Medicare RX Update Archive 2007
Click on the date to read that date's Medicare RX Update.
Sign up for the PHARMACY_MMA-L list to receive the Medicare Rx UpdateMonday January 1, 2007
Part D Vaccine administration... change effective January 1, 2007Wednesday, January 31, 2007
2007 Open Enrollment by the Numbers… Medicare Drug Plans Strong and GrowingThursday, February 08, 2007
Medicare Part D Generic Drug Utilization Rates Continue to Rise…Monday May 14, 2007
2008 Part D Vaccine Administration Policy is Final…Tuesday May 15, 2007
DMEPOS Competitive Bidding Opens Today…Monday May 21, 2007
CMS Proposes Part D Compliance regulation…Thursday May 24, 2007
CMS Releases NPI Data Dissemination Policy…Wednesday May 30, 2007
CMS Issues Clarification Regarding March 31 Coverage Year Deadline...Tuesday June 12, 2007
NPI Data Dissemination Roundtable on June 14th… Register today
Part D Vaccine administration... change effective January 1, 2007
Late Friday, all Medicare Fiscal Intermediaries and/or Carriers were given instructions to implement Section 202(b) of the Tax Relief and Health Care Act of 2006 (TRHCA), which permits payment under Part B for administration of a Part D-covered vaccine. Effective January 1, 2007, payment may be made by DME MACs and DMERCs to pharmacies for the administration of Part D vaccines (See attached Change Request).
Specifically, payment under Medicare Part B may be made to a pharmacy for the administration of a Part D-covered vaccine furnished to a Medicare beneficiary during 2007, provided that on the date of service the pharmacy is enrolled with the National Supplier Clearinghouse and the beneficiary is enrolled in Medicare Part D.
Implications for pharmacies...
CMS has created a G code (G0377: Administration of vaccine for Part D drug) to be used for the administration of Part D-covered vaccines in 2007. The Part B allowed charge for G0377, effective for 2007, is $19.33. The Medicare payment would be 80% of that amount ($15.46, assuming the beneficiaries Part B deductible is met). The beneficiary would pay $3.87 as a co-insurance payment, plus any Part B deductible payment that may be due.
Because administration of vaccines is now a Medicare-covered service, pharmacies should not bill beneficiaries directly for administration of vaccines (except for Medicare co-insurance). Also, it is important to note that this CR addresses only Part D-covered vaccine administration fees and it does not address payment for a Part D-covered vaccine itself. Payment for Part D-covered vaccines is made solely by participating Part D Prescription Drug Plans.
S. Lawrence Kocot
Senior Advisor to the Administrator
Centers for Medicare and Medicaid Services (CMS)
Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201
2007 Open Enrollment by the Numbers… Medicare Drug Plans Strong and Growing
HHS Secretary Mike Leavitt yesterday announced that more than 1.4 million beneficiaries have enrolled in Medicare’s Part D program since June of 2006, bringing the total number of people with Medicare now receiving comprehensive prescription drug coverage to more than 39 million.
“Over 90 percent of all people eligible for the Medicare prescription drug benefit are receiving the prescription drug coverage they need and are leading healthier, better lives. It’s not surprising that five separate surveys show that more than 75 percent of beneficiaries are satisfied with the program” Secretary Leavitt said.
S. Lawrence Kocot
Senior Advisor to the Administrator
Centers for Medicare and Medicaid Services (CMS)
Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201
Medicare Part D Generic Drug Utilization Rates Continue to Rise…
More Americans are cutting their prescription drug costs by switching to generic medications. New data from the Centers for Medicare & Medicaid Services (CMS) indicates that generic use is especially high among those in the new Medicare drug benefit, with generic dispensing surging to 61% of all reported Medicare prescriptions in the third quarter and accounting for nearly 60 percent (59.6 percent) of the drugs dispensed to people in Medicare Prescription Drug Plans (PDPs) and Medicare Advantage (MA) plans through the end of third quarter of 2006.
Generic medications are as effective as their brand-name counterparts and offer significant savings. In addition, for enrollees in the Medicare drug benefit concerned about the coverage gap, generics can lower one’s costs and thus delay reaching the gap or help avoid it altogether.
According to the National Association of Chain Drug Stores (NACDS), generic utilization in private third-party plans has increased by 9 percent over the past year—from 48.4 percent in 2005 to 52.6 percent in 2006. The most recent CMS data demonstrate that generic dispensing to those enrolled in the Medicare drug benefit is 13 percent higher than generic utilization rates reported for private third-party plans, demonstrating that the Part D program is delivering savings well above the national average to beneficiaries and the government alike.
According to CMS Acting Administrator Leslie V. Norwalk, “Generics are as effective as more expensive brand-name drugs in treating chronic conditions and other health-care problems. That is why a growing number in Medicare and elsewhere are asking their doctors and pharmacists about this alternative. With tools such as the Medicare Plan Finder and the ‘Medicare and You’ handbook, CMS is helping people better understand how they can save even more with generics, and to find the plans that cover the medications they need.”
