Course | Basic | Medicare Payment and Reimbursement
In this course we will address scheduling processes, including<div><ul><li>Patient identification</li><li>Requested service</li><li>Medical necessity screening</li><li>Medicare Advance Beneficiary Notice of Noncoverage processing</li><li>Pa...
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Course | Overview | Medicare Payment and Reimbursement
This course provides a brief history and overview of Medicare and Medicaid. It describes government organizations that regulate and administer this program. This course also discusses Medicare reimbursement. In addition, it highlights recen...
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Course | Intermediate | Medicare Payment and Reimbursement
This course provides an overview of the prospective payment systems used in the Medicare program and as well as Medicare fee schedules. This course provides a general discussion and overview of Medicare reimbursement under the Inpatient Pro...
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Course | Intermediate | Medicare Payment and Reimbursement
This course provides a general discussion and overview of reimbursement provided by Medicare under the outpatient prospective payment system. It also discusses the use of ambulatory payment classifications in the outpatient prospective paym...
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On Demand Webinar | Intermediate | Medicare Payment and Reimbursement
As the senior population continues to outpace the relative growth of the general population, and Medicare Advantage is accounting for about one-third (and growing every year) of all new Medicare eligible enrollees, providers are increasingl...
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Fact Sheet | Medicare Payment and Reimbursement

Modernizing Part D and Medicare Advantage Final Rule Summary

Fact Sheet | Medicare Payment and Reimbursement

Modernizing Part D and Medicare Advantage Final Rule Summary

On May 16, 2019, the Centers for Medicare & Medicaid Services (CMS) put on public display at the Federal Register a final rule providing for revisions to the Medicare Advantage (MA) and Voluntary Prescription Drug Program (Part D) regulations to support plan negotiations for lower drug prices and lower out-of-pocket costs for enrollees of MA and Part D plans.

Major changes finalized in the rule include:

  • Permitting plan sponsors to use prior authorization and step therapy for protected class drugs (other than antiretrovirals) only for new starts, including to confirm that the use is for a protected class indication;
  • Requiring plan sponsors to implement an electronic real-time benefit tool (RTBT) that can integrate with at least one prescriber’s e-Prescribing (eRx) or electronic medical record (EMR) systems by 2021;
  • Allowing Medicare Advantage Prescription Drug (MA-PD) plans to impose step therapy utilization management practices on beneficiaries initiating therapy (new starts) of Part B drugs; and
  • Requiring MA and Part D plan sponsors to provide enrollees with information about drug price changes and lower-cost therapeutic alternatives.

Download the summary

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