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Panel debates Medicaid move to pharmacy billing for continuous glucose monitors; committee sends rule to rules committee with no recommendation
Summary
DHS told the committee a rule implementing Act 393 would shift continuous glucose monitor billing to the pharmacy point-of-sale system (making claims eligible for manufacturer rebates). Providers and DMEs debated access, unit prices, and whether rebates benefit beneficiaries or the Medicaid program; the committee voted to send the rule to the rules committee with no recommendation.
The Senate Public Health, Welfare and Labor Committee reviewed a Department of Human Services rule to change how continuous glucose monitors (CGMs) are billed under Medicaid so that pharmacies can adjudicate and be eligible for manufacturer rebates.
Janet Mann, Medicaid director, and Elizabeth Pittman, medical services, explained DHS's reading of Act 393 and said the rule would allow pharmacists and DME vendors to provide CGM benefits while enabling the state to collect pharmacy rebates through the pharmacy point-of-sale system. Mann told the committee that pharmacy adjudication is necessary to secure manufacturer rebates and that those rebates are used within the Medicaid program; she said beneficiaries would not receive the rebates directly.
Some legislators and DME representatives warned the change could price DMEs out of parts of the market because of differences in reimbursement schedules. Representative Ryan and others asked whether shifting billing to the pharmacy channel would raise the vendor'level unit price before rebate by roughly $100; DHS said gross prices vary by vendor and that, after rebates, independent analyses project net savings for the program. Committee members asked DHS to provide supporting CMS documentation and a clearer breakdown of the fiscal impact.
Industry and clinical witnesses urged faster access for patients. Morgan Butler and Jennifer Sellers, both registered nurses and certified diabetes care and education specialists, said the DME approval process for Medicaid can take "upwards of 30 business days," delaying patients who clinicians say can begin using a CGM within two to three days if dispensed by a pharmacy. John Burris, representing Dexcom, told the committee that commercial plans and the state's employee benefits plan already use the pharmacy channel and that shifting Medicaid to the same channel both increases access and allows the state to claim rebates that reduce net spending.
Committee members debated several procedural motions: a motion that the committee "do not review" the rule on grounds of alleged conflict with legislative intent failed; a motion to hold the rule until more information was provided did not secure the committee's approval in the joint consideration. The committee ultimately approved a motion to "take no action," sending the rule to the rules committee without recommendation.
The committee asked DHS for written materials—specifically CMS correspondence and comparative statutory language about rebates—and for more granular fiscal detail on per-unit pricing and rebate estimates before further action.
