7.3 Long-term Care (Plan B)

Individuals living permanently in a licensed long-term care facility on PharmaCare’s list of Plan B facilities are eligible for coverage under Plan B.

Coverage is provided for individuals, rather than families.

Plan B does not apply to individuals who are:

• Staying in extended care, acute care, multi-level, or assisted living facilities.
• Receiving short-term long-term care services, including:
  • respite care
  • convalescent care
  • residential hospice palliative care
  • short-term care for other purposes determined appropriate by a health authority to meet the unique needs of the client

These short-term residents receive PharmaCare coverage under their primary PharmaCare plan (i.e., Fair PharmaCare, Plan C, Plan F or Plan W).

Each long-term care facility on the list of Plan B facilities is served by a contracted pharmacy.

Every month, PharmaCare pays the contracted pharmacy:

• A fixed fee ("capitation fee") for providing services to each occupied Plan B bed in the facility (see Related Services List), and
• The full cost of eligible prescription drugs and medical supplies/devices

Individuals do not need to apply for Plan B coverage.

Facilities on the list of Plan B facilities and contracted pharmacies identify an individual’s eligibility and submit the information to PharmaCare. Plan B coverage begins the day eligibility is entered in PharmaNet.

Plan B coverage cannot be provided retroactively.

The full cost of eligible prescription drugs and medical supplies/devices up to the maximum PharmaCare recognizes.

Eligible medical supplies/devices covered under Plan B are:

• Prosthetics
• Ostomy supplies
• Insulin pumps, with a Special Authority request

Plan W OTC items

If a Plan B facility resident is also covered under Plan W, they may receive coverage for over-the-counter (OTC) items on the Plan W formulary that are not covered by Plan B.

OTC claims submitted under Plan W for FNHA clients in Plan B facilities should be entered at the eligible retail cost plus a $10 dispensing fee. PharmaCare’s Frequency of Dispensing Policy applies to these Plan W–paid claims.

The intent of this exception is to allow coverage for Plan W OTC benefits that are not covered under Plan B. Pharmacies should only bill OTCs (and OTC dispensing fees) to Plan W if they are not a Plan B benefit.

After submitting an OTC claim under Plan W for an FNHA client receiving care in a Plan B facility, pharmacies serving Plan B facilities must be sure to include the Plan B facility code for all subsequent (non-OTC) claims. Without the facility code, PharmaNet will continue adjudicating claims under Plan W. For details, refer to the PharmaCare Newsletter article Plan B pharmacies: Submitting OTC Claims for Plan W beneficiaries (PDF, 974 KB)

Continuous glucose monitors

Continuous glucose monitors (CGMs) are not covered under Plan B, but can be covered under the Plan B facility resident’s non-Plan B plan (i.e., Fair PharmaCare, Plan C, or Plan W—with Special Authority).

CGMs should be entered under the alternate plan at the eligible retail cost plus a $10 dispensing fee. PharmaCare’s Actual Acquisition Cost Policy applies to all CGM claims.

Note that the intent of this exception is to allow coverage for CGMs for Plan B residents, since CGMs are not covered under Plan B.  

After submitting a CGM claim under a Plan B facility resident’s alternate plan, be sure to include the Plan B facility code for all subsequent (non-CGM) claims. Without the facility code, PharmaNet will continue adjudicating claims under the plan under which the CGM was claimed.

Routine medical supplies are not covered under Plan B since they are to be provided to clients at no charge by the long-term care facility. This includes items such as needles and syringes, blood glucose test strips, and insulin pump supplies.

>> Refer to the Home and Community Care policy manual for full details of medical supplies provided by long-term care facilities.

Using another PharmaCare plan to submit PharmaCare claims for these items for individuals covered under Plan B is inappropriate. Such claims are subject to audit and recovery.

Individuals covered under Plan B are not eligible for the Palliative Care Plan (Plan P).

Claims submitted under Plan P for an individual covered under Plan B are subject to recovery.

The Frequency of Dispensing Policy does not apply to claims submitted under PharmaCare Plan B. PharmaCare’s monthly capitation fee covers all dispensing activities for eligible benefits, regardless of frequency.

Individuals covered under Plan B are eligible for coverage of clinical services fees.

Individuals covered under Plan B are eligible for coverage for administration of publicly funded vaccines.

Individuals covered under Plan B are not eligible for Medication Review Services. PharmaCare’s monthly capitation fee for Plan B facilities covers a similar review service.

