Monday, December 7, 2009

Is there a small employer exception for employers who are subject to the creditable coverage requirement under Part D?

Question: Is there a small employer exception for employers who are subject to the creditable coverage requirement under Part D?

Answer: No, the final regulation does not include an exception for small employers; any entity that sponsors prescription drug benefits for a Medicare eligible individual is required to provide the creditable coverage disclosure.


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What constitutes “creditable coverage”?

Question: What constitutes “creditable coverage”?

Answer : Creditable coverage is prescription drug coverage that, on average, expects to pay out at least as much as the standard coverage available through a Medicare prescription drug plan. This may be prescription drug coverage that is provided through a current or former employer, or union, the VA, a state sponsored plan, etc. Entities providing prescription coverage are required to notify their Medicare eligible members of whether their coverage is creditable or not on an annual basis and at other times as specified at 42 CFR 423.56.

Additional information regarding creditable coverage can be found on the CMS web site at: http://www.cms.hhs.gov/CreditableCoverage/01_Overview.asp


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Where should manufacturers submit their ASP data?

Question: Where should manufacturers submit their ASP data?

Answer : When sending ASP data to CMS via first class mail, federal express mail, or overnight delivery, please use the following address:

Centers for Medicare & Medicaid Services
Hospital and Ambulatory Policy Group
Division of Ambulatory Services
ATTN: Medicare ASP Data
Mail Stop No. C4-01-26
7500 Security Boulevard
Baltimore, MD 21244
Phone: 410-786-0548

Please include technical contact information for questions that may arise with the data submitted. Specifically, include the technical contact name, phone number, fax number, and e-mail address. Manufacturers requiring acknowledgment of our receipt of their diskette or CD-ROM data must include a stamped, self-addressed postcard or envelope with their submission. This postcard or envelope will be date stamped and returned but will only acknowledge receipt of the diskette, or CD-ROM data. If the ASP information is unreadable, is in the wrong format, is blank or, in any other way cannot be processed by us (e.g., virus), a phone call to the technical contact will be made. Diskettes or CD-ROMs will NOT be returned under ANY circumstances.

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Medicare drug discount card program

Question: Should manufacturers include discounts given under the Medicare drug discount card program in their average sales price data submitted to CMS?

Answer : No, as consistent with the MMA, manufacturers should exclude prices negotiated for covered discount card drugs under an endorsed discount card program in calculating ASP data. Beginning in 2006 when the Medicare Part D prescription drug benefit is implemented, manufacturers should also exclude any prices negotiated by a prescription drug plan (including a Medicare Advantage plan) or by a qualified retiree prescription drug plan (as defined in section 1860D-22(a)(2)) on behalf of Part D eligible individuals.

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Question: Will the availability of the $600 credit or discount prices prevent or delay an individual's eligibility for Medicaid under a "spenddown?"

Answer : No. Neither the $600 credit nor the discount prices will have a negative impact on the Medicaid eligibility process. The discount and any portion of the $600 credit used for precription drugs will be treated as incurred medical expenses for purposes of Medicaid spenddown, and there will be no delay in the onset of Medicaid eligibility. CMS will issue guidance on how the Medicaid State agencies will calculate the applicant's level of drug spending to apply to "spenddown."

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