CMS, new drug plans: Not always on same page

Sunday, January 29, 2006

BALTIMORE -- If the calls to an Open Door Forum Jan. 24 are any indication, it seems that providers are just as confused as beneficiaries when it comes to Part B vs. Part D drugs.

A common source of frustration: billing. Many providers called in and said they billed Part D drug plans for Part D drugs, only to be told that they must first bill Part B and get a rejection before billing under Part D.

Not true, said CMS officials. A part B rejection is not the first step to Part D coverage. If a prescription drug plan (PDP) rejects a claim, the PDP must provide evidence justifying why, in this specific situation, the claim should be covered under Part B, said a CMS official.

In some instances, drugs are covered under either Part B or Part D, depending on the beneficiary, how the drug is used and whether the patient resides at home or in a long-term care facility.

Part B will continue to reimburse for inhalation drugs delivered through a nebulizer in the home, but the same drugs delivered through an MDI are covered under Part D.

IV drugs or insulin delivered through a pump when used in the home are Part B, but those same drugs delivered though other means or in a long-term care facility are billed to Part D.

Services and supplies associated with infusion therapy are not covered under Part D, but might be covered under Part B, Medicaid or secondary insurance.

Parenteral nutrition therapy in either the home or the LTC setting is considered Part B for patients with a "permanent" dysfunction of the digestive tract, but Part D for all other situations.

Prescription drug plans are expected to have policies in place regarding the determination of B vs. D coverage, but CMS has not provided specific guidance for plans to follow.

A CMS official stated that such drug plans should conduct due diligence before making determinations.

"Specifics should be taken into consideration," said a CMS official. "It doesn't need to be one-size-fits all."

Many calls ended with CMS asking callers to e-mail Medicare questions regarding specific coverage issues. But, it's unlikely everyone will get the clarification they seek.

Said a CMS official: "Each state works differently, and we can't and won't tell the state how to act."