Professional intervention fees (special services fees) are not eligible under Plan B. PharmaCare’s monthly capitation fee for Plan B facilities already covers professional interventions.

If a pharmacy is going to provide services to a long-term care facility that will open in the near future, the facility must first contact the Information Support unit at Health Insurance BC (HIBC) to request that they be added as a Plan B facility with BC PharmaCare.

The facility must submit the following information to Information Support, allowing thirty days’ notice:

• A completed Request for PharmaCare Plan B Services to a Long-Term Care Facility form (Information Support will fax the form to the new facility when the initial request is made.)
• A copy of the facility licence
• When Information Support receives these documents from the facility, they will ensure the pharmacy is enrolled in the Plan B sub-class. If the pharmacy is not enrolled in the Plan B sub-class, the pharmacy must submit a request for the sub-class using the Provider Information Change form (HLTH 5433) (PDF, 746 KB) available at Information for Pharmacies
• When Information Support receives the completed Request for PharmaCare Plan B Services to a Long-Term Care Facility and a copy of the facility license, and confirms the pharmacy is enrolled in the Plan B sub-class, they will link the pharmacy and the facility on PharmaNet so preparations for service can begin (e.g., setting up patient profiles and preparing dosage packages) before the opening date of the facility. To ensure timely processing, we request that pharmacies confirm they are enrolled in the Plan B sub-class prior to submitting the Request for PharmaCare Plan B Services to a Long-Term Care Facility form and a copy of the licence

A pharmacy provider intending to terminate services to Plan B patients must give notice to Information Support. The termination date must be the last day of a month (end of day) and notice must be given no later than the last day of the month preceding the month in which service will cease. (Please note that PharmaCare cannot make capitation payments for partial months.)

If an existing facility intends to enter into a contract with a different pharmacy, the new pharmacy must

• Submit a Request for PharmaCare Plan B Services to a Long-Term Care Facility form to Information Support (or provide equivalent information to Information Support by fax or e-mail), with 30 days’ notice, along with a copy of the facility licence
• Information Support will ensure the pharmacy is enrolled in the Plan B sub-class
• When Information Support receives the completed Request for PharmaCare Plan B Services to a Long-Term Care Facility and a copy of the facility license, and confirms the pharmacy is enrolled in the Plan B sub-class, they will link the pharmacy and the facility on PharmaNet so preparations for service can begin (e.g., setting up patient profiles and preparing dosage packages) before the opening date of the facility. To ensure timely processing, we request that pharmacies confirm they are enrolled in the Plan B sub-class prior to submitting the Request for PharmaCare Plan B Services to a Long-Term Care Facility form and a copy of the licence

LTC facilities may be evacuated due to fires, floods, or other natural disasters, and residents temporarily relocated to other LTC facilities across the province.

Continuity of care is crucial during this disruption, and PharmaCare will support the work of community pharmacies to assist evacuated residents, regardless of the Plan B status of their home facility.

Definitions

Home facility	The facility a person is normally residing in
Home pharmacy	The pharmacy that provides services to the home facility
Receiving facility	The facility a person is evacuated to
Receiving pharmacy	The pharmacy that provides services to the receiving facility

Long-term care residents who are evacuated from their home facility to a receiving Plan B facility are eligible for and will receive coverage through Plan B.

The receiving pharmacy will provide services for the evacuated residents, unless there is express direction otherwise from the receiving facility to establish an alternate arrangement and appoint an additional pharmacy. Note: The additional appointed pharmacy could be the home pharmacy or another pharmacy. 

If an additional appointed pharmacy is not required

The following directions apply in the absence of an alternate arrangement.

The receiving pharmacy may bill the Plan B capitation fee for each bed occupied by an evacuated resident, including if the bed is only occupied for a partial month.

The receiving pharmacy must notify Health Insurance BC (HIBC) Information Support of the:

• Number of evacuated residents
• Name of the receiving Plan B facility
• Name of each evacuated resident’s home facility (which may or may not be a Plan B facility), and
• Date that pharmacy services begin at the receiving facility

The receiving pharmacy must also notify HIBC Information Support of the last date that pharmacy services end for evacuated residents at each receiving facility they provide services to. If requested, HIBC Information Support can provide the name of the home pharmacy, if the home facility is a Plan B facility, to facilitate any transfer of prescriptions and continuity of care.

