Health Insurance Report™ helps you track and analyze legal, legislative, and regulatory developments affecting the health-insurance industry throughout implementation of the Affordable Care Act...
May 1 — The Centers for Medicare & Medicaid Services May 1 allowed some providers who aren't enrolled in Medicare to prescribe medications for enrollees in the Part D prescription drug benefit, after concerns that beneficiaries would be harmed if turned away at the drugstore counter.
The interim final rule with comment period will allow beneficiaries to continue receiving medications prescribed by professionals who are prevented from enrolling in or opting out of Medicare but who may prescribe under state law.
The rule is scheduled to be published in the May 6 Federal Register, and comments will be accepted until July 6.
The latest regulation makes some changes to a provision in a final rule published in May 2014 that required a Part D sponsor to deny claims if the physicians or other eligible professionals who wrote the prescriptions weren't enrolled in Medicare or didn't have a valid record of opting out. At the time, the Medicare agency said requiring Part D sponsors to deny pharmacy claims from these prescribers would “help CMS ensure that Part D drugs are only prescribed by qualified individuals”.
Medicare plan industry representatives had expressed concern that enrollees would be harmed if their claims were rejected.
In the interim final rule, the agency said that it has since “learned that certain pharmacists and other provider types who do not meet the statutory definitions of ‘physician' or ‘eligible professional' to enroll in Medicare are permitted to prescribe under state laws.” However, “without further action by CMS, valid prescriptions from these providers would be denied because the prescriber is neither enrolled in nor opted-out of Medicare.”
To prevent interruptions in coverage and harm to beneficiaries, the CMS said it would require that pharmacy claims and beneficiary requests for reimbursement for Medicare Part D prescriptions, written by prescribers other than physicians and eligible professionals who are permitted by state or other applicable law to prescribe medications, not be rejected at the point of sale.
The May 2014 rule had been effective as of June 1, 2015, although the CMS later said it would delay enforcement until Dec. 1, 2015.
The May 2014 requirements are now applicable on Jan. 1, 2016, at which point a Part D plan sponsor must reject, or require its pharmaceutical benefit manager to reject, a pharmacy claim for a Part D drug unless the claim contains the prescriber's National Provider Identifier (NPI), the CMS said.
The agency said it assumes that, as of Jan. 1, 2016, 250,000 prescribers will still need to enroll in or opt out of Medicare to prescribe Part D drugs, and it urged them to submit their enrollment applications as soon as possible.
On a related issue under the interim final rule, plans must allow a provisional supply of three months when a prescription is written by a prescriber who is eligible to enroll but who isn't enrolled in or opted out of Medicare. The plan must also provide individualized written notice to the beneficiary that the supply is being provided on a provisional basis.
The three-month provisional fill is intended to give the prescriber time to enroll or the beneficiary time to find a new prescriber, the CMS said.
To contact the reporter on this story: Mindy Yochelson in Washington at email@example.com
To contact the editor responsible for this story: Ward Pimley at firstname.lastname@example.org
All Bloomberg BNA treatises are available on standing order, which ensures you will always receive the most current edition of the book or supplement of the title you have ordered from Bloomberg BNA’s book division. As soon as a new supplement or edition is published (usually annually) for a title you’ve previously purchased and requested to be placed on standing order, we’ll ship it to you to review for 30 days without any obligation. During this period, you can either (a) honor the invoice and receive a 5% discount (in addition to any other discounts you may qualify for) off the then-current price of the update, plus shipping and handling or (b) return the book(s), in which case, your invoice will be cancelled upon receipt of the book(s). Call us for a prepaid UPS label for your return. It’s as simple and easy as that. Most importantly, standing orders mean you will never have to worry about the timeliness of the information you’re relying on. And, you may discontinue standing orders at any time by contacting us at 1.800.960.1220 or by sending an email to email@example.com.
Put me on standing order at a 5% discount off list price of all future updates, in addition to any other discounts I may quality for. (Returnable within 30 days.)
Notify me when updates are available (No standing order will be created).
This Bloomberg BNA report is available on standing order, which ensures you will all receive the latest edition. This report is updated annually and we will send you the latest edition once it has been published. By signing up for standing order you will never have to worry about the timeliness of the information you need. And, you may discontinue standing orders at any time by contacting us at 1.800.372.1033, option 5, or by sending us an email to firstname.lastname@example.org.
Put me on standing order
Notify me when new releases are available (no standing order will be created)