Part D Prescribers Must Enroll in (or Validly Opt-Out of) Medicare

As a Medicare Advantage organization, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is reminding providers who currently prescribe drugs for Medicare patients, but who are not enrolled in (or validly opted-out of) Medicare, of an important new Medicare requirement. Failure to comply could result in your Medicare patients not being able to obtain the drugs you prescribe for them if you do not enroll in Medicare or validly opt out of Medicare, either fully to bill or for the limited purpose of prescribing Part D drugs.

What’s Changed?

The Centers for Medicare & Medicaid Services (CMS) published rules that will soon require nearly all providers (i.e.; dentists, physicians, psychiatrists, residents, nurse practitioners, and physician assistants), who prescribe drugs for Medicare Part D patients to enroll in Medicare (or validly opt out of Medicare, if appropriate). Beginning June 1, 2016, CMS will enforce a requirement that Medicare Part D prescription drug benefit plans may not cover drugs prescribed by providers who are not enrolled in (or validly opted out of) Medicare, except in very limited circumstances.

Why Is This Important?

Unless enrolled (or validly opted out of), Medicare Part D plans, providers will be required to notify Medicare patients that they are unable to prescribe covered Part D drugs. Please also note providers who have opted out of Medicare cannot receive reimbursement from traditional Medicare or a Medicare Advantage plan, either directly or indirectly (except for emergency and urgent care services; see 42 CFR 405.440 for details.)

Next Steps

To help your Medicare patients, please enroll in Medicare either fully to bill or for the limited purpose of prescribing Part D drugs. There are no fees to complete the process. You can do so electronically or via a paper application:

• Electronic Process: Use the PECOS system at go.cms.gov/pecos. For limited enrollment, we recommend using the step-by-step instructions at go.cms.gov/PECOSsteps and viewing a video tutorial at Go.cms.gov/PECOSVideo.
• Paper Process: Or, complete the paper application for limited enrollment at go.cms.gov/cms855o, and submit it to the MAC in your geographic area. To locate your MAC, please refer to the MAC list at go.cms.gov/partdmaclist.

If you need assistance with the enrollment process (or validly opting out) of Medicare, please contact the MAC within your geographic area.

Thank you for your prompt and careful attention to this important matter and for serving Medicare members. These new CMS rules will enable federal officials to better combat fraud and abuse in the Medicare Part D program through verification of providers’ credentials via the Medicare enrollment or opt-out process.