What prescribers need to know about Medicare Part D


Medicare Part D is no longer new, but there is always something new to keep up with. Currently, approximately 39 million of 52 million Medicare beneficiaries, or 75%, are enrolled in Part D plans. So, even physicians who do not participate in Medicare will likely write prescriptions for a Part D beneficiary.

Effective July 1, 2015, physicians who prescribe drugs to Part D enrollees must be either be enrolled in Medicare or have a valid opt-out affidavit on file in order for the prescriptions to be paid for. Even if the beneficiary is seeing a non-participating provider, the prescriber must be registered. The final regulation (42 CFR β 423.120(c)(6)) states that the effective date for this requirement would be June 1. However, the Centers for Medicare and Medicaid services has said that it will delay enforcement until Dec. 1, which gives prescribers additional time to enroll.

Prescribers should submit Medicare enrollment applications or opt-out affidavits to their Medicare Administrative Contractors by June 1, so that that MACs have enough time to process the applications or opt-out affidavits and avoid their patients' prescription drug claims from being denied by their Part D plans beginning Dec. 1. Enrollment may be done electronically using the Internet-based Provider Enrollment, Chain, and Ownership System or by completing the paper-based CMS-855I or CMS- 855O applications. The CMS-855O form is only for purposes of ordering and referring, including Part D prescriptions, not for billing services. For instructions on how to enroll or how to opt out, go online.

The bottom line is that this will enable Medicare patients to have their prescriptions paid for by their Part D plan. Because, if the prescribing provider is not properly registered (or opted out), then the claim will be denied and the patient will be responsible. Thus, even if the physician is non-participating in Medicare, physicians are encouraged to register so that patients are not left to pay for their drugs out of pocket.

For more information on Part D enrollment process, go online. For more information on beneficiary Part D eligibility and enrollment, go online.