2015 National Training Program Medicare Prescription Drug Coverage Under Part A, Part B, and Part D July 2015

2015 National Training Program

Medicare Prescription Drug Coverage Under Part A, Part B, and Part D

July 2015

Lesson 1—Inpatient Prescription Drug Coverage

Inpatient status Medicare prescription drug coverage in

hospitals, skilled nursing facilities, and hospice care

06/01/2015 Medicare Drug Coverage Under Part A, Part B, and Part D 2

Hospital Inpatient Status

You’re an inpatient starting when you’re formally admitted as an inpatient to a hospital with a doctor’s order and you’re• Expected to stay in the hospital 2 or more midnights

The 2-midnight rule applies o Explains the standard for inpatient hospital stays


Hospital Status Determination2-Midnight Rule

Clarification of inpatient hospital and critical access hospital admissions for payment purposes• Helps hospitals determine whether a beneficiary should be

admitted for an inpatient stay (vs. observation status) Payment generally appropriate under Medicare Part A• When the doctor expects the beneficiary to require a stay

that crosses at least 2 midnights and admits the beneficiary to the hospital based upon that expectation

• For surgical procedures, diagnostic tests, and other treatments generally appropriate for inpatient hospital admission


Inpatient Hospital and Skilled Nursing Facility (SNF) Prescription Drug Coverage

Part A generally covers all drugs received as part of treatment during a covered inpatient stay• In a hospital or SNF

Part B may pay hospitals and SNFs for certain categories of Part B covered drugs if• You don’t have Part A or your coverage has run out• The stay isn’t covered by Part A

Medicare Drug Coverage Under Part A, Part B, and Part D 06/01/2015 5

Medicare Drug Coverage Under Part A, Part B, and Part D

Prescription Drug Coverage for Hospice Care

Part A per-diem payments are made to the hospice to cover all related patient-care needs • Including drugs or biologicals• Drugs that were used prior to the hospice election

are also covered if necessary for the palliation and management of the terminal illness and related conditions

Drugs or biologicals covered under the Part A per-diem payment are excluded from coverage under Part D

06/01/2015 6

Prescription Drug Coverage for Hospice Care—Continued

To be covered by Part D, the drug must be for treatment of a condition that's completely unrelated to the terminal illness or related conditions• CMS expects that the occurrence of Part D covered

hospice drugs will be fairly uncommon, therefore Hospices should communicate with Part D plans and

prescribers about drugs that should be considered for coverage under Part D o Voluntary standardized form “Hospice Information for

Medicare Part D Plans CMS-10538” and its instructions are available on CMS' website


Lesson 2—Coverage of Vaccinations

Overview of Medicare vaccination coverage


Medicare Vaccination Coverage

Part A cover vaccines that are administered for therapeutic purposes when you are an inpatient• E.g., a tetanus booster shot given to a SNF resident in response to an

actual exposure to the disease (if the SNF stay is covered by Part A) Part B covers vaccines that are preventive in nature whether you

are an inpatient or outpatient • Must be in one of the 3 categories

Pneumococcal pneumonia Hepatitis B*, or Influenza

Part D cover vaccines for which no Part B benefit category exists• And aren’t be covered under Part A or B


*Your Hepatitis B (HBV) vaccine series would be covered under Part B if you’re at high or medium risk for HBV. If you aren't at high or medium risk your HBV vaccine series would be covered under Part D.

Pearl was given a tetanus shot after being scratched by a rusty nail. If she’s receiving Medicare-covered skilled nursing facility care and has Original Medicare and Part D, which part of Medicare will cover the shot?a. Part Ab. Part Bc. Part Dd. Her Medigap policy


Check Your Knowledge—Question 1

Albert is receiving Medicare-covered care in a skilled nursing facility and was given a preventive poliomyelitis vaccine. If he has Original Medicare and Part D, which part of Medicare will cover his poliomyelitis vaccine?a. Part Ab. Part Bc. Part Dd. His Medigap policy



Lesson 3—Outpatient Prescription Drug Coverage

Outpatient status Medicare prescription drug coverage in

outpatient settings


Hospital Outpatient Status

You're an outpatient if the doctor hasn't written an order to admit you to a hospital as an inpatient, and you’re getting• Emergency department services• Observation services

The services you receive while in observation status• Outpatient surgery • Lab tests, or X-rays • Any other hospital servicesYou’re in observation status when you receive hospital outpatient services

while your doctor decides whether you’ll be admitted as an inpatient or discharged.


