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 06/01/2015 Medicare Drug Coverage Under Part A, Part B, and Part D 3 Medicare Prescription Drug Coverage 1
Hospital Status Determination 2-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 06/01/2015 Medicare Drug Coverage Under Part A, Part B, and Part D 4 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 06/01/2015 Medicare Drug Coverage Under Part A, Part B, and Part D 5 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 Medicare Drug Coverage Under Part A, Part B, and Part D 6 Medicare Prescription Drug Coverage 2
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 06/01/2015 Medicare Drug Coverage Under Part A, Part B, and Part D 7 Lesson 2 Coverage of Vaccinations Overview of Medicare vaccination coverage 06/01/2015 Medicare Drug Coverage Under Part A, Part B, and Part D 8 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. 06/01/2015 Medicare Drug Coverage Under Part A, Part B, and Part D 9 Medicare Prescription Drug Coverage 3
Check Your Knowledge Question 1 Pearl was given a tetanus shot after being scratched by a rusty nail. If she s receiving Medicarecovered skilled nursing facility care and has Original Medicare and Part D, which part of Medicare will cover the shot? a. Part A b. Part B c. Part D d. Her Medigap policy 06/01/2015 Medicare Drug Coverage Under Part A, Part B, and Part D 10 Check Your Knowledge Question 2 Albert is receiving Medicarecovered 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 A b. Part B c. Part D d. His Medigap policy 06/01/2015 Medicare Drug Coverage Under Part A, Part B, and Part D 11 Lesson 3 Outpatient Prescription Drug Coverage Outpatient status Medicare prescription drug coverage in outpatient settings 06/01/2015 Medicare Drug Coverage Under Part A, Part B, and Part D 12 Medicare Prescription Drug Coverage 4
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 services You re in observation status when you receive hospital outpatient services while your doctor decides whether you ll be admitted as an inpatient or discharged. 06/01/2015 Medicare Drug Coverage Under Part A, Part B, and Part D 13 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 circumstances 06/01/2015 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 06/01/2015 Medicare Drug Coverage Under Part A, Part B, and Part D 15 Medicare Prescription Drug Coverage 5
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 06/01/2015 Medicare Drug Coverage Under Part A, Part B, and Part D 16 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 06/01/2015 Medicare Drug Coverage Under Part A, Part B, and Part D 17 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 Medicare Prescription Drug Coverage 6
Check Your Knowledge Question 3 Based on the information provided, what s Mary s hospital status? a. Inpatient b. Outpatient c. There isn t sufficient information to make a determination d. Requiring skilled level of care 06/01/2015 Medicare Drug Coverage Under Part A, Part B, and Part D 19 Check Your Knowledge Question 4 If Mary was a hospital outpatient, which of her prescription drugs would Part B cover? a. Maxalt and Losartan for treatment of her chronic conditions b. 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 06/01/2015 Medicare Drug Coverage Under Part A, Part B, and Part D 20 Check Your Knowledge Question 5 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 A b. Part B c. Part D d. Her Medigap policy 06/01/2015 Medicare Drug Coverage Under Part A, Part B, and Part D 21 Medicare Prescription Drug Coverage 7
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. 06/01/2015 Medicare Drug Coverage Under Part A, Part B, and Part D 22 Check Your Knowledge Question 6 Why did the pharmacy bill Medicare Part B for Pearl s Hepatitis B vaccine? a. Because Part B always covers Hepatitis B vaccines b. Because Pearl is in the High-Risk Category c. In this case, it should ve been covered by Part D d. It shouldn't have been covered by Part B 06/01/2015 Medicare Drug Coverage Under Part A, Part B, and Part D 23 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. 06/01/2015 Medicare Drug Coverage Under Part A, Part B, and Part D 24 Medicare Prescription Drug Coverage 8
Check Your Knowledge Question 7 Which part of Medicare should cover Marian s self-injected insulin? a. Part A b. Part B c. Part D d. Her Medigap policy 06/01/2015 Medicare Drug Coverage Under Part A, Part B, and Part D 25 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. 06/01/2015 Medicare Drug Coverage Under Part A, Part B, and Part D 26 Check Your Knowledge Question 8 Which part of Medicare should cover Bob s selfinjected immunosuppressant prednisone? a. Part A b. Part B c. Part D d. His Medigap policy 06/01/2015 Medicare Drug Coverage Under Part A, Part B, and Part D 27 Medicare Prescription Drug Coverage 9
CMS National Training Program (NTP) To view all available NTP materials, or to subscribe to our email list, visit CMS.gov/outreach-andeducation/training/cmsnationaltrainingprogram/ For questions about training products email training@cms.hhs.gov Medicare Prescription Drug Coverage 10