________________________________
_______________________________________________________

4. 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

5. 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.

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C. 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.
a) What is your maximum number of days allowed for an initial opioid prescription for
an opioid naïve patient?
# of days
b) 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



Other

90-day supply

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

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.
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 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.

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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.

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 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.
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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

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 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.
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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

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D. 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.
a) 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.
 Other, please specify.

mg per day

mg per day

 More than 1 MME accessed in State
b) 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?).

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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.
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a) Please name the developer of the calculator.

 CDC
 Academic Institution
 Other, please specify.
__________________________________________________________________________

b) How is the information disseminated? Check all that apply:

 Website
 Provider notice
 Educational seminar
 Other, please explain.

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E. 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
buprenorphine/naloxone combination drugs?

on the use of buprenorphine

and

 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
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 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.
a) What is your reduced (maintenance) dosage?

 8 mg
 12 mg
 16 mg
 Other, please explain.

b) What are your limitations on the allowable length of the reduced dosage treatment?

 No limit
 6 months
 12 months
 Other, please explain.

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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
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and/or state Medicaid program under protocol

 Yes, prescribed independently
 No

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F. 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.

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

 Yes
 No, please explain.



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

 Child’s Age

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 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 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.

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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.

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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 institutions for mental diseases

individuals over the age of 18 residing in intermediate care facilities for individuals with
intellectual disabilities
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).
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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”, skip to question 6.d.
If “Yes”, please continue with questions 6.a, 6.b and 6.c.
a) Does your MCO manage and monitor:

 Only children in foster care under 18 y.o.
 All children including foster care under 18 y.o.
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 Other, please explain.

b) Do you have edits in place to monitor

(check all that apply):

 Child’s Age
 Dosage
 Indication
 Polypharmacy
 Other, please explain.

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

If “No”, please continue.
d) 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

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







Child’s age
Dosage
Indication
Polypharmacy
Other, please explain.

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

If “No,” please continue.
d. 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.

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 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.
a. 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. Does your MCO have edits in place to monitor




(check all that apply):

Child’s age
Dosage
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



Indication
Polypharmacy
Other, please explain.

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

If “No,” please continue.
d. 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.

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







Child’s age
Dosage
Indication
Polypharmacy
Other, please explain.

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

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If “No,” please continue.
d. 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.

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IX.

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 FDAapproved 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).

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X.

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.

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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 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.

Comprehensive
MCO

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

BHO Only (PIHP
and/or PAHP)

Dental only (PAHP)

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).
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.
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.

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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.
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-toface 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;

PCCM entity

(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.

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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
+MLTSS (if benefits include
LTSS)

Traditional PCCM Provider

•

PCCM

Enhanced PCCM Provider

•

PCCM

HIO

•

Comprehensive MCO

Medical-only PIHP (risk or non-risk/noncomprehensive/with inpatient hospital or
institutional
services)

•

Other PHP

Medical-only PAHP (risk or non-risk/noncomprehensive/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

Comprehensive MCO

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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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