Health Information Management

Hospitals now eligible to bill self-administered drugs

APCs Insider, February 18, 2005

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Hospitals now eligible to bill self-administered drugs

Question:  The Medicare Prescription Drug Benefit Final Rule was published in the January 28, 2005, Federal Register. Did the rule say anything about the new Part D benefit covering hospital self-administered drugs that are billed to patients?

Answer: Yes, on p. 4268 of the Final Rule CMS had the following to say on this issue:

1) Part D pharmacy plans can choose to include hospital pharmacies in their networks. If a hospital pharmacy is in the network, then self-administered drugs are covered by that plan.

2) Medicare mandates that all Part D pharmacy plans guarantee out-of-network access to covered Part D drugs dispensed to patients by hospitals and other institution-based pharmacies.

There are no details about how the Part D plans will guarantee the access or what the possible requirements are for hospitals to bill the pharmacy plans. It is not even clear whether hospitals will bill the plans or continue to bill the beneficiary who must submit the hospital invoice to the plan for reimbursement. Presumably, CMS will issue further guidance in an upcoming transmittal.

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