New Jersey-2016-S1175-Amended

An Act concerning Medicaid and NJ FamilyCare and supplementing Title 30 of the Revised Statutes.

Be It Enacted by the Senate and General Assembly of the State of New Jersey:

1. As used in this act:

"Division" means the Division of Medical Assistance and Health Services in the Department of Human Services.

"Medicaid managed care contract" means a contract for the provision of health care services by a managed care organization to individuals eligible for the Medicaid program pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.) or the NJ FamilyCare program pursuant to P.L.2005, c.156 (C.30:4J-8 et al.).

"Medication therapy management" means the systematic process ¹,¹ performed by a ¹[pharmacist or physician licensed pursuant to Title 45 of the Revised Statutes] qualified provider, that is¹ designed to optimize therapeutic outcomes through improved medication use and reduced risk of adverse drug events, ¹[including] and which includes¹ all of the following:

(1) a medication therapy review and ¹[in-person]¹ consultation relating to all medications, vitamins, and herbal supplements currently being taken by an individual;

(2) a medication action plan communicated to the individual or the individual's caretaker and the individual's primary health care provider or other appropriate prescriber of medication to address safety issues, inconsistencies, duplicative therapy, omissions, and medication costs; and

(3) documentation and follow-up with the individual or the individual's caretaker to ensure consistent levels of pharmacy services and positive outcomes, including, as deemed necessary to maintain or improve positive outcomes, follow-up discussions with the individual's primary health care provider or other appropriate prescriber.

¹The medication therapy review and consultation shall be conducted at least once per plan or calendar year, and shall be provided in person, unless providing the medication therapy review and consultation in person creates a physical hardship for the enrollee, in which case the medication therapy review and consultation may be provided by an alternate delivery method.

"Qualified provider" means a physician licensed pursuant to Title 45 of the Revised Statutes, an advanced practice nurse licensed pursuant to P.L.1991, c.377 (C.45:11-45 et seq.), or a pharmacy or pharmacist registered pursuant to P.L.2003, c.280 (C.45:14-40 et seq.).¹

2. a. A Medicaid managed care contract shall include medication therapy management services as a required benefit for any enrollee:

(1) who takes ¹[three] one¹ or more prescription drugs to treat or prevent ¹[two or more] any¹ chronic medical ¹[conditions] condition, provided that enrollee participation standards shall mirror the requirements established for medication therapy management programs offered by Medicare Part D plan sponsors that are approved annually by the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services¹;

(2) whose primary health care provider or other appropriate prescriber identifies the individual as having a prescription drug therapy problem and refers the individual ¹[to a pharmacist]¹ for medication therapy management; or

(3) who meets other criteria established by the Commissioner of Human Services.

b. The Medicaid and NJ FamilyCare fee-for-service programs shall cover medication therapy management services for a fee-for-service recipient who meets the eligibility criteria in subsection a. of this section.

3. a. The Medicaid managed care contract shall ¹[require that] permit¹ the managed care organization ¹to administer the medication therapy management program, or to¹ enter into a contract with a third party entity to administer the medication therapy management program ¹[, which shall be approved by the division]¹. ¹[The contract between the managed care organization and the third party entity] A medication therapy management program¹ shall ¹[include] meet¹ the following requirements:

(1) ¹[The] If the managed care organization has entered into a contract with a third party entity to administer the medication therapy management program, the¹ third party entity shall guarantee demonstrated annual savings, including savings associated with cost avoidance at least equal to the amount owed to the third party entity under the contract, with any shortfall amount refunded to the State. Prior to entering into the contract, the managed care organization ¹[,] and¹ the third party entity ¹[, and the division]¹ shall agree on the terms, conditions, and applicable measurement standards associated with the demonstration of savings, which shall be specified in the contract.

(2) The ¹[third party entity and the]¹ managed care organization ¹and a third party entity administering the program, if any,¹ shall report annually to the division on the costs, savings, cost avoidance, return on investment, and change in patient outcomes related to the provision of medication therapy management services.

(3) The ¹managed care organization or¹ third party entity ¹administering the medication therapy management program¹ shall contract with ¹[pharmacies or pharmacists] qualified providers¹ to provide medication therapy management services. Medication therapy management services required by the Medicaid managed care contract shall not be provided by employees of the managed care organization or the third party entity. ¹Fees paid to qualified providers for medication therapy management services shall be reasonable and based on the resources and time required to provide the services.

(4) To ensure that enrollees have access to a competitive selection of providers, the medication management therapy program shall:

(a) permit the enrollee to choose any qualified provider for the provision of medication management therapy, provided that the qualified provider is a contracting provider;

(b) provide that no qualified provider shall be denied the right to participate as a contracting provider, under the same terms and conditions currently applicable to all other contracting providers, provided that the qualified provider accepts the terms and conditions of the health maintenance organization; and

(c) provide that no copayment, fee, or other condition shall be imposed upon an enrollee selecting a qualified provider that is not also equally imposed upon all enrollees selecting a qualified provider.¹

b. The division ¹[shall] may administer the medication therapy management program, or¹ enter into a contract with a third party entity to administer the medication therapy management program ¹,¹ for Medicaid or NJ FamilyCare fee-for-service recipients. The ¹[contract shall include] medication therapy management program shall meet¹ the same requirements as ¹[the contract between a Medicaid managed care organization and a third party entity pursuant to] apply to a medication therapy management program established under a Medicaid managed care contract, as set forth in¹ subsection a. of this section.

¹c. In the event that a managed care organization, the Medicaid fee-for-service program, or the NJ FamilyCare fee-for-service program contracts with a third party entity to administer the medication therapy management program, the managed care organization, Medicaid fee-for-service program, or NJ FamilyCare fee-for-service program shall be held harmless against any claim arising out of the contract or the administration of the medication therapy management program by the third party entity.¹

4. ¹[A] In the event that a managed care organization, the Medicaid fee-for-service program, or the NJ FamilyCare fee-for-service program contracts with a third party entity to administer the mediation therapy management program, the¹ Medicaid managed care contract ¹[and the] ,¹ Medicaid ¹[and] fee-for-service program, or¹ NJ FamilyCare fee-for-service ¹[programs] program¹ shall require that fees paid for medication therapy management services to the third party entity contracted to administer the program are reasonable and based on the resources and time required to provide the service. Fees for pharmacist-delivered medication therapy management services shall be separate from reimbursements for prescription drug products or dispensing services.

5. If any part of a medication action plan developed by a pharmacist incorporates services that are outside a pharmacist's scope of practice as defined by P.L.2003, c.280 (C.45:14-40 et seq.), including the initiation of therapy, modification of dosages, therapeutic interchange, or changes in drug therapy, the express authorization of the individual's primary health care provider or other appropriate prescriber shall be obtained prior to making any changes to the individual's medication treatment regimen and shall be documented in the patient's pharmacy records.

¹6. The provisions of this act shall not apply to nursing facilities, assisted living facilities, assisted living programs, comprehensive personal care homes, adult day health services facilities, or pediatric medical day care facilities, which are licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.).¹

¹[6.] 7.¹ The Commissioner of Human Services shall adopt rules and regulations, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), in order to effectuate the purposes of this act.

¹[7.] 8.¹ This act shall take effect on the first day of the seventh month next following the date of enactment, and shall apply to any Medicaid managed care contract executed on or after the effective date of this act, except that the Commissioner of Human Services ¹[may] shall¹ take such anticipatory administrative action in advance thereof as shall be necessary for the implementation of this act.