Bridgett Edgar, CPht Pharmacy Owner WSPA and SWPA Board Member INTRODUCTION I have no Disclosures Disclosures Objectives Able to submit a clean claim when billing a vaccine Able to bill and collect an administration fee Familiarize yourselves with Medicare D 2016 Understand the new pharmacy technician standards effective in 2020 1
What do you do all day? Is your pharmacy collecting an administration fee? Does every insurance company have the same process for submitting a claim? How much money has the pharmacy lost by missing these billing codes? Claim submission for vaccine administration is same as other drugs dispensed by the pharmacy except that the pharmacy must submit the following DUR/PPS codes and fee for vaccine administration in the additional information section. The Prescriber is the pharmacist, not the doctor whom the pharmacist has the agreement with. 2
Professional Service Code = MA (Medication Administration) Reason for Service Code = PH (Preventative Health Care) Result of Service Code = 3N (Medication Administrated) Incentive amount submitted acceptable amount is greater than 0. This is the administration fee that you are submitting. If the insurance doesn t pay for administration, consider charging the patient for administration. The patient may be able to submit this fee to their medical insurance for reimbursement. Exceptions to the above rule: All Regence plans including Medicare Part D and Medicare D Asuris: DUR/PPS codes are PH, MA and 00 for reason, professional and result of service codes respectively with an incentive fee of $20. 3
Providence Health Plan (PHP): Providence health plan requires the submission of PA code of #1420142 specifically for Adacel and Zostavax. DUR/PPS codes are not needed when processing these claims. A message will appear if PA was not submitted on the claim. If total amount paid is equal to or greater than $176 for Zostavax and $57.88 for Adacel, that means the administration fee was charged but it might not appear on "Incentive fee paid". Note: This PA code only applies for Adacel and Zostavax but it may be useful to try this same code for other vaccines if administration fee is not paid by the insurance. Also, this exception applies only to PHP but not to Medicare D Providence Plans. Those plans still require DUR codes and $20.00 administration fee to be submitted in the claim. Other Important aspects: For many insurance plans, the administration fee will be paid if the pharmacy submits the correct codes. The PH and 3N codes are not mandatory for some insurance plans. For example, for Medco health insurance, if the pharmacy enters MA for professional service code and submits the incentive fee then administration fee will be charged. 4
During the claim submission is that the gross amount due should include the incentive amount. As a general rule, the pharmacy will be processing one prescription for both the vaccine and the administration fee if they are billing the vaccine to the insurance. However, if the pharmacy is billing the vaccine or the administration fee as a cash claim, they will need to process two different prescriptions for the vaccine and the administration fee. Note: Merck has a patient rebate program for Zostavax. Merck will provide a rebate for the vaccine if the patient has a co pay between $30 and $140. For more information, or to get the rebate forms call 1 888 ZOSTAINFO or www.rebate4.zostavax.com. Benefit Plan changes from 2015 to 2016. Initial Deductible: will be increased by $40 to $360 in 2016. This means: If you enroll in a Medicare Part D plan with a standard initial deductible, you will pay slightly more in 2016 before your Medicare Part D plan coverage begins. Initial Coverage Limit: will increase from $2,960 in 2015 to $3,310 in 2016, a $350 increase over the 2015 initial coverage limit of $2,960. This means: Since the Initial Coverage Limit is based on the negotiated retail value of your medications, you will be able to buy slightly more medications before reaching the 2016 Donut Hole or Coverage Gap. Please note that, if you purchase medications with an average retail value of less than $276 per month, you will not enter the 2016 Donut Hole. 5
Out of Pocket Costs or TrOOP will increase: TrOOP is the actual dollar figure you must spend to get out of the Donut Hole or Coverage Gap, excluding monthly premiums. The 2016 TrOOP threshold will increase by $150 to $4,850 from the current 2015 value of $4,700. As noted above, brand name medication purchases in the Donut Hole are discounted by 55%, but you will receive credit of 95% of the retail drug price toward meeting the 2016 TrOOP threshold. This means: You will have to spend slightly more to get out of the 2016 Donut Hole than you did in 2015. Maximum Co payments below the Out of Pocket Threshold for certain Low Income Full Subsidy Eligible Enrollees: will increase to $2.95 for generic or preferred drug that is a multi source drug and $7.40 for all other drugs in 2016. No 2016 Medicare Advantage plan can have an in-network Maximum Out-of- Pocket (MOOP) spending limit over $6,700: CMS establishes a limit on how high a Medicare Advantage plan can set their Maximum Out-of-Pocket limit (MOOP) and, as in 2015, no 2016 Medicare Advantage plan can have a MOOP higher than $6,700 for in-network eligible medical expense cost-sharing. This means: Your 2015 Medicare Advantage plan can raise your maximum out-ofpocket spending limit (MOOP) in 2016, but you can expect that your Medicare Advantage plan covered healthcare expenses will not exceed $6,700 for in-network cost-sharing. (Please note that, depending on your Medicare plan, your out-ofnetwork medical costs may count toward a higher MOOP or not count at all toward your annual MOOP.) 6
