Medicare Part D 2013CAPT Pamela Schweitzer

IHS Pharmacy Consultant

General Information, 2013 Coverage Gap Creditable coverage notice/letter Fraud Waste & Abuse Training Plan Information, 2013 Processing Claims Resources

Topics for today

Open Enrollment:◦ October 15th through December 7th

Medicare & You 2013 handbook CMS, Social Security and Plan Mailings

General Information

http://www.medicare.gov/Pubs/pdf/10050.pdf

Medicare & You 2013

Indian Health Services—Joining a Medicare drug plan may help your Indian health facility because the drug plan pays the Indian health facility for the cost of your prescriptions. Talk to your local Indian health benefits coordinator who can help you choose a plan that meets your needs and tell you how Medicare works with the Indian health care system.

Medicare & You 2013

Consumer Mailing

Medicare Part D - For those AI/AN beneficiaries that reach the coverage gap (donut hole), and use I/T/U pharmacy, spending counts toward out-of-pocket threshold.

Duel-eligible patient (those receiving Full Low Income Subsidy) are not affected by coverage gap.

Coverage Gap

Closing the Coverage Gap

Review and be familiar with policy Newly eligible Medicare eligible Indian

beneficiaries may not be aware that they have creditable coverage.

Beneficiary might need to show proof of creditable coverage if changing plans.

Creditable Coverage Notice

Affects all staff involved in enrolling and billing Medicare Part D

Documentation of Annual FWA training required

OIG Exclusion list – checking on hiring and annually thereafter

Attestation Local policy and procedures

Fraud, Waste and Abuse (FWA) training

Previous PBM Name New PBM Name

Prescription Solutions Optum Rx

SXC Catamaran

Catalyst Catamaran

Medco Express Scripts

Benecard RxAlly

Pharmacy Benefit Manager (PBM) Changes

Smart D Rx Saver (PDP) Readers Digest ValueRx (PDP) Community Care RX and HealthNet Orange

are now SilverScript

New Plans for 2013

Agreements in place with all stand-alone PDP’s

2013 Plans

Medicare Drug Plans are rated on how well they perform in four different categories:

Drug Plan Customer Service Member Complaints, Problems getting

service and choosing to leave the plan Member experience with drug plan Drug pricing and Patient safety A plan can get ratings between one and five

stars (5 = excellent, 1 = poor).

Star Ratings

Common 2013 Part D plans by Contract ID

Emdeon web site

To obtain your own access:https://secure.erxnetwork.com/NewUserRequest.aspx Be sure to include pharmacy NCPDP and NPI number

For sites using RPMS POS Emdeon access

New Safety edits for patients patients older than 65 years old.

Overrides are not allowed Prescribers are encouraged to use safer

alternative. For more information and list of drugs:

http://www.pqaalliance.org/files/PQA-update-HRM-measure-2012NL.pdf

High Risk Drugs – Hard rejects

Significant increase in audits this year:- Provider ID (prescriber NPI required)- Signature log- E-prescribing- Focus on high cost claims- Completion of FWA training- Double billing

Pharmacy Audits

– FTP site: ftp://ftp.ihs.gov/rpms/POS/ Medicare & You 2013:

http://www.medicare.gov/Pubs/pdf/10050.pdf

Resources

Questions?