Outpatient Prescription Drug Coverage—Part B

Part B covers limited outpatient drugs• Generally, the drugs you wouldn’t usually give yourself

Unless required for hospital outpatient services you’re getting• Most injectable and infusible drugs given as part of a doctor’s

service• Drugs and biologicals used for the treatment of End-Stage Renal

Disease (ESRD)• Drugs used at home with some types of Part B-covered

durable medical equipment (DME) such as nebulizers and infusion pumps

• Some oral drugs with special coverage requirements like Certain oral anti-cancer and oral antiemetic Immunosuppressive drugs, under certain circumstances06/01/2015 Medicare Drug Coverage Under Part A, Part B, and Part D 14

Immunosuppressive Drugs Under Part B


Covered by Medicare Part B for people who were entitled to Part A at the time of a kidney transplant provided that the transplant was performed at a Medicare-approved facility and• Medicare made payment for the transplant, or • Medicare was secondary payer

If you don’t meet the conditions for Part B coverage• You may get coverage by enrolling in Part D

Must be enrolled in Part B for Part D to cover these drugs

Self-Administered Drugs in Hospital Outpatient Settings

Part B doesn’t cover self-administered drugs in a hospital outpatient setting • Unless required for hospital outpatient services

you’re getting Part D may cover the self-administered drugs

you get in hospital outpatient settings • If they’re not related to the services you’re getting• You may have to pay out-of-pocket, then send a

claim to your Part D plan for reimbursement


Coverage of Insulin

Generally, Medicare Part B covers insulin used with an infusion pump

Medicare Part D Covers• Injectable insulin not associated with the use of an

insulin infusion pump• Inhaled insulin


Case Scenario—1

Mary was taken to the ER with an injured leg and remained in the hospital for one night. While there, she was given Percocet and an antibiotic injection for treatment related to her injury, Maxalt for her chronic migraine, and Losartan for hypertension. Mary believes that there may have been a billing error because Medicare only paid for some of her drugs and she was charged for others. She has Original Medicare and a Part D plan.06/01/2015 Medicare Drug Coverage Under Part A, Part B, and Part D 18

Based on the information provided, what’s Mary’s hospital status? a. Inpatientb. Outpatientc. There isn’t sufficient

information to make a determination

d. Requiring skilled level of care



If Mary was a hospital outpatient, which of her prescription drugs would Part B cover?a. Maxalt and Losartan for treatment

of her chronic conditionsb. Percocet and the antibiotic

injection for treatment of her broken leg

c. All of her drugs will be covered by Part A

d. All of her drugs will be covered by Part B



The charges that Mary received were for the Maxalt and Losartan which she was given for treatment of her chronic conditions. Which part of Medicare should cover these drugs?a. Part Ab. Part B c. Part Dd. Her Medigap policy



Case Scenario—2

Pearl has Original Medicare and Part D. She is 73 with diagnoses of high blood pressure and End-Stage Renal Disease. After consulting with her doctor, he prescribed the Hepatitis B vaccine series. Pearl went to her local pharmacy for the first vaccine in the series.


Why did the pharmacy bill Medicare Part B for Pearl’s Hepatitis B vaccine?a. Because Part B always

covers Hepatitis B vaccinesb. Because Pearl is in the

“High-Risk” Category c. In this case, it should’ve

been covered by Part Dd. It shouldn't have been

covered by Part B



Case Scenario—3

Marian is 67 and has type 1 diabetes, congestive heart failure, and chronic pain. She takes all of her medications orally except for her insulin which she self-injects. Marian has Original Medicare and Part D.


Which part of Medicare should cover Marian’s self-injected insulin?a. Part Ab. Part B c. Part Dd. Her Medigap policy



Case Scenario—4

Bob is 82 and has Autoimmune Hepatitis. He was recently prescribed immunosuppressant prednisone for this condition. He has Original Medicare and Part D.


Which part of Medicare should cover Bob’s self-injected immunosuppressant prednisone?a. Part Ab. Part B c. Part Dd. His Medigap policy



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Documents

2015 National Training Program Medicare Prescription Drug Coverage Under Part A, Part B, and Part D July 2015