Tsev Cov Chaw Muab Kev Pabcuam & Cov Neeg Koom Tes Cov Lus Nug Feem Ntau Txog Kev Them Rov Qab Tshuaj Medi-Cal​​ 

Cov lus nug nquag nug txog Medi-Cal Cov Nyiaj Them Nqi Tshuaj​​ 

Cov Lus Nug​​ 

What are “Medi-Cal” rebates?​​   

“Medi-Cal” rebates are California’s federal Medicaid rebate programs. Medi-Cal is California’s health program which provides free or low-cost health coverage for California residents who meet eligibility requirements. Drug manufacturers are required to pay a rebate for all outpatient drugs that are dispensed and paid for by the State’s Medi-Cal program. Invoicing for drug rebates began January 1, 1991 and continues today​​ 

What are “Medi-Cal supplemental” rebates?​​   

“Medi-Cal supplemental” rebates are additional rebates drug manufacturers have agreed to pay the state. Supplemental rebates are based on the same utilization as the federal rebate program. Drug manufacturers that have agreed to pay supplemental rebates are included on the State’s Contract Drug List (CDL). Generally, these products are not subject to prior authorization. The Pharmacy Benefit’s Drug Contracting Branch is responsible for managing the program and negotiating contracts. Supplemental rebates are required for all federal programs except for utilization from managed care organizations (MCOs). Supplemental rebates have been part of the California rebate program since 1991. Prior to 1997, supplemental rebates were calculated as a percentage of Average Manufacturer Price (AMP) on all covered drugs. However since 1997, contracts are negotiated on specific drugs. California currently has two types of supplemental contracts: Net Cost and AMP. Supplemental contracts pertain to all rebate programs except for managed care organizations (MCO) that became rebate eligible in 2010.​​ 

Puas yog cov nyiaj rov qab ntxiv yuav raug them cov paj laum?​​      

Yes. Section 14105.33 of the Welfare & Institutions Code was amended in 1997 allowing state supplemental contracts to include interest and penalty provisions. Contracts include the following:​​ 

  • Yog tias tsis tau txais cov nyiaj them ntxiv tsis pub dhau 38 hnub txij li hnub xa ntawv xa tuaj, cov paj laum suav ntawm CMS tus nqi (Lub Limtiam Federal Treasury-bill rate) yuav dhau.​​ 
  • Yog tias tsis tau txais kev them nyiaj ntxiv tsis pub dhau 69 hnub txij li hnub xa ntawv xa tuaj, yuav raug nplua nyiaj paj ntawm 10 feem pua cov ntsiab lus ntxiv rau CMS tus paj laum. Cov paj laum thiab 10% raug nplua txuas ntxiv mus kom txog rau thaum hnub kawg ntawm kev them nyiaj.​​ 

Kuv puas tau txais ib daim ntawv them nqi cais rau cov nyiaj rov qab ntxiv?​​    

Yes. Beginning 4th quarter 2001, DHCS began sending labelers separate supplemental invoices. Prior to October 2001, labelers were instructed to calculate the supplemental rebate using their Medi-Cal invoice.​​ 

Tsoom Fwv Teb Chaws thiab Lub Xeev Txoj Cai Lij Choj Hais Txog Qhov Kev Pab Them Nqi Tshuaj Hauv Xeev California / Tsoom Fwv Teb Chaws Txoj Cai Li Cas?​​     

Tsoom Fwv Teb Chaws Txoj Cai:​​ 

Social Security Act Section 1927 [42 USC 1396r-8] (a)​​  

Tsoom Fwv Teb Chaws txoj cai lij choj hais txog Medicaid (Medi-Cal hauv California) Txoj Kev Pab Them Nqi Tshuaj. Mus saib lub vev xaib Social Security kom paub ntau ntxiv.​​ 

Xeev Txoj Cai:​​ 

  • Welfare and Institutions (W&I) Code Section 14105. Contains information on the Medi-Cal Drug Rebate Program.​​ 
  • Senate Bill 391, 1997 Amended W & I Code 14105.33. Authorized the State to charge interest and a penalty for late state supplemental rebate payments. (Effective date 10/1/97)​​ 

To Access W & I Code, visit the California Legislative Information website, and select the button labeled “California Law,”  then select Welfare and Institutions Code. Next enter a section, select the “Enter” button to search.​​ 

Hom kev pab cuam twg koom nrog hauv Department of Health Care Services Drug Rebate Program?​​ 

California invoices drug manufacturers for all federal Medicaid programs, including those incorporated by waiver. In addition, manufacturers receive supplemental invoices if they have entered into a contract with the State. Programs for which rebates are due include: Medi-Cal (FFS, COHS, Managed Care Organizations (MCOs)), CCS/Healthy Families, GHPP, Blood Factors, FPACT and BCCTP. Separate invoices are mailed for pharmacy, PADs and compound claims for many of the programs.​​ 

What is “FPACT”?​​      

Family Planning, Access, Care, and Treatment (FPACT) was a State-only program until December 1, 1999 when CMS approved California’s 1115 waiver. As a result, the program became eligible for Title XIX funding. Effective 4Q1999, the State began invoicing for rebates. With the approval of the waiver, the FPACT program also became eligible for supplemental rebates. The Department of Health Care Services submitted a State Plan Amendment (SPA) to transition the current FPACT waiver into the Medi-Cal State Plan. The SPA was approved on March 24, 2011 by CMS. As approved by CMS, the SPA transitioned the FPACT waiver into the State Plan with a retroactive effective date of July 1, 2010. Additional information is available on the FPACT program webpage.​​ 

What is a “Physician Administered Drug (PAD)”?​​      

A physician administered drug is any covered outpatient drug provided or administered to a recipient, and billed by a provider other than a pharmacy. Such providers include, but are not limited to, physician offices, clinics and hospitals. A covered outpatient drug is broadly defined as a drug that may be dispensed only upon prescription, and is approved for safety and effectiveness as a prescription drug under the Federal Food, Drug and Cosmetic Act. Physician-administered drugs include both injectable and non-injectable drugs.​​ 

What is “HCPCS”?​​   

Txoj Kev Kho Mob Cov Txheej Txheem Txheej Txheem Txheej Txheem (HCPCS) yog lub teb chaws, cov qauv coding zoo ib yam tsim los ntawm Lub Chaw rau Medicare & Medicaid Services (CMS) los ua qauv txheej txheem coding uas siv los ua cov txheej txheem Medicare thiab Medicaid (Medi-Cal) thov raws lub teb chaws.​​ 

Tus Kws Kho Mob Tus Thawj Saib Xyuas Tshuaj thov kom muaj HCPCS code txhawm rau txheeb xyuas tus txheej txheem thiab txiav txim siab tus nqi them rov qab rau tus kws kho mob. Tsis tas li ntawd, tag nrho cov Kws Kho Mob Tswj Tshuaj (PAD) cov lus thov yuav tsum suav nrog National Drug Code (NDC) yog li cov chaw tsim tshuaj yuav raug xa mus rau cov nyiaj rov qab. DHCS tseem xav kom cov neeg thov uas tau sau nrog 340B yuav cov tshuaj kom suav nrog "UD" hloov kho, uas tshem tawm qhov kev thov los ntawm cov chaw tsim tshuaj hauv daim ntawv xa nyiaj rov qab tshuaj.​​ 

What is “FPACT HCPCS”?​​     

FPACT HCPCS are Family Planning Access Care and Treatment (FPACT) Physician Administered Drug (PAD) claims. These are claims from non-pharmacy providers. Usually the claim is submitted by a clinic, but not always. The claim requires a HCPCS code, the NDC and a “UD” modifier if filled with a 340B purchased drug.​​ 

What is a “COHS”?​​     

County Organized Health Systems (COHS) is a non-profit, independent public agency that contracts with the State to administer Medi-Cal benefits through local care providers and/or Health Maintenance Organizations. COHS have been part of the Medi-Cal program since CMS approved the first COHS plan in 1983. COHS have been part of the rebate program since 1991 and invoiced separately since fourth quarter 2001.​​ 

