An Act Concerning An Equitable Medicaid Audit, Billing And Reimbursement Policy For Pharmacies.
Summary
HB 6091 would change how the Department of Social Services audits and reimburses Medicaid-participating pharmacies. It prohibits the commissioner from using extrapolation based on clerical or minor technical errors as the basis for denying Medicaid reimbursements in pharmacy audits, limiting the use of audit findings that are not tied to substantive wrongdoing. The bill also requires the department to create a receipt-confirmation process for pharmacy notices and to maintain a reliable, pharmacy-accessible database of the preferred drug list with real-time updates on drug approvals and denials.
The bill further directs the commissioner to establish, by October 1, 2025, a grievance process under the Uniform Administrative Procedure Act so pharmacies can challenge Medicaid reimbursement rates that do not cover the pharmacy’s cost to dispense a prescribed drug. In that process, pharmacies would be able to present evidence comparing their dispensing costs with the disputed reimbursement amount. Overall, the bill is aimed at making Medicaid pharmacy audits and reimbursement practices more transparent, more accurate, and more responsive to pharmacy costs.
Impact
If enacted, the bill would add a new section to the general statutes effective July 1, 2025, restricting DSS audit practices and creating new administrative obligations for Medicaid pharmacy billing and reimbursement. It would affect the Department of Social Services, Medicaid-participating pharmacies, and the state’s preferred drug list administration by requiring notice tracking, database maintenance, and a formal grievance pathway for reimbursement disputes. The measure would not broadly rewrite Medicaid law, but it would materially change audit standards and pharmacy reimbursement procedures within the state Medicaid program.
Sentiment
The available voting history suggests strong support for the bill in committee: it received a 23-0 joint favorable vote after an initial vote-to-draft tally. There are no committee transcript excerpts provided showing debate or opposition, but the unanimous committee vote indicates the proposal was viewed favorably by members at that stage. The bill’s framing around fairness, transparency, and pharmacy reimbursement suggests a generally supportive policy environment.
Contention
The main points of potential contention are the limits placed on DSS audit authority and the requirement that the department create a grievance process for under-reimbursed prescriptions. Supporters are likely to view these provisions as necessary protections against overbroad audit recoveries and inadequate reimbursement, while critics may be concerned about reduced flexibility for program integrity enforcement, added administrative burden, and possible cost implications for Medicaid. Another likely issue is the requirement for real-time preferred drug list updates and reliable notice confirmation, which could raise implementation and compliance concerns for the agency.