CMS Issues guidance on Part B vs. D Coverage

On a January 24, 2006 conference call Craig Miner and Lawrence Kocot issued guidance on how plans should and should not be determining drug coverage under Parts B and D.

“Part D plans should not be requiring a Part B rejection as their first step before they’ll start thinking about covering it under Part D,” Craig Miner, a pharmacist with CMS’s Division of Drug Plan Policy, told call participants. “In other words, they need to take further steps to see if there is reason to believe that it should be Part B [which covers outpatient medical expenses], and in that case, perhaps, they can get to the situation where it makes sense for them to say, ‘we’re not going to cover it under D unless there’s a Part B rejection,’” he said.

CMS will not reimburse for drugs that can be covered under Part B if they are billed as Part D. According to call participants, as a result, many plan sponsors are refusing to cover injectable and infusible drugs unless a Part B rejection is presented first.

Miner acknowledged that in some cases whether to request a Part B rejection is clearly a judgment call, and that CMS does not provide specifics on the issue. Instead, “I would say…what we would expect in general is that plans would have policies and procedures…[at] the level that is appropriate and necessary…to make B vs. D determinations,” he said. “It doesn’t have to be a one size fits all.”

CMS officials emphasized that Part B coverage has not changed, so that drugs previously covered under Part B — including immunosuppressants for patients who received transplants at a Medicare-approved facility, oral oncology agents used for cancer indications, and erythropoietin for treatment of anemia in dialysis patients — remain under Part B. CMS staff also clarified that inhalation drugs dispensed through machines in nursing homes, as well as diluents used for mixing drugs (but not saline and other flushes) are indeed covered under Part D.

One area of controversy surrounding CMS’s Part B vs. Part D policy is reimbursement for home infusion (HI) drugs. Under Part D, although the drugs themselves are covered, the related supplies, equipment and support services are not, creating billing problems, coverage gaps and confusion for plan sponsors, HI providers and patients. The National Home Infusion Association and its members are calling for HI drugs to be shifted to coverage under Part B.

A few Medicare Advantage prescription drug plans (MA-PDs) have crafted their own solution to the Part D HI problem, but it is not yet clear whether their policy will withstand CMS scrutiny. According to NHIA, at least two managed care organizations — Blue Cross Blue Shield of Massachusetts and Horizon Blue Cross Blue Shield of New Jersey — have made the decision to continue covering HI for their MA-PD patients as a medical benefit, instead of split-billing drugs and services.

View CMS’s Part B vs. D coverage guidelines at www.cms.hhs.gov/Pharmacy/ Downloads/partsbdcoverageissues.pdf.

Excerpts from AISHEALTH News of the Week