Keeping you updated on the latest Medicare and Part D news

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CMS Finalizes CY 2015 Program Changes for Part D

Last week, CMS released the finalized program changes for Medicare Advantage and Prescription Drug Benefit Programs for the 2015 contract year. The proposals were originally published on January 10, 2014 and open to a 60-day comment period, during which CMS received over 7,500 public comments. Controversial aspects of the proposal, such as regulating preferred pharmacy networks and reducing protected drug classes, were withdrawn by CMS in early March. The finalized changes increase CMS’ oversight to prevent and investigate fraud and inappropriate prescribing. By June 1, 2015, prescribers must either enroll in Medicare or formally opt out. Only those who are enrolled in Medicare can prescribe drugs covered by Part D. Also, CMS can revoke the Medicare enrollment of prescribers with inappropriate prescribing patterns or licensing issues. According to Medicare officials, this authority will only be exercised in “very limited and exceptional circumstances.”

CMS Fact Sheet

ProPublica Article


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Recent Analysis on Potential Medicare Part B Overspending

Overused Medical Services Cost Medicare Billions Of Dollars– Harvard Medical School study finds prevalent use of “low-value” services for Medicare beneficiaries in 2009.

For Some Doctors, Almost All Medicare Patients Are Above Average-ProPublica analysis of CMS’ recent release of 2012 Medicare Part D spending data shows that certain doctors bill Medicare exclusively at the highest level for office visits.

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New Medicare Guidance Aims to Prevent Duplicate Payments for Drugs in Hospice

New Medicare guidance went into effect today to prevent duplicate payments for drugs beneficiaries receive while in hospice care. Drugs related to palliative, end-of-life care are covered by the hospice benefit, while other drugs are supposed to be covered by Part D. When hospice care-related drugs are covered by Part D, Medicare is essentially paying twice for the same prescription. A 2012 OIG investigation found that in 2009, Part D plans paid more than $33 million for drugs that should have been covered by the hospice benefit, and beneficiaries paid nearly $4 million in copayments. 

The new rule requires Part D sponsors to “place beneficiary-level prior authorization (PA) requirements on all drugs for beneficiaries who have elected hospice to determine whether the drugs are coverable under Part D.” Following standard PA procedures, after the initial claim is rejected, the patient or doctor, with the hospice provider’s agreement, must explain why the drugs are not related to hospice care. Sponsors must then decide whether to cover the drugs, though CMS has not yet provided objective criteria for payment determinations.