Comprehensive Oncology State Legislation Tool
The NCODA Oncology State Legislation Tracking Tool provides comprehensive access to the most up-to-date information on state legislation interests related to oncology health policy. This NCODA member tool allows users to select individual states of interest and access relevant bill numbers, complete bill readings, a brief bill summary and a ‘why it matters’ section for each bill.
All NCODA Members Have Access To This Tool.
MONITOR STATE ONCOLOGY LEGISLATION EFFICIENTLY & EFFECTIVELY
This tool allows busy healthcare professionals to become more active participants in their state’s legislative affairs that directly impact their practice and the patients they serve.
“This tool is revolutionary in how much of an impact it will make for all practices that are trying to navigate state health policy change. It’s difficult for state practices to be involved in policy, and NCODA’s State Legislation Tracker is really going to help us be up-to-date on the recent policy changes in different states to help each state understand how and where they need to act to be effective.”
Debra Patt, MD, PhD, MBA
Executive Vice President | Texas Oncology
Frequently Asked Questions
Who is the "insured"?
- The person covered under a health insurance policy/plan.
- Also referred to as the “covered individual” or “an individual under a health plan.”
- Resources: https://economictimes.indiatimes.com/tdmc/your-money/these-are-the-participants-in-your-insurance-contract/tomorrowmakersshow/60490992.cms?query=Insurance
Who is the “uninsured”?
- A person who is not under a health insurance policy/plan
- Also referred to as an “individual without health insurance”
Who is the “underinsured”?
- A person whose out-of-pocket costs or deductible costs a significant amount of their household income
Who is the "insurer"?
- Health insurance company that provides the coverage under a health insurance policy.
- Also referred to as a “health plan” or “health insurance plan.”
- Resources: https://economictimes.indiatimes.com/tdmc/your-money/these-are-the-participants-in-your-insurance-contract/tomorrowmakersshow/60490992.cms?query=Insurance
What is a deductible?
- Amount the insured pays yearly before their health plan starts to pay their medical bills.
What is a copay?
- Flat amount the insured pays for covered services (e.g., physician visits, at the pharmacy counter, specialists, etc.).
What is co-insurance?
- The insured’s shared responsibility with insurance company after deductible is met.
- The Insurance pays a set % and the insured pays a set %.
What are health benefits?
- Health care items or services covered under a health insurance plan.
- These include but are not limited to: prescription drugs, pediatric services, chronic disease management services, preventive health services, emergency services, hospitalization, mental health services, ambulatory patient services, laboratory services, and rehabilitation services.
What are Pharmacy Benefit Managers (PBMs)?
- Third-party administrators contracted by health insurance plans, unions, and government forces to manage prescription drug benefits programs.
- They are involved with evaluating claims (for medical treatment, injuries, etc.) for payment of benefits, manage pharmacy networks, determine what brand/generic drugs are covered by an insured’s health plan, set co-pays, and set prior authorization criteria and the criteria for the insured’s choice of pharmacy.
What is telemedicine or telehealth services?
- Involves the use of electronic information and communication technology to provide healthcare services including assessment, diagnosis, consultation, treatment, education, care management, and self-management of a patient.
What is biomarker testing and what are some examples?
- Biomarker testing is the analysis of blood, other body fluids, and/or tissue for the presence of various biomarkers such as blood pressure, blood glucose, and the size of a tumor.
- Biomarker testing has been applied in the diagnosis and monitoring of various conditions including cancer, heart disease, infections, and genetic disorders.
What is "spread pricing”?
- A model of prescription drug pricing in which a pharmacy benefits manager (PBM) charges a health plan a contracted price for a prescription drug that is DIFFERENT from the amount the PBM pays (directly or indirectly) the pharmacist or pharmacy for the prescription drug.
- In this case, the PBM keeps a portion of the amount paid to them by the health plan for the prescription drugs, instead of paying pharmacies in full; keeping the difference (or “spread”) as profit.
What is the Maximum Allowable Cost (MAC) pricing?
- A standard measure used by pharmacy benefit managers (PBMs) when paying back retail pharmacies in their network. It is the upper limit/highest amount that the PBM will pay the pharmacy for a drug.
