1. Introduction
   • Brief overview of the historical context of long-term care (LTC)
   • Introduction to the influence of CMS guidance and regulatory changes
2. Evolution of LTC Billing Practices
   • 2005: CMS’s initial guidance on the definition of long-term care pharmacy
   • Key components defined for LTC pharmacies
   • Focus on skilled nursing as a federally defined opportunity for increased reimbursement
3. Expansion to Assisted Living Facilities
   • 2008: CMS guidance on reimbursing pharmacies for services to assisted living facilities
   • Comparison to reimbursement for skilled nursing
   • Transition period and challenges with PBM adoption of increased reimbursement
4. Guidance vs. Regulatory Language
   • Differentiation between CMS guidance and regulatory language
   • Importance of understanding the nuances in language for reimbursement
   • Challenges and considerations for the industry in following guidance
5. Industry Response to Guidance
   • Shifts in the strength of agency guidance over time
   • Impacts on industry practices, citing the example of changes in 340B programs
   • Speculation on the future role of CMS guidance in long-term care
6. Regulatory Pressure in 2011
   • Overview of regulatory pressure, particularly in the short cycle dispensing regulation
   • Initial intent for weekly dispensing, later amended to 14-day supplies
   • Dispense fee payment for short cycle dispensed medications
7. Long-Term Care Reimbursement Challenges
   • Industry drive to reduce overall costs, particularly with Medicare Advantage plans
   • Emphasis on the role of quality pharmacy care in cost reduction
   • The impact of compliance packaging and shorter dispensing cycles on reimbursement
8. CMS Guidance in December 2021
   • Overview of recent CMS guidance similar to 2008, emphasizing increased dispensing fees for LTC at home
   • Individual PBM plans articulating reimbursement levels
   • The challenge of establishing consistent reimbursement across plans
9. Future Opportunities and Challenges
   • Exploration of potential opportunities with Medicare Advantage plans
   • The need for specific data and value demonstration in the LTC at-home setting
   • Challenges with variations in PBM recognition and reimbursement for LTC at home

Long-Term Care Guidance Overview

Issued on March 16, 2005, this document serves as a resource for Medicare Part D plans in developing policies aligned with CMS requirements for pharmacies serving Long Term Care (LTC) facilities. It provides direction on pharmacy performance criteria, access standards, formulary considerations, and beneficiary protections. This guidance aims to ensure that Part D plans deliver comprehensive prescription drug benefits to Medicare beneficiaries in LTC settings, including skilled nursing facilities and Medicaid-covered medical institutions.

Recognizing and Supporting Long-Term Care at Home Pharmacies

Community-based long-term care programs are vital for delivering essential healthcare services to individuals in community settings, with funding primarily sourced from private Medicaid and Medicare dollars. While these programs offer a wide range of services, including medical care, therapy services, nursing services, social work, and case management, there exists a noticeable gap in dedicated pharmacy services tailored specifically to long-term care at home settings. Long-term care at home pharmacies, also referred to as community-based long-term care pharmacies, are indispensable components of comprehensive healthcare delivery in community settings. These pharmacies specialize in providing medication management, dispensing, clinical and counseling services customized to the unique needs of individuals who are chronically ill and aging at home. Despite their critical role in ensuring medication safety, adherence, and overall health outcomes, long-term care at home pharmacies are often sidelined due to the lack of clear and standardized reimbursement structures or models. These pharmacies provide a high-touch, patient centric level of care to chronically ill individuals residing in the community, yet they face challenges in securing fair and standardized reimbursement to support their essential services.

Why Payers and Plans Should Recognize Long-Term Care at Home:

• Improved Health Outcomes: Long-term care at home pharmacies contribute to improved health outcomes for patients and providers engaged in value-based care by ensuring proper medication management, adherence, and monitoring in home settings.
• Patient Preference: Many individuals prefer to receive long-term care services in the comfort and familiarity of their own homes. Recognizing and supporting long-term care at home pharmacies aligns with patient-centered care and improves patient satisfaction.
• Cost Savings: Effective medication management and adherence facilitated by long-term care at home pharmacies can lead to cost savings by reducing hospitalizations, emergency room visits, and complications associated with medication errors.
• Enhanced Care Coordination: Integrating long-term care at home pharmacies into existing community-based long-term care programs promotes seamless care coordination among healthcare providers, leading to better overall outcomes for patients.
• Addressing Health Disparities: Recognizing the importance of long-term care at home pharmacies ensures equitable access to comprehensive healthcare services in community settings, addressing disparities in care delivery and improving health outcomes for underserved populations.
• Incorporating long-term care at home pharmacies into funding and reimbursement mechanisms is essential to sustainably support their services and ensure equitable access to comprehensive pharmacy care services in community settings. Stakeholders should prioritize funding and resource allocation to bridge the gap in pharmacy services and enhance patient care in home settings.