8.7 Capitation Fees for Plan B (Residential Care)

General Policy Description

PharmaCare Plan B covers British Columbians who are permanent residents of residential care facilities licensed under the Community Care and Assisted Living Act and patients of hospitals licensed under Part 2 of the Hospital Act.

Policy Details

PharmaCare Plan B covers British Columbians who are permanent residents of residential care facilities (excluding extended-care, acute-care, multi-level and assisted living facilities) that are licensed under the Community Care and Assisted Living Act.

Each residential care facility is served by one contracted pharmacy.

To receive payment of claims for services to a residential care facility, a pharmacy must be enrolled with PharmaCare in the plan sub-class. See the PharmaCare Provider Enrolment Guide for more information.

Pharmacies servicing residential care facilities provide residents with medications packaged in a monitored dosage system.

PharmaCare pays a monthly payment (capitation fee) to pharmacies that are contracted to provide service to a residential care facility for each bed occupied by a patient receiving Plan B coverage. See Related Services List for what is included in the capitation fee.

At the end of each month, PharmaCare pays the contracted pharmacy a fixed fee, called a capitation rate, for each bed that

  • The pharmacy has serviced, regardless of the level of service provided, and
  • Was occupied by a recipient of PharmaCare Plan B coverage

PharmaCare pays a capitation fee of $43.75 per serviced bed occupied by a patient receiving coverage under PharmaCare Plan B.

Payments are per serviced bed, regardless of the different residents who may have occupied it during the month.

Plan B capitation rates are paid in addition to eligible drug costs.

Calculation of capitation rates is based on the actual occupancy of the residential care facility (i.e., the actual number of occupied beds for the month), not on the maximum licensed capacity of the facility.

Capitation fees are not made for short-term (“respite”, “swing”, or “temporary”) patients in a facility. Claims for pharmacy services for respite patients must be made under Fair PharmaCare or Plan C, depending on each patient’s eligibility.

Plan B payments are monitored. Any over-payment in a given month will be recovered. 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 were made on the invoice) for each month must be retained on file by the pharmacy in accordance with the Audit Policy.

No dispensing fees or special services fees are paid for Plan B patients. These are already covered by the capitation fee.

Pharmacists may charge a fee for administering a publicly funded vaccine to a Plan B patient. For details, see Section 8.10 - Payment for Publicly Funded Vaccinations.

The British Columbia PharmaCare Pharmacy Agreement for the Provision of PharmaCare Services to Long Term Care Facilities signed for residential care is valid only for the licensed facility named in the agreement.

In the event of a change in the facility licence or licensee (e.g., a change in facility name, address, etc.), the pharmacy must

  • Obtain a new “Appointment of Pharmacy Services” agreement from the facility; and
  • Sign a new British Columbia PharmaCare Pharmacy Agreement for the Provision of PharmaCare Services to Long Term Care Facilities

If there is a change of administration at a residential care facility, the facility must

  • Provide the pharmacy with a new “Appointment of Pharmacy Services” agreement

 

Procedures for Pharmacies

Submit only one invoice per pharmacy per month for Plan B capitation rates (i.e., all contracted care facilities must be claimed on the same invoice). Multiple invoices cannot be processed.

Invoices for Plan B must be submitted regularly, on a monthly basis, using PharmaCare Prescription Invoices.

>> To order additional Invoices, contact the PharmaNet Help Desk.

Submit Plan B monthly invoices to PharmaCare at or near the end of each month. This ensures that the information on the number of occupied and serviced beds for the month is accurate.

 

  1. On a PharmaCare Prescription Invoice, complete the following:
    • Pharmacy identification (i.e., name and address of the pharmacy)
    • Current date
    • Number of claims submitted (i.e., number of claimed beds)
    • Pharmacy code
    • Total $ amount invoiced.
       
  2. Write "Nursing Home Beds" at the top of the invoice.
  3. Write the month to which the invoice applies at the top of the invoice.

    This is necessary as the "Current Date" in step 1 does not always reflect the month of service.
     
  4. Sign the invoice and include your position in the pharmacy.

    Unsigned invoices will be returned by PharmaCare without payment.
     
  5. Mail the invoice to the PharmaCare Information Support.

 

Tools and Resources

For questions about Plan B billings, contact PharmaCare Information Support at Health Insurance BC.

To order PharmaCare Prescription Invoices, contact the PharmaNet Help Desk and provide your Site ID.