Muaj pes tsawg COHS?​​    

Muaj rau COHS txoj kev npaj them rau 22 lub nroog.​​ 

  1. “CalOPTIMA” – Orange County​​ 
  2. “Central California Alliance for Health” – Santa Cruz, Monterey and Merced counties​​ 
  3. “Health Plan of San Mateo” – San Mateo County​​ 
  4. “Partnership Health Plan” – Napa, Solano, Yolo, Sonoma, Marin, Mendocino, Del Norte, Humboldt, Lake, Lassen, Modoc, Shasta, Siskiyou and Trinity counties.​​ 
  5. “CenCal” – Santa Barbara and San Luis Obispo counties​​ 
  6. “Gold Coast Health Plan” — Ventura County​​ 

What is “CCS/GHPP”?​​     

California Children’s Services (CCS) is a program that treats children with certain physical limitations and chronic health conditions or diseases. The Genetically Handicapped Persons Program (GHPP) is a health program for adults with certain genetic diseases. CMS approved a Medicaid program waiver, effective September 01, 2005, which allowed the State to invoice drug manufacturers for rebates.​​ 

Qhov kev zam ntawm Medicaid los sau cov nyiaj them rov qab rau cov tshuaj rau lub xeev nkaus xwb CCS thiab GHPP siv tas sijhawm rau lub Kaum Ob Hlis 31, 2020. Vim tias tsis muaj kev txuas ntxiv ntawm tsoomfwv cov nyiaj pab rau CCS thiab GHPP cov pej xeem, DHCS tsis muaj txoj cai los sau nqi thiab sau nyiaj rov qab los ntawm tsoomfwv Medicaid rau cov kev pabcuam no. Raws li ntawm Q1 2021, CCS thiab GHPP invoices tau raug rho tawm los ntawm kev them nqi.​​ 

What are “Blood Factors”?​​     

Blood Factors or Factor 8 is an essential blood-clotting protein, also known as anti-hemophilic factor (AHF). DHCS invoices drug manufacturers on separate invoices for drugs that are used to treat blood factor diseases. Providers of AHF drugs are reimbursed at their acquisition cost plus 20 percent.​​ 

BCCTP yog dab tsi?​​    

Breast Cancer and Cervical Treatment Program (BCCTP) provides cancer treatment for eligible low-income California residents who are screened by Cancer Detection Program: Every Woman Counts (CDP:EWC) or Family Planning Access Care and Treatment (FPACT) programs and found to be in need of treatment for breast and/or cervical cancer. Assembly bill (AB) 430, (Chapter 171, Statutes of 2001) provided the State with statutory authority to implement the optional federal Breast and Cervical Cancer and Treatment Act of 2000. California’s SPA was approved by the federal government with an effective date of January 1, 2000. Drug manufacturers have been required to pay rebates since the program was included in California’s Medicaid State Plan. Visit the BCCTP webpage for more information.​​  

California tus nqi them rov qab rau cov tsev muag tshuaj yog dab tsi?​​    

Siv tau rau cov tsev muag tshuaj thov nrog cov hnub ua haujlwm rau lossis tom qab lub Plaub Hlis 1, 2017, Medi-Cal cov nyiaj them rov qab raws li qhov qis dua ntawm Tus Nqi Tshaj Lij Tshaj Lij (AAC) ntxiv rau cov nqi xa khoom, lossis cov nqi them raws li ib txwm muaj. AAC yog txiav txim siab raws li qhov qis tshaj ntawm:​​ 

  • Tus Nqi Siv Tshuaj Hauv Tebchaws (NADAC), lossis Tus Nqi Muag Khoom Muag (WAC) + 0% yog tias tsis muaj NADAC,​​ 
  • Federal Upper Limit (FUL), los yog​​ 
  • Tus Nqi Tshaj Lij Tshaj Lij Tshaj Tawm (MAIC).​​ 

California cov hnub ntau tshaj plaws yog dab tsi thaum muab tshuaj?​​    

California muaj 100-hnub cov khoom siv ntau tshaj plaws rau cov tshuaj feem ntau. Qhov no txawv ntawm ntau lwm lub xeev uas muaj ntau tshaj 30-hnub khoom. Nws yog ib qho tseem ceeb uas yuav tsum tau siv 100-hnub qhov khoom siab tshaj plaws los txiav txim siab thaum sib cav txog kev siv.​​ 

Vim li cas Medi-Cal thiaj li them nyiaj rov qab rau qee tus kws kho mob ntawm tus nqi qis li ntawd?​​      

