Medicare

 

What Every Pharmacist Should Know about Medicare Part D
 

First and foremost, it is important to realize that Medicare Part D – the prescription drug benefit – is here -- effective January 1, 2006.  It redefines much of the way retail pharmacy operates and the profession of pharmacy.  The best thing a pharmacist can do is be prepared and explore opportunities to make the most of the changes.

Information will be regularly added to this website.  Plan to check it regularly!

Medicare Prescription Drug Updates

In the next few days, pharmacists will inevitably have to serve some Medicare beneficiaries who have enrolled in a plan or switched plans late in February. As a result, some of these beneficiaries may not yet be identified in pharmacy systems. As a reminder to pharmacists, we are once again sending instructions for using the eligibility (E1) functionality to check on plan enrollment and Medicare eligibility status. Per-Se Technologies has issued recommendations for optimizing the E1. For more information you may visit their Medicare Part D home page, or contact your software vendor. For beneficiaries who are eligible for both Medicare and Medicaid but who do not appear to have been enrolled in a plan, we are also sending instructions for using the Point of Sale Facilitated enrollment process. This process, known as the "Wellpoint Point of Sale solution," will allow pharmacies to submit claims to Wellpoint for a dual eligible beneficiary who does not appear to be enrolled in a plan so the beneficiary will not have to leave the pharmacy without the medications they need. An FAQ document and instructions, can be found at Anthem Prescription's Part D home page.

Medicare Part D/B Helpful Documents

CCRx Memos

Humana Bulletins

What each and every pharmacist should do - Six Key Steps 

1)   Be prepared -- Focus on learning as much as possible about the Benefit.  You only have a few days – so start NOW!

  • Go to CMS website with Information for Providers.  Read the articles in the Drug Coverage Series.  They are relatively short - 2 to 3 pages.

  • Visit the CMS specific section for Pharmacists.

  • CMS has posted additional information about the new benefit including an educational video tool specifically for pharmacists that can help answer questions about implementation.  The video tool as well as additional information is now available on the CMS website (http://new.cms.hhs.gov/PrescriptionDrugCovGenIn/).  The video covers details on the new E1 eligibility transaction, instructions on billing for Katrina evacuees and facilitated point of sale enrollment of dual eligibles, as well as other pharmacy related topics of interest.  

  • Save this list of key terminology to help you understand the benefit

  • The Pennsylvania Pharmacists Association has added an additional list of key terminology. 

  • Here is a list of terms to help in talking to patients about the Part D Benefit.

  • CMS offers an acronym search engine here. 

  • VPhA has a list of continuing education courses so you can earn CE while learning about the benefit.

  • Bookmark key websites.  So you can check for additional information frequently.

  • Frequently Asked Questions are available from CMS that are updated frequently.   

  • Consider participating in CMS Open Forums to hear from and ask questions of CMS leadership on topics of interest to your particular provider type; for information about these forums visit http://new.cms.hhs.gov/OpenDoorForums/. 

  • Sign-up to receive email notification of new information for pharmacies and pharmacists about the Medicare Modernization Act and Medicare Prescription Drug Coverage. Click here for access and to sign up for the CMS mailing list.

2)  Specifically understand the low income benefit and promote it to seniors who may qualify.  Seniors who may qualify for this need to apply NOW!             

3) Determine to what extent your pharmacy might be ready and interested in providing Medication Therapy Management Services (MTMS).             

4) Work with your Medicare eligible patients to promote plans that will work for both them and your pharmacy.

  • The Prescription Drug Plan Finder is available online at the Medicare.gov website.  With this tool, you can help beneficiaries list their drugs and search for appropriate plans.  
  • CMS has posted the Landscape of Local Plans (PDPs and MA-PDs) available for all states. 

  • Final Marketing Guidelines  (11/1/05)

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  • Overall Fact Sheet for Beneficiaries

  • Low Income Application (provided with the notices mailed out - per section 2 above)

  • Promotional Opportunities - Posters titled "Have Low Income? Social Security Can Help with Prescription Costs" can be ordered free of charge on the Centers for Medicare and Medicaid Services (CMS) website.  The posters direct Medicare beneficiaries with low income to a toll free number where they can find out if they are eligible for help with prescription drug costs. The posters are suitable for display in a pharmacy, Order the size and style appropriate for your use. To view and order the posters, go to http://www.cms.hhs.gov/medlearn/drugcoverage.asp on the CMS website.      

  • Review the scripts being used by 1-800-MEDICARE.  These scripts are posted for your reference and to understand what call center customer service representatives are telling beneficiaries.  As the scripts are modified, updates will be posted to this website.  You can find the scripts at http://new.cms.hhs.gov/partnerships/downloads/scripts.pdf  on the CMS website.

5)  Get your NPI as an individual pharmacist

  • CMS is pleased to announce the availability of a new identifier for use in the standard electronic health care transactions. The National Provider Identifier (NPI) will be the single provider identifier, replacing the different provider identifiers currently in use for each health plan with which they do business.  Obtaining the NPI is required in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and will be the single national provider identifier for pharmacists, pharmacies, and prescribers no later than May 23, 2007.