What are Direct and Indirect Remuneration (DIR) fees and "clawbacks"?
- DIR fees are fees charged to pharmacies by pharmacy benefit managers (PBMs) and can include fees for being a part of the PBM’s network of pharmacies, compliance fees, fees for filling a prescription drug, fees based on pharmacy performance on meeting metrics, etc. These fees are sometimes charged weeks to months after a prescription drug is filled in a pharmacy.
- Ultimately, a clawback is the process of pharmacy benefit managers recovering from the dispensing pharmacy, and keeping as profit, the difference between a patient’s co-payment and the pharmacy drug cost when the co-payment exceeds the pharmacy drug cost. This leads to a higher drug cost than what the actual cost is and leads patients to pay higher copays for their medications.
What is a Medicaid Managed Care Model?
- Plans that focus on preventive health care.
- These plans contract with various types of Managed Care Organizations (MCOs) to deliver Medicaid program health care services which can lead states to REDUCE Medicaid program costs and better manage the use of health services.
What is the Wholesale Acquisition Cost (WAC) of a drug?
- An estimate of the manufacturer’s list price for a drug to wholesalers or direct purchasers.
- This does NOT include discounts or rebates.
What are Pharmacy Services Administrative Organizations (PSAOs)?
- These organizations communicate with health plans and pharmacy benefit managers on behalf of community pharmacies (including independent pharmacies).
- They help these pharmacies in various ways, including (but not limited to): understanding pharmacy benefit managers’ audit findings and appealing them, identifying unpaid or incorrect claims, and other administrative operations.
What is the National Average Drug Acquisition Cost (NADAC)?
- NADAC is based on the retail price surveys focused on the retail community pharmacy acquisition cost.
- It is used as a standard point of reference that reflects prices paid by community pharmacies to obtain (or acquire) prescription and over the counter drugs.
- Medicaid updates the NADAC data on a weekly basis with the goal of pharmacy providers are paid back adequately for their professional services.
What is a utilization review process?
- The process of making sure healthcare services are being used appropriately and efficiently.
- This review is done by a covered individual’s health plan to evaluate the covered individual’s care plan, including the need for certain medications and services.
- It is done to confirm whether or not the health plan will provide coverage for the medication, service, or treatment plan under review.
What is a therapeutic interchange process?
- Practice of replacing, with the prescriber’s approval, a prescription medication originally prescribed for a patient with an alternative prescription medication that produces equivalent therapeutic and clinical effectiveness based on available scientific evidence.
- Essentially, this process may allow a pharmacist to substitute the originally prescribed drug for a drug that is “therapeutically equivalent,” which can save patients money for the care that they need.
What is "extrapolation" in audits conducted by pharmacy benefit managers?
- A process in which the auditor, chosen by the pharmacy benefit manager, reviews only a CERTAIN NUMBER of all claims submitted INSTEAD of all of the claims. From that number, the auditor counts the number of claims with errors or claims that do not comply with regulations, and extrapolates that across the TOTAL number of claims submitted.
- For example, if 500 claims are submitted by a pharmacy of which the auditor reviews 50 of them and finds that 5 contain errors, the auditor will EXTRAPOLATE and seek recoupment (or refund) for 10% of ALL 500 claims submitted.
- This is not an accurate representation of how many claims actually contained errors/non-compliance.
What is a drug formulary for a health plan?
- A list of generic and brand name prescription drugs covered by an individual’s health plan.
What are “white bagging” practices and the risks associated with them?
- White bagging practices occur when insurance companies require oncologists and health care facilities to administer medications that have been prepared from outside of the hospital. More specifically, the drug is purchased from an OUTSIDE PHARMACY (usually specialty pharmacy), that is under contract with the insurance company, and then SHIPPED to the hospital, physician’s office, or clinic to be administered to the patient
- Concerns with white bagging involve the uncertainty of whether or not the drugs have been properly stored, mixed, transported, and labeled. This leads to uncertainty with the safety and effectiveness of the drugs, increasing the risk of fragmentation of care and delays in treatment.
What are “brown bagging” practices and the risks associated with them?
