Medicaid is a joint federal-state program that provides health coverage to certain categories of low-income persons including children, pregnant women, parents of eligible children, and persons with disabilities. One of its most important benefits is prescription drug coverage. Outpatient prescription drug coverage under Medicaid is an optional benefit; however all state Medicaid programs cuurently provide coverage for prescription drugs, although there are differences in state policies with regard to copays, types of drugs that are covered, and the number of prescriptions that can be filled. While Congress and the Centers for Medicare and Medicaid Services (CMS) set out the general rules under which Medicaid operates, each state runs its own program.
In the wake of the Affordable Care Act and the Supreme Court decision handed down in the Summer of 2012, states will have the option to expand their Medicaid enrollees if they so choose. For states that decided to do so, the Federal Government will pay 100% of the cost of the expansion for three years; and after that time reduce its funding to 90%. Despite this federal funding, most states will need to upgrade their administrative and IT capabilities which will require significant financial outlays. This comes at a time when many states are looking to cut Medicaid provider reimbursements and shift their Medicaid population into managed care. In addition, a number of states are now looking to shift the Medicaid pharmacy reimbursement benchmark to Average Acquisition Cost (AAC)—similar to what Alabama and Oregon have done. Below you will find links to an NCPA Medicaid Pharmacy Manual, guidelines and NCPA comments for states seeking to utilize AAC for Medicaid pharmacy reimbursement.