    National standards for electronic health care transactions encourage electronic commerce in the health care industry and simplify the processes involved to reduce the administrative burdens on health care providers.  A May 6th letter (linked below) was distributed to aid in understanding the background of this requirement & what steps are necessary to apply for and receive your NPI.   http://www.cms.hhs.gov/hipaa/hipaa2/npi_provider.asp     or go directly to https://nppes.cms.hhs.gov/

Obtaining your NPI is recommended for individual pharmacists now.  Pharmacies may wish to hold off on this process

  • Pharmacists: The NPI is the first opportunity for pharmacists to have an individual provider number with which to bill third parties.* This includes billing prescription drug plans (PDPs) for medication therapy management services (MTMS) under the Medicare Part D drug benefit.  Pharmacists are encouraged to obtain an individual NPI. This is a new opportunity for pharmacists. The provider identifier number does not guarantee that payment will be provided, but may be required by payers in the future.              
  • Pharmacies:  For pharmacies, the NPI will replace all other provider identifiers, for example, such as the NCPDP pharmacy ID number, formerly the NABP number presently required by health plans.  Before you pursue a NPI for your pharmacy, you should be aware of an upcoming initiative by the National Council for Prescription Drug Programs (NCPDP). Under NCPDP’s guidance, the pharmacy industry is currently developing a transition plan to move pharmacies from the NCPDP number to the NPI over the next two years. NCPDP plans to submit its application to CMS to be a bulk NPI enumerator in late summer. Once its application is approved, NCPDP will contact pharmacies and request authorization to become their agent in obtaining their NPI. NCPDP will then work with CMS and obtain NPIs for all authorizing pharmacies no later than May 2006, giving processors and pharmacies a full year to test and implement the NPI before the required implementation date of May 23, 2007.  NCPDP requests that you delay your pharmacy’s application for an NPI until this fall when NCPDP has been certified to obtain NPIs on behalf of pharmacies. If you authorize NCPDP to obtain a NPI on behalf of your pharmacy, your new NPI and current NCPDP number will automatically be disseminated to the pharmacy industry (including payers). This will ensure your claims process normally with minimal disruption. NCPDP will not charge any fees for its enumeration activities on your behalf. For more information on this initiative, visit http://www.ncpdp.org or read this NPI Enumeration update (added 12/7/05) from NCPDP.

  • Pharmacies and individual pharmacists are advised in CMS’s NPI letter not to use the NPI until health plans and PDPs have issued specific instructions on accepting the NPI, which could begin prior to but no later than May 23, 2007.

  • Beginning May 1, 2006, the Centers for Medicare & Medicaid Services (CMS) announces the capability for health industry organizations to submit health care providers' applications for National Provider Identifiers (NPIs) to the National Plan and Provider Enumeration System (NPPES) via Electronic File Interchange (EFI). With EFI, a CMS-approved health industry organization can submit a health care provider's NPI application data, along with the application data of many other health care providers, in a single electronic file in a CMS-specified format.

    EFI is an alternative to health care providers having to apply for their NPIs via the web-based or paper application process. After the NPPES processes a file, it makes available to the organization a downloadable file containing the NPIs of the enumerated health care providers. Interested health industry organizations should avail themselves of the EFI materials available from the CMS NPI page (www.cms.hhs.gov/NationalProvIdentStand/) and from the NPPES page (https://nppes.cms.hhs.gov) before downloading and completing the Certification Statement (available at https://nppes.cms.hhs.gov) and registering as EFI Organizations. A completed Certification Statement must be approved by CMS before an interested health industry organization can participate in EFI.

6) Medicare Updates

Patient Assistance Programs

On Wednesday, the Centers for Medicare & Medicaid Services posted on its website guidance outlining how pharmaceutical company patient assistance programs can work with Medicare Part D in light of a recent Office of the Inspector General Bulletin (November 22, 2005). 

There is nothing in the law that prohibits a pharmaceutical company from making a patient assistance program available to Medicare beneficiaries -- even beneficiaries who have enrolled in a Part D plan.  The decision to keep a patient assistance program, as well as the terms of the program, are up to the pharmaceutical company, not the US government.  However, any assistance provided to a Part D enrollee must be clearly outside of the Medicare Part D program and would not count as Part D "true out-of-pocket" spending by the beneficiary.   CMS will work with companies interested in entering into a voluntary data sharing arrangement with CMS, in accordance with the OIG guidance, to facilitate coordination of benefits.  Pharmaceutical companies also have the option to make cash donations to bona fide, independent charities that assist Medicare beneficiaries with out-of-pocket drug expenses. 

CMS understands the value that pharmaceutical patient assistance programs provide to many financially needy individuals, including those with Medicare.  Individuals currently without drug coverage who are eligible for Medicare should consider enrolling in a Medicare prescription drug plan that meets their needs.  In addition, beneficiaries who think they may be eligible for extra help may file an application with the Social Security Administration for the Part D limited-income subsidy.  These steps will ensure that people have access to the prescriptions they need.

The guidance, which provides more detail about this issue, as well as an example of how this would work for a Medicare beneficiary can be accessed by clicking on the link below.

http://www.cms.hhs.gov/PrescriptionDrugCovGenIn/05_Pharma.asp#TopOfPage

Provider Update

Also, attached is a letter from HHS' Physicians' Regulatory Issues Team with valuable information for providers about how to assist beneficiaries with appeals, coverage determinations and exceptions as well as other general information about Medicare Prescription Drug Coverage.  Providers Letter

 

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