- Brown bagging practices occur when insurance companies require a medication to be dispensed from a pharmacy (usually specialty pharmacy) DIRECTLY to the PATIENT, who then TRANSPORTS the drug to the physician’s office or clinic to have it administered
- Concerns with brown bagging involves the uncertainty of whether or not the drugs have been properly stored by the patient and transported by mailing services or the patient. This leads to uncertainty with the safety and effectiveness of the drugs, increasing the risk for fragmentation of care and delays in treatment.
What are “clear” and “gold” bagging practices as well as the benefits of adopting them?
- Clear bagging practices occur when a health system’s OWN SPECIALTY PHARMACY delivers medication to the hospital, physician’s office, or clinic for administration to a patient.
- Gold bagging is an emerging and more modern term that is very similar to clear bagging but with more of a gold-standard, comprehensive, and patient centered approach ensuring that quality care is delivered. It is more controlled and focuses on updated information regarding patients’ physicians, patients’ electronic medical records, and emphasizes the health system’s own pharmacy processes (monitoring patients’ labs, ensuring proper infusion preparations, etc.).
- Benefits of these practices include improved transparency among stakeholders involved with patient care, reduced concern with stability/storage/effectiveness of drugs, reduced risk of treatment delays, and improved continuity of care.
What is the Maximum Out Of Pocket (MOOP) expense?
- Maximum amount the insured has to pay yearly for medical services.
- Once the insured meets the MOOP, their plan will begin to pay at 100%.
What is a premium?
- Amount the insured pays to obtain the insurance.
- This does not include the insured’s deductible, copay, MOOP, and other coverages.
What are copay accumulator programs?
- Started by insurers and pharmacy benefits managers to track an insured’s accumulated, or total gathered, out of pocket expenses.
- These programs STOP manufacturer coupons from counting towards the insured’s deductible & MOOP.
What are copay maximizer programs?
- Started by insurers and pharmacy benefits managers to increases an insured’s copay amount for a medication and evenly divide it to estimate the manufacturer coupon’s monthly value.
- These programs also prevent manufacturer coupons from counting towards an insured’s deductible & MOOP.
What are prior authorizations?
- A process used by health plans to determine if a prescribed product will be covered in full or a portion.
- This process requires the doctor, or another provider prescribing the medication/other services, to get approval from the insured’s health plan BEFORE the cost is covered by the health plan and the medication is given to the patient.
- This process can be long and DELAY patients from getting the care that they need.
What are cost sharing requirements?
- The share of costs covered by an insured’s health plan that the insured pays out of their own pocket.
- This includes deductibles, coinsurance, and copayments, or similar charges, but it doesn’t include premiums, balance billing amounts for providers out of the health plan’s network, or the cost of services that are not covered under the health plan.
What is the 340B Drug Pricing Program and its entities?
- Requires pharmaceutical manufacturers participating in Medicaid to sell outpatient drugs at DISCOUNTED prices to health care organizations that care for patients who do NOT have health insurance and those with LOW INCOME.
- Entities under this program include disproportionate share hospitals (DSHs), children’s hospitals, cancer hospitals exempt from the Medicare prospective payment system, sole community hospitals, rural referral centers, and critical access hospitals.
What are step therapy protocols?
- A process used by health plans/pharmacy benefit managers which require a patient to try and fail other medications (which are usually less expensive or generic) before they can use the medication/treatment originally prescribed to them by their doctor or provider (which may be more expensive or branded).
What are Generic Effective Rates (GERs) and Brand Effective Rates (BERs)?
- GERs and BERs are rates set by a pharmacy benefit manager (PBM) when they get into a contract with a pharmacy to manage the pharmacy’s generic or brand drug spend. PBMs promise that they will provide a certain percentage discount off the average wholesale price of the generic or brand drug. For example, a GER/BER of 75% means the PBM will pay a pharmacy 75% less than the average wholesale price of that generic or brand drug.
- Although this may seem beneficial for pharmacies, the actual cost for the pharmacy of acquiring the generic/brand drug may be a lot higher than the reimbursements they receive from PBMs through GERs/BERs. Also, PBMs may not be clear in the contract and use maximum allowable cost (MAC) pricing and if PBMs pay the pharmacy above the MAC, they charge the pharmacy to get their money back. GERs and BERs may lead to significant loss in profit for pharmacies.
