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March 2016 Update:

CMS is now delaying enforcement of the Part D Prescriber Enrollment Requirements until February 1, 2017.

Nevertheless, prescribers of Part D drugs should submit their Medicare enrollment applications or opt-out affidavits to their Part B Medicare Administrative Contractors (MACs) by January 1, 2016, or earlier, to ensure that MACs have sufficient time to process the applications and opt-out affidavits. Various guidance documents are available at: https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/Prescriber-Enrollment-Information.html.

October 2015 Update:

CMS released a memo announcing a delay in the enforcement of the Medicare Part D Prescriber Enrollment Requirement.

The effective date was June 1, 2015.  The revised prescriber enrollment requirement applicability date is January 1, 2016.  Further, CMS is delaying enforcement of the requirements until June, 2016.  Nevertheless, prescribers of Part D drugs should submit their Medicare enrollment applications or opt-out affidavits to their Part B Medicare Administrative Contractors (MACs) by January 1, 2016, or earlier, to ensure that MACs have sufficient time to process the applications and opt-out affidavits.

See: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1434.pdf

May 2015 Update:

A new federal rule issued May 23, 2014, requires physicians, including psychiatrists and other prescribers of Part D drugs, to be enrolled in Medicare in an approved status or to formally opt out of Medicare to prescribe medications for their Part D patients.

Since the publication of the final rule, however, CMS has learned that certain pharmacists and other provider types who do not meet the statutory definitions of “physician” or “eligible professional” to enroll in Medicare are permitted to prescribe under state laws.  Without further action by CMS, valid prescriptions from these providers would be denied because the prescriber is neither enrolled in nor opted-out of Medicare.

CMS has therefore revisited this final rule.  Per an Interim Final Rule Issued May 1, 2015:

  • Part D sponsors are allowed to pay claims for providers who are permitted to prescribe under state law, but who do meet the statutory definitions to enroll in Medicare (referred to as “authorized prescribers”).
  • In addition, for prescribers who are eligible to enroll but have not done so or opted out, a Part D plan sponsor must allow beneficiaries a provisional 3-month supply of their drug and individualized written notice that they are receiving their drug only on a provisional basis.  This provisional supply is meant to give the prescriber time to enroll, or the beneficiary time to find a new prescriber.

The two changes made to the new Interim Final Rule should help protect beneficiary access to necessary medications under Medicare Part D.


Original Article:

In order to prescribe medications for their Part D patients, a new federal rule requires physicians, including psychiatrists and other prescribers of Part D drugs, to be enrolled in Medicare in an approved status, or to formally opt out of Medicare.  The original start date for this rule was June 1, 2015 but the actual implementation date has been pushed back.  Beginning December 1, 2015, patients presenting scripts written by prescribers who do not meet either one of these requirements will not be able to fill their prescriptions through their Part D plans.

The new rule is based on 42 CFR 423.120 (c) (6).  Prescribers of Part D drugs must submit their Medicare enrollment applications, or their opt-out affidavits, to their Part B Medicare Administrative Contractors no later than June 1, 2015 to allow the MACs sufficient time to process the requests by the policy start-date of December 1, 2015.  Prescribers may enroll in Medicare in order to be reimbursed for all Medicare-covered services, OR, they may enroll only for the purpose of prescribing Part D drugs.  Separate application forms for each purpose, and opt-out affidavit forms, may be completed electronically or on paper. There are no fees to complete either process.

A complete description of the new rule, instructions to complete the applications or affidavits, links to both paper and electronic documents, and links to a continuously updated enrollment file that identifies providers who are currently in an approved or opt-out status, are available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1434.pdf

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