Medicare Part D: Forum addresses confusion

Tuesday, February 28, 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.
CMS officials also made the following clarifications:
- If a drug was billed under Part B before Jan. 1, it is still billed as Part B. There are some instances where drugs are covered under either Part B or Part D. 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 are Part B, but those same drugs delivered through other means 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 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.
"Specifics should be taken into consideration," said a CMS official. "It doesn't need to be one-size-fits all."