8.7 Capitation and GeoMod Fees for Plan B (Long-term Care)

General Policy Description

PharmaCare Plan B covers B.C. residents who are permanent residents of long-term care (LTC) facilities licensed under the Community Care and Assisted Living Act and residents of hospitals licensed under Part 2 of the Hospital Act.

To claim services under Plan B, pharmacies that are contracted to provide services to a Plan B LTC facility must be enrolled in PharmaCare's Plan B sub-class. They claim the Plan B monthly capitation fee for services provided to each bed occupied by a Plan B resident, and the monthly Geographic Modifier (GeoMod) fee if the facility is in an area with lower population density as defined by PharmaCare.

Policy details

Eligible facilities

LTC facilities that are licensed under the Community Care and Assisted Living Act, and hospitals licensed under Part 2 of the Hospital Act (excluding extended care, acute care, multi-level and assisted living facilities) are eligible for enrolment in PharmaCare Plan B.

Each facility is served by one contracted pharmacy.

To receive payment for services to a Plan B facility, a pharmacy must be enrolled with PharmaCare in the Plan B pharmacy sub-class and have completed the Request for PharmaCare Plan B Services to a Long-term Care Facility form (contact the PharmaCare Help Desk for the form). Refer to the PharmaCare Provider Enrolment Guide for more information. 

Contracted pharmacies

Each month, PharmaCare pays the contracted pharmacy a capitation fee for each bed:

• That the pharmacy serviced, regardless of the level of service provided, and
• That was occupied by a recipient of PharmaCare Plan B coverage

A GeoMod fee is also paid when the bed is in a facility that is in an eligible Community Health Service Area (CHSA) as defined by PharmaCare.

Capitation fees and GeoMod fees are based on the actual number of occupied beds, not on the maximum licensed capacity of the facility. Payments are per serviced bed, regardless of whether different residents have occupied a bed during the month. 

Capitation fees and GeoMod fees are not paid for individuals receiving short-term care services, e.g., temporary, respite, convalescent, residential hospice palliative, or swing beds. Claims for pharmacy services for people receiving short-term care must be made under their primary PharmaCare plan (e.g., Fair PharmaCare (Plan I), Plan C, or Plan G).

All PharmaCare payments are subject to audit by the Ministry of Health. All supporting documentation for Plan B invoices (e.g., working papers, prescriptions, authorizations, and the PHN list for which claims where made on the invoice) must be retained on file by the pharmacy in accordance with Section 10.1 – PharmaCare Audit Policies. Any over-payment in a given month will be recovered. 

Capitation fee

PharmaCare pays a monthly capitation fee to pharmacies contracted to provide service for a long-term care facility for each bed occupied by a resident receiving Plan B coverage. Refer to the Related Services List for what is included in the capitation fee. 

Pharmacies servicing long-term care facilities provide residents with medications packaged in a monitored dosage system. 

No dispensing fees or special services fees are paid for Plan B residents. The dispensing fee, medication review services, and special services/professional intervention fees are covered by the capitation fee. 

Pharmacists may charge a fee for administering a publicly funded vaccine to a Plan B resident, as per Section 8.10 – Pharmacist Administration of Drugs and Vaccines. 

The capitation fee is $65 per bed per month and paid in addition to the GeoMod fee and eligible drug costs. 

Geographic Modifier (GeoMod) fee

The GeoMod fee is claimed for beds occupied by a Plan B resident in a facility located in a Community Health Service Area (CHSA) defined as remote, rural, rural hub, small urban, or medium urban. Only pharmacies serving facilities located in these areas can claim the fee. 

The GeoMod fee is $15 per occupied bed per month, and is paid in addition to the capitation fee and eligible drug costs. 

Refer to Plan B Geographic Modifier program for the locations of facilities currently eligible for GeoMod fees. 

Changes in facility licence, licensee or administration

In the event of a change in the facility licence or licensee (e.g., a change in facility name, address, etc.), the pharmacy must complete the Request for PharmaCare Plan B Services to a Long-term Care Facility form (contact the PharmaCare Help Desk for the form).

Procedures for pharmacies

Invoicing

Invoices for Plan B must be submitted monthly using the PharmaCare Prescription Invoice (HLTH 5335). Order invoices by contacting the PharmaCare Help Desk.

Submit only one invoice per pharmacy per month for Plan B capitation fees and, if applicable, GeoMod fees, for all contracted care facilities. All contracted care facilities must be claimed on the same invoice, as multiple invoices cannot be processed. 

Submit Plan B monthly invoices to PharmaCare at or after the end of each month to ensure that the count of occupied and serviced beds for the month is accurate. 

Completing the PharmaCare Prescription Invoice

1. At the top of the invoice, write "Plan B long-term care beds" and the current date. 

2. In the identification section on the left, write:

• The name and address of the pharmacy
• The pharmacy code
• The number of claims (i.e., number of claimed beds). Make separate lines for the number of beds eligible for the capitation fee and beds eligible for the GeoMod fee, if applicable. For example:

Plan B GeoMod beds ($65 + $15) x 130 = $10,400
Plan B beds that are not GeoMod ($65) x 320 = $20,800
Total beds: 450

​3. Sign the invoice and include your position in the pharmacy. Unsigned invoices will be returned by PharmaCare without payment. 

4. Mail the invoice to:

PharmaCare Help Desk
PO Box 9655 Stn Prov Govt;
Victoria BC V8W 9P2

Sample invoice: