With the end of the year rapidly approaching, Medicare prescription drug plans are notifying their enrollees of changes for 2015. If an example shared with me by one family physician is any indication, those enrollees are getting some bad information.
Express Scripts included the following in its Medicare Annual Notice of Changes for 2015:
“Effective June 1, 2015, before your drugs can be covered under the Part D benefit, CMS [Centers for Medicare & Medicaid Services] will require your doctors and other prescribers to either accept Medicare or to file documentation with CMS showing that they are qualified to write prescriptions.”
This statement has its origins in section 6405(c) of the Affordable Care Act, which allows the Department of Health and Human Services to require that prescriptions for covered Part D drugs be prescribed only by a physician or other eligible professional who is enrolled in the Medicare program. CMS published its final rule on this matter in the Federal Register on May 23, 2014. In the final rule, CMS said that, beginning June 1, 2015, a prescriber of Medicare Part D drugs must have an approved enrollment record in the Medicare program or have a valid opt-out affidavit on file with one of the Part A/Part B Medicare administrative contractors (MACs).
Based on this information, the notice that Express Scripts (and others, possibly) is sending to Medicare patients is technically incorrect. CMS is not in the business of determining whether physicians are qualified to write prescriptions. By law, CMS is only requiring that physicians be enrolled with Medicare or otherwise have a valid opt-out affidavit on file with Medicare in order for Part D to pay claims for prescriptions written by them.
The vast majority of physicians are already enrolled in Medicare for purposes of billing their services under Medicare Part B. Among those who are not, many have a valid opt-out affidavit on file with the MAC in their area. Thus, it will be the rare physician whose Part D prescriptions are affected by this change in Medicare policy. With luck, this information will help you reassure any Medicare beneficiary concerned by what their Part D drug plan is telling them.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
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