Part B Versus Part D Coverage Determinations

[yogooglethis]

I can't get a straight question from Med Supp carrier on this. I have a prospect that pays over 400.00 a month as the spouse of a State of NC retiree with a EGHP with a 700.00 deductible and 20% for most outpatient and inpatient services including part B drugs up to the 3200.00 MOOP.He is getting shots in his eye of the medication Avastin and Eylea and is paying about 500.00 month in part B charges for this.I spoke to the Express scripts group part D customer service and they said these drugs could be billed under part D and the cost would be about 200.00 a month but he can possibly save much more by switching to a Med Supp.


He can get a Med Supp for about 150.00 a month and have part B drugs covered at 100% .The rest of his meds are low cost. I assume that since Medicare is his primary now and his doctors bill now bill this under part B they would continue to bill this under part B and that any Med Supp carrier would have no say in the matter? I believe this is right but i can't find any literature that directly addresses this.If you research part B vs part D coverage determination the literature is somewhat vague for some part B vs part D overlap drugs but in this case the determination has already been made and the treatment would still be provided by same provider in same outpatient setting so this shouldn't change if Medicare will continues to be primary right?

 

[Josh]

Here's what's concerning me about your situation:

Part B vs Part D drugs is a slightly grey area, but the line is generally drawn at if it's provided in a physician office vs picked up at a pharmacy. I'll admit I've been out of the Medicare game for a little while at this point, but I can't think of how the drug can be covered under both. Either it's a Part B drug or it's not.

Another question that comes to mind is that if he's on a supp with such an expensive drug, how would he qualify for a different supp? Each state has it's own rules and situations can vary, so that may not be important, but that's a flag that's going up for me.

What I think answers your question is that a supp pays after Medicare. If Part A/B are covering something, they pay what's left (such as they have to). If Medicare A/B pay 80% and the client has a plan F (to make things simple) then the supp is on the hook for the 20%. The supp can't go back and cry foul because it's up to Medicare A/B. If Medicare A/B kicks rejects the claim, then the supp will deny the claim because Medicare A/B kicked it.

That make sense? That help?

To put it another way, of patient was receiving XYZ drug at their doc with Medicare paying primary, changing supp wouldn't change that and the new supp (provided they went through underwriting and any other applicable requirements) would be on the hook for the gap up to the coverage amounts.

That answer your question?

 

[asher]

In this situation your client would be better off with a supplement. Less expensive and comprehensive. The OOPS on current far too high relative to cost. Avastin & Eaylea are Part B drugs.
Medicare pays 80% sup pays balance. I've never heard anyone getting eye injections thru Medicare D.

Do him a service put this prospect on a supplement NOW!
Good Luck.

 

[G.Gordon]

Yep, my clients getting those shots are billed on pt. B. Give him to a carrier you don't like or that has deep pockets. AARP comes to mind.

 

[yogooglethis]

In this situation your client would be better off with a supplement. Less expensive and comprehensive. The OOPS on current far too high relative to cost. Avastin & Eaylea are Part B drugs.
Medicare pays 80% sup pays balance. I've never heard anyone getting eye injections thru Medicare D.

Do him a service put this prospect on a supplement NOW!
Good Luck.

Right normally the medications in these shots would be covered under part B because the drugs were procured and administered by provider however if a patient was to " brown bag " these drugs it can be billed under part D.

If I don't write this case on a Med Supp I advised client to get their doctor bill it under their group part D plan because it would be only 200.00 a month even through the gap.
- - - - - - - - - - - - - - - - - -

Here's what's concerning me about your situation:

Part B vs Part D drugs is a slightly grey area, but the line is generally drawn at if it's provided in a physician office vs picked up at a pharmacy. I'll admit I've been out of the Medicare game for a little while at this point, but I can't think of how the drug can be covered under both. Either it's a Part B drug or it's not.

Another question that comes to mind is that if he's on a supp with such an expensive drug, how would he qualify for a different supp? Each state has it's own rules and situations can vary, so that may not be important, but that's a flag that's going up for me.

What I think answers your question is that a supp pays after Medicare. If Part A/B are covering something, they pay what's left (such as they have to). If Medicare A/B pay 80% and the client has a plan F (to make things simple) then the supp is on the hook for the 20%. The supp can't go back and cry foul because it's up to Medicare A/B. If Medicare A/B kicks rejects the claim, then the supp will deny the claim because Medicare A/B kicked it.

That make sense? That help?

To put it another way, of patient was receiving XYZ drug at their doc with Medicare paying primary, changing supp wouldn't change that and the new supp (provided they went through underwriting and any other applicable requirements) would be on the hook for the gap up to the coverage amounts.

That answer your question?

Yes thank you it does however one clarification - he is on a retiree group plan which he would be voluntarily dropping.

Now that opens the other can of worms which is what Med Supp carrier in NC offers GI in this situation? Then the carrier wants the coverage termination letter from his current coverage to issue new coverage.

I was only considering doing this because it could save him a good bit of money and give him much better medical coverage if it all falls into place and also because his retiree plan with the state of NC will allow him to opt back in plan in next open enrollment but now I think i may just leave this one alone just to be safe.