capt pamela schweitzer ihs pharmacy consultant. general information, 2013 coverage gap creditable...
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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
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
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
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
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