The Donut Hole discount for brand-name drugs will remain the same: The 2016 brand-name drug discount will remain at 55% and you will receive credit for 95% of the retail drug cost toward meeting your 2016 total out-of-pocket maximum (TrOOP) or Donut Hole exit point (the 45% you spend plus the 50% drug manufacturer discount). This means: You will have the same savings on brand-name drugs in the 2016 Coverage Gap. For example, as in 2015, if you reach the 2016 Donut Hole and purchase a brand-name medication with a retail cost of $100, you will pay $45 for the medication, and receive $95 credit toward meeting your 2016 out-of-pocket spending limit or Donut Hole exit point. Coverage Gap (donut hole): begins once you reach your Medicare Part D plan s initial coverage limit ($3,310 in 2016) and ends when you spend a total of $4,850 in 2016, a $350 increase over the 2015 initial coverage limit of $2,960. This means: Since the Initial Coverage Limit is based on the negotiated retail value of your medications, you will be able to buy slightly more medications before reaching the 2016 Donut Hole or Coverage Gap. Please note that, if you purchase medications with an average retail value of less than $276 per month, you will not enter the 2016 Donut Hole. In 2016, Part D enrollees will receive a 55% discount on the total cost of their brand name drugs purchased while in the donut hole. The 50% discount paid by the brand name drug manufacturer will apply to getting out of the donut hole, however the additional 5% paid by your Medicare Part D plan will not count toward your TrOOP. For example: if you reach the donut hole and purchase a brand name medication with a retail cost of $100, you will pay $45 for the medication, and receive $95 credit toward meeting your 2016 total out of pocket spending limit. Enrollees will pay a maximum of 58% co pay on generic drugs purchased while in the coverage gap (a 42% discount). For example: If you reach the 2016 Donut Hole, and your generic medication has a retail cost of $100, you will pay $58. The $58 that you spend will count toward your TrOOP. 7
Minimum Cost sharing in the Catastrophic Coverage Portion of the Benefit**: will increase to greater of 5% or $2.95 for generic or preferred drug that is a multi source drug and the greater of 5% or $7.40 for all other drugs in 2016. Medicare Part D Benefit Parameters for Defined Standard Benefit 2012 through 2016 Comparison Comparison 2006 to 2016 2016 2006 Deductible $360 $250 Initial Cover Limit $3310 $2250 Out of Pocket Threshold $4850 $3600 Total Covered Part D Drug $7062.50 $5100 8
What do you do all day? PTCB Pharmacy Technician April 2014, adding one hour of required patient safety CE; Effective in January 2015, requiring all earned CE hours to qualify as technician specific; and reducing the number of allowable in service CE hours from 10 to 5. By 2018, PTCB will completely phase out inservice CE hours New Requirements 2016 This is a reminder that effective January 1, 2016, PTCB will implement a change in continuing education (CE) recertification requirements for Certified Pharmacy Technicians (CPhTs) that reduces the allowable number of CE hours earned via college/university courses from 15 to 10. Beginning in 2016, a maximum of 10 of your 20 CE hours may be earned by completing a relevant college course with a grade of 'C' or better. This is part of a series of Certification Program changes PTCB announced in early 2013 to advance pharmacy technician qualifications by elevating PTCB's standards for certification and recertification. 9
New Requirements 2020 Beginning in 2020, PTCB will require initial candidates for certification to complete a pharmacy technician education program accredited by the American Society of HealthSystem Pharmacists (ASHP)/Accreditation Council for Pharmacy Education (ACPE) New Requirements by 2020 Why? Leaders in the profession have demonstrated a desire for pharmacy technicians to follow the same credentialing model as pharmacists by becoming certified and registered with the state. In a March 2012 survey, 78% of respondents agreed that 2020 is a reasonable year by which to implement required accredited education What does this all mean? This requirement will affect new individuals applying for national certification following the implementation date. It will not affect already certified pharmacy technicians applying for PTCB recertification 10
RECERTIFICATION with PTCB Renewing your membership with PTCB is not a state mandate. It is highly recommended that you keep your certification, as we don t know what is in the future. Networking, up to date information There are other approved programs other than PTCB Patient Safety CE As part of the 20 hours of CE currently required for PTCB recertification, CPhTs must complete one CE hour of patient safety, in addition to the one hour of law CE required. This requirement took effect in 2014. Pharmacy Technician Specific CE PTCB requires CE hours completed on or after January 1, 2015 to be in pharmacy technicianspecific subject matter to count toward recertification. Pharmacy technicians need to be educated through programs that specifically address their responsibilities and knowledge requirements in the workplace. 11
Pharmacy Technician Specific CE Note that an ACPE accredited CE course sometimes is intended for both pharmacists and pharmacy technicians. The two courses have identical Universal Activity Numbers but different last digits either T or P (pharmacist) to indicate the audience. WSPA is here to help you. Note: 10 hours a year continuing education is available from the WSPA website FREE with your membership. The C.E will align with the new changes with PTCB certification and training standards. Continuing education topics will change so each year will be different. Review How do you bill an administration fee to a PBM? If you are already certified and licensed in Washington state, what changes between now 2020? Where can I go to get more information about Medicare Part D? 12
What do you do all day? References and contact info Bridgett Edgar Work: bridgett@pasmonroe.com Private: byankey@hotmail.com Cell 425 876 4911 Twitter: EDGARGIRL Linkedin Facebook Reference Material https://www.ptcb.org/about ptcb/news room/news landing/2015/09/30/your ce requirements whatwill change in 2016 #.VkzPptKrQdU WSPA Vaccine billing 2012 http://www.q1medicare.com/ 13