Cov nyiaj rov qab los tsis yog qhov qhia tau zoo tshaj plaws ntawm pes tsawg units (cov ntsiav tshuaj, milligrams, vials, thiab lwm yam) ntawm cov tshuaj tau muab xa tawm vim qee tus kws kho mob tsis suav tag nrho cov ntaub ntawv.​​ 

Lwm cov ntaub ntawv Kev Pabcuam Kev Noj Qab Haus Huv lossis Third Party Liability (TPL) qee zaum tsis suav nrog hauv Medi-Cal thov. Nws yog ib txwm pom cov kws kho mob tau them rov qab tsuas yog rau cov nyiaj them ua ke (piv txwv li $5, $15, $30, thiab lwm yam) tsis muaj TPL cov ntaub ntawv. Vim li ntawd, feem ntau cov lus thov nrog cov nyiaj them rov qab qis yog qhov tseeb thiab cov chav nyob hauv cov nqi them rov qab kuj raug.​​ 

It is typical for managed care organizations (MCOs) to provide either a low reimbursement or no reimbursement amount on the claim. CMS’s Medicaid Drug Rebate Program Notice for Manufacturer’s Release No. 84 addresses the issue of low or no reimbursement for MCO claims. According to CMS, rebates are owed even if the MCO invoice does not show any paid amount since the drug cost is part of the capitated payment made by the State to the MCO. Consequently, reimbursement amount should not be used to dispute utilization since it has no relationship to units.​​ 

Cov kev coj noj coj ua ib txwm tuaj yeem sib txawv thiab / lossis raug hla dhau?​​   

Yog lawm. Daim Ntawv Thov Kev Tso Cai Kho Mob (TAR) tuaj yeem siv los hla cov kev coj noj coj ua ib txwm muaj (piv txwv li daim ntawv tshuaj ntau tshaj li rau 6 daim ntawv tshuaj nyob rau ib lub sij hawm rau ib tug neeg tau txais kev pab, ntau npaum li cas loj tshaj li ib txwm dispensing quantities, tshuaj tsis nyob rau hauv daim ntawv cog lus tshuaj, thiab lwm yam.)​​ 

Vim li cas kuv thiaj li yuav tsum xa Cov Ntaub Ntawv Nruab Nrab Tus Nqi (AMP) rau qee qhov NDCs?​​    

Only labelers who have an AMP based State Supplemental Drug Rebate Agreement with California need to provide AMP data. The contract requires AMP data to be submitted quarterly so a unit rebate amount (URA) can be calculated for invoice purposes. AMP data must be provided for each NDC for each quarter as required by the terms of the contract.​​ 

Thaum twg yog Tus Neeg Tsim Khoom Nruab Nrab Tus Nqi (AMP) cov ntaub ntawv them nqi hauv California?​​     

AMP information for each NDC must be submitted to the California Department of Health Care Services (DHCS) fiscal intermediary, Gainwell Technologies, LLC (Gainwell), within 30 days after the end of each quarter. This deadline is the same as CMS’s deadline for the federal drug rebate program.​​ 

What happens if I don’t turn in the AMP data timely?​​   

Cov ntawv sau npe yuav tsum paub tias yog tias lawv tsis xa lawv cov ntaub ntawv rau ob lub quarter sib law liag, lawv daim ntawv cog lus California Ntxiv AMP tuaj yeem raug txiav lossis tsis txuas ntxiv thaum daim ntawv cog lus tam sim no tas sijhawm. Yog tsis muaj daim ntawv cog lus ua haujlwm, DHCS tuaj yeem ua rau daim ntawv lo cov tshuaj muaj los ntawm kev tso cai ua ntej.​​ 

Kuv yuav xa cov ntaub ntawv AMP li cas?​​ 

AMP data for Supplemental contracts is submitted to Gainwell. AMP data is due within 30 days after the end of the quarter. Please contact the Drug Rebate Branch at drugrebatebranch@dhcs.ca.gov, for instructions on how to submit AMP data.​​  

Yuav ua li cas yog kuv AMP hloov?​​    

If a labeler’s AMP changes for a period under contract, the labeler must submit that updated AMP to Gainwell. The AMP data is submitted in the same manner as the initial AMP was submitted. Please contact the Drug Rebate Branch at drugrebatebranch@dhcs.ca.gov, for instructions on how to submit AMP data.​​  

