**RPMS POS and Medicare Part D**

Frequently Asked Questions (FAQ)

**Will RPMS POS software be able to transmit Medicare Part D
Prescription Claims?**

Yes. The Office of Information Technology is in the process of obtaining
payer sheets for CMS approved plans. The payer sheets are used to make
the formats needed to transmit claims. A patch will be released in early
December along with instructions on how to set up the format in the POS
package.

By early November, information, including Insurer Names and addresses
will be distributed to assist sites in setting up the Insurers in Third
Party Billing Table Maintenance.

**How will the process change for Pharmacies transmitting electronic
prescription claims?**

From the pharmacies perspective, there will be very little change as
most of the changes are occurring behind the scenes by the Switch
company and the TrOOP facilitator.

One new feature that will be added to RPMS POS will be the Eligibility
transaction. This will enable users to send a transaction to the TrOOP
facilitator to determine Medicare Plan information. OIT is currently in
the testing phase of this new feature. There will be a fee (pass through
from the TrOOP facilitator) for this service of \$ 0.015 per transaction
(including rejected transactions).

**What is the process for transmitting a Medicare Part D prescription
claim?**

![](media/image1.wmf){width="4.989583333333333in"
height="3.751388888888889in"}

![](media/image2.wmf){width="4.989583333333333in"
height="3.751388888888889in"}

**What does the TrOOP facilitator do?**

The True Out-of-Pocket (TrOOP) Facilitator Contractor works with CMS,
Prescription Drug Plans (PDP), Medicare Advantage Prescription Drug
Plans (MAPD) and carriers of supplemental coverage to coordinate
benefits and track the sources of cost-sharing payments. NDC Health was
awarded the contract and is the TrOOP facilitiator.

<http://medifacd.ndchealth.com/home/MediFacd_home.htm>

**Do we have to pay for the transmission to the TrOOP facilitator for
PRESCRIPTION CLAIMS?**

No. Prescription claims will be transmitted through our contracted
Switch company, Emdeon (used to be WebMD) at the normal transaction
rate. Primary claims will be sent directly to the Prescription Drug Plan
(PDP). Claims for supplemental plans will be transmitted through the
Switch to the TrOOP facilitator at the normal transaction rate.

**Will we continue to use Emdeon (used to be WebMD) as our switch?**

Yes. Emdeon will support all facets of Part D claims, including
accepting and routing E1 (eligibility) messages, Medicare Part D
prescription claims and supplemental claims.

For [eligibility claims]{.underline}, Emdeon will bill the pharmacy the
regular switch fee (\$0.025) for routing the E1.  Emdeon will pass thru
a fee charged by NDC for processing the inquiry. The price of the
transaction has been set at \$0.015 for each claim.  The total charge
for this transaction would be \$0.025 + \$0.015 = \$0.04.

For [Medicare Part D prescription claims]{.underline}, Emdeon will
switch Medicare PDP and supplemental claims at the regular switch rate.
Emdeon switch developers are developing the necessary interfaces for
this traffic.

**How will TrOOP balances be provided to pharmacies?**

It will not be provided to the pharmacies. Prescription Drug Plans
(PDP's) are responsible for calculating TrOOP and for answering
questions regarding that TrOOP calculation. Pharmacies and patients
should contact the Part D plan for questions regarding TrOOP balances.

**How can pharmacies determine a patient's TrOOP balance?**

TrOOP balance is not provided to the pharmacies by the TrOOP Facilitator
(NDCHealth). If the patient has questions about their balance, they can
contact their Part D plan. The facility can choose to assist the patient
in contacting the Part D plan, if appropriate.

**For 340B pharmacies, does the waived cost-sharing count toward
TrOOP?**

No. Any entity, including a 340B pharmacy -- that has an obligation to
pay for covered Part D drugs on behalf of Part D enrollees, or which
voluntarily elects to use public funds for that purpose, will not count
toward that beneficiary's TrOOP expenditures.\"

**Does help from churches or charities count towards the TrOOP?**

Out-of-pocket spending consists of costs related to the \$250
deductible, the 25 percent beneficiary co-insurance (or equivalent
co-pays) up to the initial coverage limit, 100 percent co-insurance
during the coverage gap, and the roughly 5 percent co-insurance paid in
the catastrophic coverage. By law, only cost-sharing paid by certain
sources counts toward the drug benefit's out-of-pocket limit, which
defines the start of the catastrophic coverage. These sources include:

-   The enrollee (or another person on behalf of the enrollee)

-   CMS (on behalf of a low-income enrollee who qualifies for low-income
    subsidies)

-   A State Pharmaceutical Assistance Program (SPAP)

-   A charitable organization

So, any drug payments it makes on behalf of Part D enrollees would count
toward True out-of-pocket costs (TrOOP) unless otherwise excluded as
payments by a group health plan, insurance or otherwise, or similar
third party payment arrangement.

