Issue 2006-05, May 2006

Access to the Part D Drug Benefit in Long-Term Care Settings

Provider Types Affected
Skilled nursing facilities (SNFs) and nursing homes with Medicare residents

Impact on Providers
To simplify access to the Part D drug benefit in the long-term care (LTC) setting, the Centers for Medicare & Medicaid Services (CMS) recommends that providers take steps to clearly differentiate those drugs which may qualify as Part B drugs and those which may qualify as Part D drugs.

Important Points to Remember
CMS released the following information via the Minimum Data Set (MDS) submission system’s Welcome Page on March 14, 2006:

Drugs Administered Through a Part B Covered Item of Durable Medical Equipment (DME) Such as a Nebulizer or Pump

Medicare Part B only covers the above categories of drugs when used in conjunction with Part B covered DME in the patient’s home. For those LTC facilities that do not qualify as a patient’s home, CMS recommends for the above categories of drugs that the following be included in the written order:

• The diagnosis and indication for the drug, and
• A statement of status such as “Nursing Home Part D.”

Certain Infusion and Injectable Drugs

Medicare Part B covers injectable and infusible drugs that are not usually self-administered and that are furnished incident to a physician’s service. If an LTC facility, rather than a physician, furnishes and administers these drugs to a patient who is not in a Medicare Part A stay, CMS recommends including a statement of status such as “Administered by Facility, Nursing Home Part D.”

Certain Oral and Immunosuppressive Drugs
At this time, Part B covers three categories of drugs: oral anticancer, oral antiemetic, and immunosuppressive drugs listed below under certain circumstances.

This does not represent an exhaustive list of Part B covered drugs. It is possible for the list of drugs covered by Part B to change over time.

The following are immunosuppressive drugs for transplants paid for by Medicare:

The following are the oral anti-cancer drugs paid for by Medicare Part B:

The following are oral anti-emetics paid for by Medicare when prescribed for use within 48 hours of chemotherapy except as noted below:

For these categories of drugs, CMS recommends including in the written prescription the diagnosis and the indication as well as the statement of status as “Part B” (for above indications) or for “Part D” (for all other indications).

For example, Methotrexate for rheumatoid arthritis should have the diagnosis specified, and the designation “Part D” added to the prescription.

While this guidance does not guarantee payment or coverage, following the process may help pharmacists respond more readily to additional information to support Part D or Part B coverage, and facilitate processing by the appropriate plan.

Additional Information

For more detailed information on Part B versus Part D coverage, see http://www.cms.hhs.gov/PrescriptionDrugCovGenIn/Downloads/PartBandPartDdoc_07.27.05.pdf on the CMS Web site.

A comprehensive list of links to agency-wide Part D resources for physicians is available at http://www.cms.hhs.gov/center/provider.asp , scroll to “Part D Tools for Health Care Professionals.”

As always, the source for Part D information for Fee-for-Service (FFS) providers is located on the Medicare Learning Network’s drug coverage page at http://www.cms.hhs.gov/MedlearnProducts/23_DrugCoverage.asp on the CMS Web site.

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

Medlearn Matters Number: SE0614
Related Change Request (CR) #: N/A
Effective Date: N/A