Final Rule for Medicare Prescription Drug Benefit Program Coordination Requirements

Where has the summer gone? When you get your formulary submission approval email, you breathe a sigh of relief and can relax for…a second. It’s time to start planning for Part D Readiness and Benefit Administration testing so when November 15 arrives, you are well on your way to having those completed.

For Medicare Advantage plans, the heat is on for point of sale Part B versus Part D determinations. The regulation set to take effect on January 1, 2016, follows:

Final Rule, MA, PDP, CMS-4159-F2

MA-PD Coordination Requirements for Drugs Covered under Parts A, B, and D – The Centers for Medicare & Medicaid Services (CMS) acknowledges beneficiary access to needed drugs is impeded when a Medicare Advantage Prescription Drug plan (MA-PD) does not properly adjudicate claims for drugs that may be covered under Part A or B, rather than Part D, at the point of sale (POS). Thus, CMS is requiring MA-PDs to establish and maintain a process to ensure appropriate payment is assigned at the POS. If a denial under Part D is based on the existence of coverage under Parts A or B, the MA-PD plan should authorize or provide the drug under that other benefit without requiring the enrollee to make a subsequent request for coverage under that other benefit. According to the preamble of the final rule, CMS is amending 42 CFR §422.112(b)(7) to “require MA-PDs to coordinate with their network pharmacies and prescribers to improve existing processes and develop new ones in order to ensure that enrollees receive their Medicare-covered prescription medications, without delay, when they present at the network pharmacy.” While CMS did not include beneficiary advocates’ request to require plans to treat a POS claim transaction as a request for a coverage determination under Part D, this new rule should nonetheless improve coordination of and access to drug coverage for MA-PD enrollees.

Benefit administration testing is a relatively inexpensive insurance policy for 2016. Picture yourself on January 1 watching the adjudication system paying claims, adhering to the CMS-submitted benefit parameters, and no calls to 1-800-MEDICARE. That could be your experience with the enhanced benefit administration testing expertise GHG employs. We use a set of approximately 100 specific parameters against which to test approximately 1,000 claims. When we find issues, we work with you and your Pharmacy Benefit Manager (PBM) to get them resolved BEFORE live claims start rolling in on January 1. The countdown is on—123 days until January 1!

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This blog was originally posted on blog.gormanhealthgroup.com.

John Gorman: Under John’s leadership, Gorman Health Group has become the leading professional services and solutions firm for government-sponsored health care, providing thought leadership and expert strategic, operational, and technology-based solutions. Read more.