Charities that are established, maintained, or otherwise controlled by
an employer or union will likely fall under the definition of "group
health plan" and will therefore be excluded from TrOOP on this basis.\
\
Cost-sharing in the Indian Health Service will not count toward the
out-of-pocket limit.

**What is the Eligibility (E1) Transaction?**

A facility (Patient Registration or the Pharmacy) uses the E1
transaction when they need to know the insurance coverage information
for a patient enrolled in a Medicare Part D plan.

This process allows the facility to submit real-time transactions to the
Facilitator to determine a patient's insurance coverage information. The
Facilitator returns information about each of the insurance companies
providing coverage for the patient.

+-----------------------------------------------------------------------+
| ![](media/image3.png){width="4.925694444444445in"                     |
| height="1.8118055555555554in"}                                        |
|                                                                       |
| 1.  Pharmacy submits the E1 transaction to the switch that handles    |
|     their regular billing claims.                                     |
|                                                                       |
| 2.  The Switch forwards to the Facilitator the E1 Request.            |
|                                                                       |
| 3.  The Facilitator uses the E1 Request to match the data contained   |
|     within the Request to its Eligibility file. The Eligibility file  |
|     is provided to the Facilitator by CMS and is updated nightly.     |
|                                                                       |
| 4.  The Facilitator returns the Response to the Switch.               |
|                                                                       |
| 5.  The Switch returns the Response to the Pharmacy.                  |
|                                                                       |
| 6.  The Pharmacy uses the information contained in the message to     |
|     create the billing claim for the patient.                         |
+-----------------------------------------------------------------------+

**Why would a facility use the Eligiblity (E1) Transaction?**

-   When the patient does not have their Part D plan card or information

-   To retrieve information needed for billing a claim to a patient's
    insurance plans

-   To determine billing order

**What information is transmitted in an Eligibility (E1) transaction?**

Patient's Date of Birth, first and last name, zip code, gender and
cardholder ID (Medicare Part A or B number or last four digits of their
social security number.

**Will we be able to use the Eligibility Transaction through POS?**

Yes.

**What is "wrap-around" coverage?**

This is coverage provided by the plan that would supplement the members
Part D coverage, i.e. copay, coverage gap. Wrap around coverage does not
count towards TrOOP.

**Does the deductible have to be met before the pharmacy will start
receiving** **reimbursement?**

Yes.

**What is the Limited-Income Subsidy (LIS)?**

Limited Income Subsidy is additional financial assistance for Medicare
beneficiaries (duel-eligible, QMB, QI, SLMB) that qualify for extra help
in paying for their drug premiums. Most will have their full premium
paid by Medicare if they enroll in a plan with the premium below the LIS
benchmark level.  <http://www.cms.hhs.gov/healthplans/rates/>

**Definitions:**

Dual Eligibles: Beneficiaries who qualify for both Medicare and
Medicaid. Medicare.

PBM: Pharmacy Benefit Manager

PDP: Prescription Drug Plan

QMB: (Qualified Medicare Beneficiary) A beneficiary who receives a
complete subsidy of monthly premiums and reductions in cost sharing for
the Medicare prescription drug benefit. This category is based on income
eligibility of 100% or less of the federal poverty income level and the
amount of liquid assets.

QI: (Qualifying Individual) A beneficiary who receives a complete
subsidy of monthly premiums and reductions in cost sharing for the
Medicare prescription drug benefit. This category is based on income
eligibility of 120 to 135% of the poverty guideline and the amount of
liquid resources the beneficiary owns.

SLMB: (Specific Low-Income Medicare Beneficiary) A beneficiary who
receives a complete subsidy of monthly premiums and reductions in cost
sharing for the Medicare prescription drug benefit. This category is
based on income eligibility of 100 to 120% of poverty guideline and the
amount of liquid assets (resources).

[Catastrophic Cap:]{.underline}

TrOOP: the amount needed to reach the catastrophic cap and is always
\$3,600 (250+500+2850)

Part D plan - In the standard benefit, the amount Part D pays before the
catastrophic cap is always \$1,500 (75% of \$2000).

All payers -- Total cost for all payers (standard coverage) before the
catastrophic cap is \$ \$5100 (\$2250 + \$2,850)