Reimbursement for pharmacist-provided health care services: A multistate review

Abstract

Objective(s): To better understand individual state approaches to reimbursement for pharmacist-provided health care services, we sought to (1) review existing statutes and regulations on pharmacist reimbursement from select states (Alaska, California, Idaho, New Mexico, Oregon, and Washington) and (2) suggest approaches to changing state statutes and regulations to allow for reimbursement.

Methods: We reviewed approaches taken by 4 states that currently allow for direct reimbursement of pharmacist-provided health services and 2 states that are in process. Washington requires commercial health plans to credential and privilege pharmacists as health care providers deeming reimbursement and coverage disparities among providers as compensation discrimination.

Results: Oregon does not require insurers to provide payment but requires pharmacists to contract and credential with each individual insurer, without the mandate for payment. In California, pharmacists receive 85% of the established fee schedule that physicians receive for equivalent services, and payment is issued to the pharmacy, not the individual pharmacist. California and New Mexico both only allow specified pharmacies or pharmacists to bill (advanced credentials or a tiered licensing model). In Alaska, scope and payor regulations align to allow compensation for covered services; however, insurance credentialing portals are not configured to enroll pharmacists as billing providers. In May 2020, pharmacists were added as nonphysician ordering, referring, and prescribing providers in the Idaho Medicaid basic plan regulations, and licensed pharmacists with national provider identification numbers were auto-enrolled.

Conclusion: The states we reviewed took different approaches on the basis of their established statutes and regulations (pharmacy, public and private insurance), resulting in variability in compensated services and reimbursement. An intentional alignment of statutes, regulations, and scope of practice is required to support reimbursement and sustainability of services.