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Change in rules for prescribing to Medicare patients delayed

July 20, 2015

Change in rules for prescribing to Medicare patients delayed

Even if you do not accept Medicare, if your patients fill their prescriptions with Medicare Part D, this affects YOU! Physicians who write prescriptions for Medicare must be participating providers or complete an opt-out affidavit. Patients of doctors who fail to do this will receive a message encouraging them to find a new doctor. The original implementation date of June 30, 2015 has been delayed to Jan. 1, 2016.

What do you need to do?​

This new rule is similar to a rule previously adopted by CMS. All eligible professionals who order or refer Medicare patients are required to be enrolled in Medicare Part B as a condition for the physician or supplier to whom the patient was referred to receive payment from Medicare.

CMS will delay enforcement of this rule until Jan. 1, 2016. The rule was delayed twice before, originally being scheduled to take effect on June 30, 2015 and then delayed until Dec. 1, 2015. Eligible Professionals who prescribe Part D covered drugs should submit their Medicare enrollment applications or opt-out affidavits to their Medicare Administrative Contractors (MACs) as soon as possible in order to ensure that there is sufficient time to process the applications before the Jan. 1, 2016 deadline.

As with the Ordering/Referring policy, if an Eligible Professional is only enrolling in Medicare for purposes of meeting the new prescribing requirement (i.e. will not submit claims for Medicare reimbursement), then the provider should use the 855O enrollment application rather than the 855I.

After concerns about beneficiary access, CMS announced that Part D sponsors will be required to cover a provisional supply of drugs for three months – for prescriptions that are written by physicians or eligible professionals who are not in compliance with these new rules (enrolled in Medicare or have a valid opt-out). Beneficiaries will receive written notice that their prescriptions are being covered on a provisional basis and be encouraged to find a new prescriber.

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