Article - Filling Pharmacy Claims to Medicare

Medicare Part A covers hospital services, while Medicare Part B covers a variety of outpatient and rehabilitation services, including some pharmacy services such as immunizations, medical supplies, and certain medications. Medicare Part C, also known as Medicare Advantage, is a program where private insurance companies are paid by the federal government to administer Medicare Parts A and B on their behalf. Medicare Part D covers prescription medications.

Medicare Part B

For a pharmacy to become a participating provider for Medicare B, they must first choose whether to only sell non-accredited products or both accredited and non-accredited products. Non-accredited products include erythropoietin, immunosuppressants, infusion drugs, nebulized medications, oral chemotherapy, and oral nausea medications. Accredited products include a long list of Durable Medical Equipment (DME), but pharmacies that are accredited bill commonly for diabetic testing supplies. Pharmacies wanting to get in the DME business will also need accreditation.

If choosing only to sell non-accredited products, the pharmacy will submit the CMS-855S application, along with other necessary documentation and the application fee, to a contracted third-party that is different depending on the state they are in. States are divided into jurisdictions and contracts are awarded to vendors for each jurisdiction. These companies are known as Medicare Administrative Contractors (MAC). It is the job of the MAC to administer Medicare Part A and B on behalf of the federal government, including the processing of applications according to federal law.

For pharmacies choosing to bill accredited durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) through Medicare B, they must go through several additional steps. DMEPOS products that require accreditation include diabetic testing supplies, canes and crutches, blood pressure machines, surgical dressings, parenteral and enteral nutrition, and most immunizations. To begin, pharmacies select an accreditation organization, submit the CMS-855S application, and the accreditation organization reviews the pharmacy’s policies and procedures, verifies licensure for the pharmacy and pharmacist(s), and finally conducts the on-site survey. Examples of accrediting organizations include the National Association of Boards of Pharmacy (NABP) and The Joint Commission.

Because of the complexity of the CMS-855S application, many pharmacies choose to enlist consultants to assist with filling out and submitting the application on their behalf, especially if they are seeking accreditation. Of note, the process can take a long time to complete so whether deciding to hire a consultant or not planning is crucial; CMS reports that even in the case there are no deficiencies in the application it can take up to 9 months to become accredited.

The limited list of medications that are covered under Medicare B are considered excluded medications (i.e. not covered) under Medicare Part D. Because of this, if a patient has both Part B and Part D and a claim is submitted to Part D for a Part B covered drug it will deny and should be resubmitted to Medicare Part B.

Medicare Part D

Medicare Part D covers prescription medications and is the primary focus of the community pharmacist. Medicare Part D is administered by numerous private insurance companies, all of which have their individual formularies and features.

Medicare Part D plans do, however, always consist of four different coverage periods:

  • The deductible period: 

    Just like with private insurance, a patient has to pay a certain amount of money out of pocket, known as their deductible, before the insurance will help pay for the medications. As of 2018, no deductible could be higher than $405.
  • Initial coverage period: 

    After the deductible is met the patient will receive help paying for their medications and will have a copay. After a certain amount is paid by the insurance company (most often $3750) this period expires. As a pharmacist you can help patients stay in this initial coverage period by getting their most expensive medications switched to less expensive ones, if appropriate.
  • Coverage gap: 

    This is also known as the ‘donut hole.’ This is the period when patients must again pay for their medications, although there are programs funded by the federal government and manufacturers to alleviate the high costs during this period.
  • Catastrophic coverage: 

    After the patient has spent $5,000 in True Out of Pocket Costs (TrOOP), they enter the catastrophic coverage period for the remainder of the year. During this time their copays will be very low. It is important to note that copays, full payments for medications paid during the coverage gap, and amounts paid by some other agencies count towards TrOOP; monthly insurance premiums and the cost of medications not covered otherwise do not.

This is important because if, for example, a patient is in their coverage gap and is prescribed a brand-name medication that requires a prior authorization (PA) it is in their best interest to get the PA approved prior to purchasing the drug, even if their payment will be the same. If it is not approved and the pharmacy runs the medication as cash, then it is considered a non-covered drug and does not go towards meeting their TrOOP.

One of the ways pharmacists can help their Medicare patients is by helping them select the plan that is best for them during open-enrollment; to do so, use the Medicare Find a Plan tool available at: Enter the patient’s zip code and all of their medications and it will populate a list of health insurance plans, the total cost each month, when the patient will enter each phase of coverage, and a breakdown of their monthly costs. It also provides a lot of other information on the insurance company, including service ratings, contact information, and more.

Published By - Medical Billers and Coders
Published Date - Jan-28-2020 Back

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