What is the reverse auction process involving health plans and pharmacy benefit managers?
- Occurs through an online platform in a clear and visible way. Pharmacy benefit managers compete with one another and counter offer LOWER prices in each auction round when selecting a health plan to contract with.
- The winning bid in this process is the LEAST expensive offer.
What are clinician-administered drugs?
- These are outpatient prescription drugs that is given, or administered, to the patient by a doctor or another provider.
What is an adverse determination?
- A determination made by the health plan or health maintenance organization that the health care service has been reviewed and, based on the information provided, it is not medically necessary or appropriate
What is a “Tiered network plan"?
- A health benefit plan that sorts some or all types of providers into specific “groups” or “tiers”. Different provider reimbursement, enrollee cost sharing, or provider access requirements, or any combination of these, are applied for the same services in different groups (or tiers).
What is a plan sponsor?
- An employer or organization that offers a group health plan to its employees or members.
What are A-rated or B-rated generic equivalent drugs?
- An A-rated generic equivalent is a generic medication that is equivalent to a brand medication by having identical amounts of the ingredients (including the active drug), identical dose form (tablets, capsules, etc.), and are both administered the same way.
- On the other hand, B-rated drugs are those, which the FDA considers NOT to be therapeutically equivalent due to actual or potential bioequivalence problems, which have not been resolved.
What is a Medicaid Fee-For-Service (FFS) model?
- A health care delivery system that allows the state to pay a covered individual’s healthcare providers directly, instead of having individuals being enrolled in a managed care plan. This payment model rewards healthcare providers for the number of services provided, regardless of the outcome.
What are "tiers" in a health plan's formulary?
- Health plan’s formulary are usually divided into 3 or 4 categories called “tiers” Drugs are placed in tiers based on the type of drug (such as generic, preferred brand, non-preferred brand, and specialty).
- Usually, the lower the tier, the lower the copay or out of pocket costs.
- Non-preferred medications will usually be placed in higher tiers and cost more whereas generics will be placed in lower tiers.
What is "recoupment" in an auditing process?
- For conducted audits, recoupments are requests for refunds from the auditor on claims that the health plan/PBM overpaid so that they are able to recover that extra money.
What is a fiduciary duty and how does it relate to pharmacy benefit managers and health plans?
- A fiduciary duty exists in law when a person or entity (such as a health plan) places trust, confidence, and reliance on another (such as a pharmacy benefit manager) to exercise discretion or expertise in acting on behalf of the client.
- In this case, a pharmacy benefit manager must act in the best interest of the health plan it is contracted with.
What are specialty drugs?
- Medications that require special handling, administration, or monitoring and are used for the treatment of serious health conditions that need complex therapies.
What is prescription or medication synchronization and how does it benefit patients?
- The process of a pharmacist coordinating a single day each month for patients to pick up their medication refills instead of having to come in to the pharmacy on different days to pick up their refills
- This is convenient for patients, allowing them fewer trips to the pharmacy to pick up their medications and the chance to meet with their pharmacist monthly to discuss their medications
What is the "health insurance marketplace"?
- A health insurance marketplace, also known as a health insurance exchange, is a place (both online and in-person) where consumers in the United States can purchase private health insurance plans
- They may also receive income-based subsidies to make coverage more affordable
- With the exception of people who are enrolled in Medicare coverage, almost all Americans are eligible to use the health insurance marketplace
What is the "Affordable Care Act"?
- The Affordable Care Act is the comprehensive health care reform law passed in March 2010.
- It is also known as the Patient Protechtion and Affordable Care Act or “ACA”.
- The goal of this law is to make health insurace more affordable and more available for lower-income individual or families. This leads to lower healthcare costs in general.
What is a "grandfathered health plan"?
- A health insurance policy that was in place BEFORE the Affordable Care Act (ACA) was signed on March 23, 2010
What is a “CPT” Code?
- CPT stands for Current Procedural Terminology.
- CPT codes are used by doctors and health care professionals as a way of organizing medical services and procedures in a uniform language.
- CPT codes are commonly used in the U.S to effectively and accurately report medical services under private and public health insurance programs.
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