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 06/01/2015Medicare Drug Coverage Under Part A, Part B, and Part D2

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 06/01/2015Medicare Drug Coverage Under Part A, Part B, and Part D3

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 06/01/2015Medicare Drug Coverage Under Part A, Part B, and Part D4

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 Medicare Drug Coverage Under Part A, Part B, and Part D 06/01/20155

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  If covered under the Part A per-diem payment are excluded from coverage under Part D 06/01/2015Medicare Drug Coverage Under Part A, Part B, and Part D6

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 06/01/2015Medicare Drug Coverage Under Part A, Part B, and Part D7

Lesson 2—Coverage of Vaccinations  Overview of Medicare vaccination coverage 06/01/2015Medicare Drug Coverage Under Part A, Part B, and Part D8

Medicare Vaccination Coverage  Part A covers 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 covers vaccines for which no Part B benefit category exists And aren’t be covered under Part A or B 06/01/2015Medicare Drug Coverage Under Part A, Part B, and Part D9 *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.

a.Part A b.Part B c.Part D d.Her Medigap policy 06/01/2015Medicare Drug Coverage Under Part A, Part B, and Part D10 Pearl was given a tetanus shot after being scratched by a rusty nail. If she’s receiving Medicare- covered skilled nursing facility care and has Original Medicare and Part D, which part of Medicare will cover the shot? Check Your Knowledge—Question 1

a.Part A b.Part B c.Part D d.His Medigap policy 06/01/2015Medicare Drug Coverage Under Part A, Part B, and Part D11 Albert is receiving Medicare-covered 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? Check Your Knowledge—Question 2

Lesson 3—Outpatient Prescription Drug Coverage  Outpatient status  Medicare prescription drug coverage in outpatient settings 06/01/2015Medicare Drug Coverage Under Part A, Part B, and Part D12

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 are in observation status when you receive hospital outpatient services while your doctor decides whether you’ll be admitted as an inpatient or discharged. 06/01/2015Medicare Drug Coverage Under Part A, Part B, and Part D13

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 06/01/2015Medicare Drug Coverage Under Part A, Part B, and Part D14

Immunosuppressive Drugs Under Part B 06/01/2015Medicare Drug Coverage Under Part A, Part B, and Part D15  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 the 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

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 06/01/2015Medicare Drug Coverage Under Part A, Part B, and Part D16

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 06/01/2015Medicare Drug Coverage Under Part A, Part B, and Part D17

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. 06/01/2015Medicare Drug Coverage Under Part A, Part B, and Part D18

a.Inpatient b.Outpatient c.There isn’t sufficient information to make a determination d.Requiring skilled level of care 06/01/2015Medicare Drug Coverage Under Part A, Part B, and Part D19 Based on the information provided, what’s Mary’s hospital status? Check Your Knowledge—Question 3

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 06/01/2015Medicare Drug Coverage Under Part A, Part B, and Part D20 If Mary was a hospital outpatient, which of her prescription drugs would Part B cover? Check Your Knowledge—Question 4

a.Part A b.Part B c.Part D d.Her Medigap policy 06/01/2015Medicare Drug Coverage Under Part A, Part B, and Part D21 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? Check Your Knowledge—Question 5

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. 06/01/2015Medicare Drug Coverage Under Part A, Part B, and Part D22

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 06/01/2015Medicare Drug Coverage Under Part A, Part B, and Part D23 Why did the pharmacy bill Medicare Part B for Pearl’s Hepatitis B vaccine? Check Your Knowledge—Question 6

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. 06/01/2015Medicare Drug Coverage Under Part A, Part B, and Part D24

a.Part A b.Part B c.Part D d.Her Medigap policy 06/01/2015Medicare Drug Coverage Under Part A, Part B, and Part D25 Which part of Medicare should cover Marian’s self- injected insulin? Check Your Knowledge—Question 7

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. 06/01/2015Medicare Drug Coverage Under Part A, Part B, and Part D26

a.Part A b.Part B c.Part D d.His Medigap policy 06/01/2015Medicare Drug Coverage Under Part A, Part B, and Part D27 Which part of Medicare should cover Bob’s self- injected immunosuppressant prednisone? Check Your Knowledge—Question 8

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