Assisting Low-Income Medicare Beneficiaries is an Ongoing Task …
Without question, Part D has been a positive change to the lives of Medicare beneficiaries; especially for the people who receive the Medicare Low Income Subsidy. CMS has taken a pro-active approach in reaching out to every low-income Medicare beneficiary to be sure they have access to the drug benefits to which they are entitled. However, despite many successes, some beneficiaries who received extra help in 2006 did not automatically qualify in 2007…and other low-income beneficiaries have yet to enroll in any Part D plan to date.
CMS has taken more steps to support low-income beneficiaries in 2007 including waiving the late enrollment penalty in 2007 for low-income beneficiaries and creating a special enrollment period from January 1 through March 31, 2007 for people who qualified for extra help in 2006 but no longer qualify in 2007. Additionally, we recently developed a Pharmacist LIS Tip Sheet to support pharmacists who are assisting beneficiaries with the LIS application process. As a primary source of information and assistance for low-income beneficiaries, pharmacists are encouraged to continue assisting low-income beneficiaries with completing and submitting applications for extra help.
NPI: Get It. Share It. Use It…
To date, over 1.6M providers have obtained an NPI. A recent survey of the health care industry, conducted by the Workgroup for Electronic Data Interchange (WEDI), indicates that providers should have already obtained an NPI and be focusing on implementation and testing with health plans and clearinghouses. If you have not obtained your NPI by now you should do so immediately so that you can begin the implementation and testing process. More information and education on the NPI can be found at the CMS NPI page www.cms.hhs.gov/NationalProvIdentStand. Providers can apply for an NPI online at https://nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at 1-800-465-3203.
S. Lawrence Kocot
Senior Advisor to the Administrator
Centers for Medicare and Medicaid Services (CMS)
Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201
2008 Part D Vaccine Administration Policy is Final…
The Tax Relief and Health Care Act of 2006 (TRHCA) modified the definition of a Part D drug to include “for vaccines administered on or after January 1, 2008, its administration.” CMS released detailed operational guidance today related to administration fees for Part D vaccines in 2008. This presents an opportunity for pharmacists to play an expanded role in vaccine administration for Medicare Part D beneficiaries in 2008. Please see the attached paper (MemoVaccineAdministration_05.14.07.pdf) to review the policy.
S. Lawrence Kocot
Senior Advisor to the Administrator
Centers for Medicare and Medicaid Services (CMS)
Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201
DMEPOS Competitive Bidding Opens Today…
CMS announced today that the Agency is now soliciting bids for the first round of the Medicare competitive bidding program for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). All bids are due by 9:00 p.m. E.S.T. on July 13, 2007.
For each competitive bidding area under the program, CMS has issued a detailed chart providing important bidding information for suppliers. Suppliers should use these charts when preparing their bids. The competitive bidding areas, product categories, bidding information charts, and full instructions for submitting a bid are located on the Competitive Bidding Implementation Contractor (CBIC) web site at www.dmecompetitivebid.com. Additionally, information about the types of suppliers each accrediting organization is approved to accredit and how to contact an accrediting organization is posted on the CMS website at www.cms.hhs.gov/CompetitiveAcqforDMEPOS/.
S. Lawrence Kocot
Senior Advisor to the Administrator
Centers for Medicare and Medicaid Services (CMS)
Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201
CMS Proposes Part D Compliance regulation…
CMS today issued a proposed regulation to strengthen its oversight of Medicare Advantage plans and Part D prescription drug plans. “Medicare managed care plans and prescription drug plans have been very popular among older, disabled, low income and minority Americans,” Acting Administrator Leslie Norwalk said. “With a growing program, it is important to ensure that the plans under contract to Medicare meet the high standards necessary to handle the health care needs of Medicare beneficiaries.”
…and Part D Technical Corrections regulation
CMS also released a proposed regulation that makes certain technical corrections and clarifications to the Part D prescription drug benefit final implementing regulations, published on January 28, 2005. CMS proposes, effective, 2009, to refine certain rules relating to the determination and reporting of prescription drug costs. CMS is also proposing to update the requirements of Part D sponsors to ensure adequate access to home infusion pharmacies.
Each of the proposed regulations will be posted shortly on this webpage.
Reminder: Get your NPI… now
Most HIPAA Covered entities must be in compliance with the NPI provisions by May 23, 2007. The NPI must be used by covered entities to identify providers on all HIPAA covered transactions that call for health care provider identifiers (see guidance on compliance with the NPI rule). CMS hopes all covered entities will voluntarily comply with the law; as we have communicated, CMS intends to use a complaint-driven approach for enforcement.