Kuv yuav paub li cas yog tias kuv cov ntaub ntawv AMP raug xa tsis raug (piv txwv li format, tsis muaj ntaub ntawv, thiab lwm yam)?​​ 

Gainwell lossis tus kws tshuaj ntsuam xyuas nyiaj rov qab tshuaj yuav tiv tauj lub npe yog tias muaj teeb meem nrog cov ntaub ntawv AMP xa.​​ 

What if I can’t find a copy of my state supplemental contract?​​   

Hu rau koj tus kws tshuaj ntsuam xyuas nyiaj rov qab los ntawm DHCS lossis kom koj tus neeg sawv cev hauv tsoomfwv hu rau Lub Tsev Haujlwm Saib Xyuas Tshuaj Kho Mob.​​ 

Dab tsi tsim nyog rau Tus Muab Kev Pabcuam Kev Noj Qab Haus Huv (PHS) hauv California thiab tsim nyog rau 340B tus nqi?​​     

The drug rebate program was amended by the Veterans Health Care Act of 1992 (VHCA). Under the VHCA, Congress created the 340B program which is administered by the federal Health Resources and Services Administration (HRSA), Office of Pharmacy Affairs (OPA). The 340B program requires manufacturers of drugs that are paid for by state Medicaid programs to enter into an agreement with HRSA to provide statutory discounts on drugs to “covered entities”. Covered entities are required to identify claims for which the Medicaid beneficiary received a 340B purchased drug. The State is not entitled to rebates for those claims since the covered entity has already received a discount from the drug manufacturer. California’s rebate invoicing system automatically removes pharmacy and Physician Administered Drug (PAD) claims which include the appropriate PHS/340B identifier from the drug manufacturer’s invoice. Information about the 340B program and which entities qualify can be found on the HRSA 340 B Drug Pricing Program webpage.​​  

Tus kws kho mob puas yuav tsum txheeb xyuas qhov kev thov uas cov neeg tau txais txiaj ntsig Medi-Cal tau txais 340B yuav tshuaj?​​    

Yes. In order to comply with federal law claims must be filled out correctly to prevent “duplicate discounts.” This occurs when the drug manufacturer gives the provider the discounted 340B price and pays a Medicaid rebate. In order to prevent the “duplicate discount”, providers must include the appropriate code on the claim. Physician Administered Drug claims require a “UD” modifier. Pharmacy claims need to have a “08” in the Basis of Cost Determination field. Both the “UD” modifier and the “08” inform DHCS that a 340B purchased drug was used for the claim. Our rebate system removes the claims from the drug manufacturers rebate invoice ensuring that the drug manufacturer is not subject to the “duplicate discount”.​​ 

What is “EFT”?​​   

Qhov kev xaiv them nyiaj hauv Electronic Fund Transfer (EFT) tso cai rau cov neeg siv sau npe them lawv cov ntawv xa nyiaj rov qab tshuaj hauv hluav taws xob yam tsis tas yuav xa daim ntawv txheeb xyuas ib txwm muaj. Qhov kev xaiv yeem xav kom cov neeg tuaj koom ua raws li ib hom ntawv tshwj xeeb thaum xa cov ntaub ntawv hluav taws xob.  Thov hu rau Drug Rebate Branch ntawm drugrebatebrach@dhcs.ca.gov, yog xav paub ntxiv txog yuav ua li cas rau npe rau EFT.​​ 

What is “EIS”?​​    

Electronic Interface System (EIS) tso cai rau cov tuam txhab lag luam muag tshuaj kom khaws cov ntawv xa nyiaj hauv peb lub hlis twg tam sim no thiab rub tawm 10 xyoo ntawm cov ntaub ntawv thov raws li cov ntawv them rov qab.   Thov hu rau Drug Rebate Branch Portal team ntawm drugrebateportal@dhcs.ca.gov, yog xav paub ntxiv txog kev nkag mus rau qhov system.​​  

Qhib Kev Thov los ntawm EIS System​​ 

Tom qab txuag cov ntaub ntawv thov them nyiaj txuas, siv 7-Zip kom rho tawm cov ntaub ntawv mus rau hauv cov ntawv nyeem uas tuaj yeem hloov mus rau Excel cov ntaub ntawv.​​   

