Relating to the determination of fees, charges, and rates for certain benefits under Medicaid.

Contracts

• PBM & MCO Agreements: Review "Usual and Customary" definitions in current PBM/MCO provider manuals. Most contracts define U&C as the "lowest price available." While state law supersedes these contracts, you must notify payers that your U&C calculation methodology is changing pursuant to HB2402 to prevent automated audits or breach of contract notices.
• Software Vendor SLAs: Update agreements with billing software vendors or switch intermediaries. They must reprogram claims logic to segregate "fee-based membership" transactions from the standard U&C dataset.

Hiring/Training

• Billing Staff: Train staff to distinguish between fee-based memberships (protected under HB2402) and free loyalty programs (not protected). Including free loyalty prices in your exclusion logic could lead to False Claims Act liability.
• Audit Defense: Compliance officers must prepare a "defense file" proving that excluded rates were accessible *only* via a paid membership fee.

Reporting & Record-Keeping

• Claims Submission: Modify the algorithm used to populate the U&C field on Medicaid claims. You must filter out subscription-based transactions before the claim is generated.
• Program Documentation: Maintain distinct ledgers showing membership fee revenue. You must prove the "club" price is a distinct class of trade contingent on a fee, not the general prevailing rate.

Fees & Costs

• Revenue Impact: Positive. Correct implementation prevents revenue leakage by ensuring Medicaid reimburses at your standard rate, not your discounted club rate.
• Implementation Cost: Low to Moderate (software reconfiguration).