More than one pharmacy can claim a capitation fee for a bed occupied by the same person in a month if the person is a resident of more than one Plan B facility during the month because of the evacuations. If a person is not a resident in a Plan B facility for an entire month (for example, the resident is not at their home facility for the entire month of September), the pharmacy servicing the home facility cannot bill the capitation fee for that bed for that month since the bed was not occupied.

If an additional appointed pharmacy is required

If the receiving facility has a requirement for a pharmacy other than the receiving pharmacy to dispense to the evacuated residents while they are residing in the receiving facility (e.g., for operational reasons), an alternate arrangement appointing an additional pharmacy (the “additional appointed pharmacy”) must be documented by completing the Additional Appointed Pharmacy for LTC Evacuation Form.

Instructions for completing the form:

1. The receiving facility must complete Section A of the form to document the assignment of responsibility to the additional appointed pharmacy.
2. The additional appointed pharmacy must complete Section B of the form to provide their consent to provide services to the evacuated residents at the receiving facility and request for related Plan B claim payments to be authorized.
3. Once both Sections A and B are completed, copies of the signed form must be sent by the additional appointed pharmacy to:
   • HIBC Information Support
   • The receiving pharmacy
   • The receiving facility
   • The home facility, and to the home pharmacy (if not the additional appointed pharmacy)

If as part of urgent services for evacuated residents, a Plan B facility temporarily exceeds its licensed bed capacity, the pharmacy must notify HIBC of the excess number of beds prior to submitting an invoice for capitation fees. Pharmacies will be eligible for capitation fees for temporary Plan B beds for evacuated residents for the duration of the evacuation only if notice is provided prior to receipt of the invoice.

The receiving pharmacy may need to provide emergency supplies of medications or adapt prescriptions within their scope of practice and following the guidance provided by the College of Pharmacists of BC. This may be necessary when the resident’s home facility is served by a health authority-operated pharmacy under the Hospital Act, due to differences between the Plan B formulary and health authority formularies. The receiving pharmacy may try to adapt prescriptions to Plan B benefits.

Pharmacies are asked to hold the billing for any extra costs to patients until further direction is provided by the receiving facility’s health authority.

Pharmacies are eligible for PharmaCare Clinical Services fees for adaptations for Plan B residents.

If a resident is transferred to a private long term care facility, that is neither registered as a Plan B facility nor receives health authority support, further actions may be required, including emergency temporary Plan B facility registration. In this case, please contact HIBC Information Support.

Certain changes in facility information require that the local Health Authority issue an amended license to the facility. It is the facility’s responsibility to inform the pharmacy providing services.

The pharmacy must notify Information Support (using the Request for PharmaCare Plan B Services to a Long-Term Care Facility form) if a facility experiences any of the following changes:

• Change in number of eligible Plan B beds (The pharmacy must also provide a copy of the new license indicating the change in the number of beds.)
• Change in facility name (The pharmacy must also provide a copy of the new license indicating the new name.)
• Change in license number (The pharmacy must also provide a copy of the new license indicating the new license number.)
• Change in facility type—e.g., from complex care to multi-level care (The pharmacy must also provide a copy of the new license indicating the change in facility type.)

Note: A change in ownership does not require an amended license.

>> Contact Information Support at HIBC whenever these changes occur.

A facility intending to exit from Plan B and transition to another pharmacy provider submitting claims via different PharmaCare plans must give notice to Information Support at HIBC. The termination date must be the last day of a month (end of day) and notice must be given no later than the last day of the month preceding the month in which service will cease. (Please note that PharmaCare cannot make capitation payments for partial months.)

If a facility previously exited from Plan B and intends to re-join Plan B at a later date, it is the facility’s responsibility to inform the pharmacy providing services. The pharmacy must notify Information Support and:

• Submit a Request for PharmaCare Plan B Services to a Long-Term Care Facility form to Information Support (or provide equivalent information to Information Support by fax or e-mail), with 30 days notice, along with a copy of the facility licence.
• Information Support will ensure the pharmacy is enrolled in the Plan B sub-class.
• When Information Support receives the completed Request for PharmaCare Plan B Services to a Long-Term Care Facility and a copy of the facility licence, and confirms the pharmacy is enrolled in the Plan B sub-class, they will link the pharmacy and the facility on PharmaNet so preparations for service can begin (e.g., set up patient profiles, and prepare dosage packages), before the service transition date. To ensure timely processing, pharmacies should confirm they are enrolled in the Plan B sub-class before they submit the Request for PharmaCare Plan B Services to a Long-Term Care Facility form and a copy of the licence.