Cov txheej txheem ceeb toom yog dab tsi yog tias daim ntawv lo muaj NDC uas raug txiav?​​    

Cov ntawv sau npe yuav tsum tau tshaj tawm hnub xaus rau CMS THIAB Thawj Cov Ntaub Ntawv Lub Tuam Txhab (FDB) nyob rau hauv qhov xwm txheej NDC raug txiav los xyuas kom meej tias cov ntaub ntawv Medi-Cal muaj cov ntaub ntawv tam sim no.​​ 

CMS txhais hnub txiav tawm rau cov nyiaj rov qab raws li:​​ 

  • Hnub tim cov khoom raug tshem tawm ntawm lub chaw muag tshuaj; los yog​​ 
  • Hnub tim ntawm lub txee lub neej (hnub kawg nws tuaj yeem muab faib) ntawm cov khoom muag kawg​​ 

Cov tuam txhab tshuaj yuav tsum tau tshaj tawm cov ntaub ntawv tus nqi rau cov tshuaj raug txiav rau plaub lub quarter dhau los ntawm hnub txiav tawm.​​ 

Puas yog cov ntawv thov xa los ntawm cov koom haum saib xyuas kev tswj hwm yuav raug them rov qab?​​   

Yes. Section 2501 of the Affordable Care Act (ACA) amended section 1927(b)(1)(A) of the Social Security Act requires that the manufacturers “provide a rebate …including (for) such drugs dispensed to individuals enrolled with a Medicaid MCO if the organization is responsible for coverage of such drugs.” While section 1927(b)(1)(A) of the Act references payments made under the state plan, the amended statutory language does not limit the provision of additional manufacturer rebates to only drugs for which the MCO incurred a cost. When a drug is dispensed to a Medicaid beneficiary under a managed care arrangement, the state has made a capitated payment to the MCO for the drug. Regardless of the payment terms negotiated as part of the contract between the MCO and its participating providers to provide Medicaid coverage, the manufacturer is responsible for payment of rebates for covered outpatient drugs dispensed to Medicaid beneficiaries enrolled in MCOs. DHCS began collecting rebates for claims with a date of service of March 23, 2010, the implementation date of ACA.​​ 

Puas yog nws yuav tsum tau xa ROSI thiab/lossis PQAS nrog daim ntawv lo cov nyiaj them rov qab?​​    

Yes. The Centers for Medicare & Medicaid Services (CMS) requires that the Reconciliation of State Invoices (ROSI) and the Prior Quarter Adjustment Statement (PQAS) be included with every rebate payment. Without the ROSI and/or PQAS, the state will not be able to post your rebate payment. The data required on the forms is approved through the federal Office of Management and is mandated by CMS. It is also mandatory that drug manufacturers include ROSI and/or PQAS for any supplemental rebates paid. Submit checks, ROSI, PQAS and other supporting documents to the DHC Accounting address noted on your Invoice Cover Letters.​​ 

Department of Health Care Services
Accounting Section
Medi-Cal​​ 

Tshuaj Rebate Accounts Receivable
MS 1101​​ 

PO Box 997415​​ 

Sacramento, CA 95899-7415​​ 

In order to ensure that payments are processed correctly, it is necessary to consult your Invoice Cover Letter for account information. Separate payments are required for many of the programs.​​ 

     Muaj pes tsawg tus neeg tau txais txiaj ntsig tau cuv npe hauv Medi-Cal tswj kev saib xyuas hauv California?​​  

Rau cov ntaub ntawv saib xyuas kev tswj hwm, suav nrog cov ntaub ntawv sau npe, mus saib hauv Medi-Cal Managed Care webpage.​​ 

Kalifonias puas xav kom cov tuam txhab muag tshuaj them rov qab rau cov ntawv thov sib txuas?​​   

Yes. California’s claims processing system has been capturing the information necessary to rebate drug manufacturers for compound rebates since October 2003. To ensure compliance with federal requirements, drug manufacturers will be invoiced for compounds in 2014. Invoicing will be retroactive to 2003 when the claims processing system began capturing the data.​​  

Back to Medi-Cal Drug Rebate ​​