Plans that have been making a good faith effort to comply with the NPI provisions may, for up to 12 months, implement contingency plans that could include accepting legacy provider numbers on HIPAA transactions in order to maintain operations and cash flows. CMS expects plan sponsors to urge their contract providers who have not yet done so to obtain and use NPIs…and we will continue to monitor Part D sponsor compliance with the NPI requirements.
Applying for the NPI is easy. To apply online, just visit CMS’ National Plan and Provider Enumeration System (NPPES) website. The estimated time to complete the online NPI application form is only about 20 minutes. For more information, please visit the CMS NPI Standard website.
S. Lawrence Kocot
Senior Advisor to the Administrator
Centers for Medicare and Medicaid Services (CMS)
Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201
CMS Releases NPI Data Dissemination Policy…
CMS has placed on display its notice outlining how pharmacists and other providers may access NPIs and other information required to be disclosed under the Freedom of Information Act (FOIA). CMS expects this National Plan Provider Enumeration System (NPPES) Data Dissemination Notice to be published at the Office of the Federal Register on May 30th. NPI information will be made publicly available on June 28.
All health care providers who have been assigned NPIs are encouraged to review their NPPES data and make any necessary corrections prior to the end of the 30-day period to ensure that their information is accurate when disclosed by CMS. The list of data elements that will be disclosed is included in the Notice. We will not be disclosing a health care provider’s Social Security Number (SSN), Internal Revenue Service (IRS) Individual Taxpayer Identification Number (ITIN), or date of birth. Providers who wish to delete any NPPES data that was not required to be furnished in order to obtain an NPI may do so prior to the end of the 30-day period if they prefer that those data not be disclosed by CMS.
… with more NPI information to come
CMS will post an announcement on the CMS NPI web page that will contain the locations of the downloadable files and the query-only database. The data will be available free of charge in an initial file downloadable from the Internet, with monthly update files also downloadable from the Internet, and in a query-only database whereby users can query by NPI or provider name. However, entities who would like more or less data than what are available in the downloadable files or in the query-only database, or who would like data in different formats or on different media, must submit requests under the FOIA to the CMS FOIA Office either in writing or by fax machine. There may be a charge to the requester for CMS to furnish data under FOIA.
DMEPOS Competitive Bidding Program… Bidder’s Conferences now scheduled
CMS announced the scheduling of a series of bidders conferences for those suppliers interested in participating in the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program. These conferences are designed to assist suppliers through the bidding process. They will be conducted via teleconference and will provide an opportunity for suppliers to learn more about the program. Each call will last approximately one hour, including time for questions and answers. There is no charge for these teleconferences.
To register for these conferences, please go to the Competitive Bidding Program website. Questions may be submitted ahead of time when registering for the conference.
S. Lawrence Kocot
Senior Advisor to the Administrator
Centers for Medicare and Medicaid Services (CMS)
Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201
CMS Issues Clarification Regarding March 31 Coverage Year Deadline...
CMS recently issued guidance to all Part D sponsors clarifying Plan liabilities for claims received after March 31, 2007. In the guidance, CMS notes "it is important to distinguish cut-off dates for the submission of claims associated with payment reconciliation from the liability for payment of claims arising as a result of coordination of benefit situations." Furthermore, "beneficiaries and other parties...are entitled to reimbursement by the plan under Part D coordination of benefit requirements regardless of CMS payment reconciliation timeframes." Therefore, "a March 31st deadline cannot be used as a barrier to payer requests for reimbursement of claims incurred during periods covered by the retroactive enrollment."
Additionally, "It is important to note also that plans are liable for claims received after March 31st even in those instances when retroactive enrollment is not an issue. While in these instances contractual provisions regarding timely claims filing may limit claims from network pharmacies, non-network pharmacies must still have the opportunity to submit claims for reimbursement." Please see the attached document (Retroactive Enrollments 052507.pdf) outlining our policy in full and providing several frequently occurring scenarios to further clarify how the special transition period policy should be applied in retroactive enrollment situations.
S. Lawrence Kocot
Senior Advisor to the Administrator
Centers for Medicare and Medicaid Services (CMS)
Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201
NPI Data Dissemination Roundtable on June 14th… Register today
CMS will host a national roundtable on the NPI Data Dissemination Notice on June 14, 2007 from 2-3:30 PM EDT. Visit the CMS website for registration details. Registration will close at 2:00 p.m. EDT on June 13, 2007, or when available space has been filled. Additionally, CMS has posted new FAQs related to the recently published Data Dissemination Notice. To view these FAQs, go to the CMS dedicated NPI web page. Scroll down to the section that says “Related Links Inside CMS” and click on NPI Frequently Asked Questions. Providers can apply for an NPI online at or can call the NPI enumerator to request a paper application at 1-800-465-3203.
S. Lawrence Kocot
Senior Advisor to the Administrator
Centers for Medicare and Medicaid Services (CMS)
Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201