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Medicare Part D December 1, 2005 PowerPoint Presentation
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Medicare Part D December 1, 2005

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Medicare Part D December 1, 2005 - PowerPoint PPT Presentation

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Medicare Part D December 1, 2005
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  1. Medicare Part D December 1, 2005 Neltner Billing & Consulting Services “We Bring The Pieces Together For You”

  2. NBC • Neltner Billing & Consulting Services, Inc. 6463 Taylor Mill Road Independence, KY 41051 (800) 676-7639 (859) 363-4900 www.neltnerbilling.com • Martin E. Neltner, President (859) 363-4981 office (859) 743-6192 cell mneltner@earthlink.net Neltner Billing & Consulting Services

  3. Billing Expertise • 41 practices, 139 physicians, 8 specialties in 16 states • Billing and coding • A/R management • Practice management • Process review and design • Forms development • Compliance audits and program development • Documentation review • Consulting, lobbying and advocacy Neltner Billing & Consulting Services

  4. Medicare Part D Neltner Billing & Consulting Services

  5. Part D • Medicare’s prescription drug benefit • Authorized by Section 101 of the MMA • Begins January 1, 2006 • Coverage • Prescription Drug Plans (PDPs) • Medicare Advantage (MA-PD) • Managed care plans • Includes a low-income benefit • Included in Stark prohibition Neltner Billing & Consulting Services

  6. Neltner Billing & Consulting Services

  7. Neltner Billing & Consulting Services

  8. Part D Enrollment • Initial enrollment period • Within 7 months of Medicare eligibility • Annual election period (11/15-12/31) • Special enrollment period (11/15/05 – 5/15/06) • Enroll by 12/31/05 for coverage to begin 1/1/2006 • Enroll after 12/31/05, coverage begins first of month following enrollment Neltner Billing & Consulting Services

  9. Resources • Beneficiary educational resources • www.medicare.gov • 1-800-MEDICARE • www.eldercare.gov • www.shiptalk.org • Find plans by state www.medicare.gov/medicarereform/map.asp Neltner Billing & Consulting Services

  10. Part D Plans • Part D plans required to have: • Drug utilization management program • Population-based quality assurance measures • Medication therapy management program • Optimizes therapeutic outcomes through providers working with targeted individuals • Consumer satisfaction surveys • Electronic prescription standards • Coverage determinations Neltner Billing & Consulting Services

  11. Part D Plans • Plans can vary by: • What prescription drugs are covered • How much the beneficiary pays • Which pharmacies the beneficiary can use • Some plans might offer: • More coverage • Additional medications • Higher premium Neltner Billing & Consulting Services

  12. Coverage • Covers drugs available only by prescription • Prescription drugs, biologicals, insulin • Medical supplies associated with injection of insulin • May not cover all drugs • Brand name and generic drugs will be in each formulary Neltner Billing & Consulting Services

  13. Covered Drugs • Cancer medications • HIV/AIDS treatments • Antidepressants • Antipsychotic medications • Anticonvulsive treatments for epilepsy and other conditions • Immunosuppressants Neltner Billing & Consulting Services

  14. Excluded Drugs • Drugs for • Anorexia, weight loss, or weight gain • Fertility • Cosmetic purposes or hair growth • Symptomatic relief of cough and colds • Prescription vitamins and mineral products • Except prenatal vitamins and fluoride preparations • Non-prescription drugs • Barbiturates • Benzodiazepines Neltner Billing & Consulting Services

  15. Exception Process • Ensures access to medically necessary Medicare covered prescription drugs • Provides process for enrollee to • Obtain a covered Medicare prescription drug at a more favorable cost-sharing level • Obtain a covered Medicare prescription drug not on the formulary Neltner Billing & Consulting Services

  16. Part B Drugs • Drugs covered under Part B will continue to be paid under Part B • Includes vaccines • Includes oral anti-cancer and antiemetics • Providers continue to bill • Carriers • Intermediaries • DMERC Neltner Billing & Consulting Services

  17. Low Income Benefit • Automatic eligibility • Medicare and Medicaid coverage • Medicaid drug coverage will end 12/31/05 • Beneficiaries will be automatically enrolled if they do not self-enroll • SSI benefits • Medicare Savings Program • Social Security Administration • Contact individuals who may qualify • Application form • Medicaid beneficiaries in a nursing home • Pay no out-of-pocket costs for coverage Neltner Billing & Consulting Services

  18. Part D Issues • Impact on care settings • Impact on out-of-pocket spending • Beneficiary costs count towards threshold • Movement of drugs out of physician offices • Prior authorization • Beneficiaries pay 3 premiums in addition to deductible and co-insurance • Part B • Part D • Medigap • Beneficiaries need to enroll Neltner Billing & Consulting Services

  19. Provider Resources • Provider education website: • www.cms.hhs.gov/medlearn/drugcoverage.asp • Provider toolkit • www.cms.hhs.gov/medlearn/provtoolkit.pdf • Printable material in alternate languages available • For distribution to patients: • http://www.cms.hhs.gov/medlearn/cms-11180.pdf • For distribution to staff: • http://www.cms.hhs.gov/medlearn/cms-11181.pdf Neltner Billing & Consulting Services