Changes for ESRD Capitation for 2011

December 30th, 2010

If your receive Medicare Monthly Capitation Payments (MCPs) to manage ESRD patients remember these requirements for ESRD beneficiaries to access ESRD-related drugs that go into effect January 1, 2011. It's important to follow the new rules in order for your patients to receive ESRD-related drugs.

MCP physicians and practitioners must:

  • Indicate on an ESRD patient’s prescription when a medication is not ESRD-related so payment for these non-ESRD-related medications is made under Part D.
  • If a lab is performed in office and is not related to ESRD, please append modifer AY and supply a non ESRD diagnosis.

ESRD facilities must:

  • Instruct patients to obtain their ESRD-related medications from ESRD facility-contracted pharmacies to ensure that pharmacies receive payment from the ESRD facilities and patients receive their medications with no financial obligation.
  • Instruct physicians and practitioners who receive MCPs to manage ESRD patients, to direct their patients to use ESRD facility-contracted pharmacies to ensure that pharmacies receive payment from the ESRD facilities and patients receive their medications.
  • Indicate on ESRD claims each ESRD-related drug (except for composite rate drugs) furnished to an ESRD patient either directly or through a prescription filled by a pharmacy.
  • Use the AY modifier on ESRD claims for each non-ESRD-related drug furnished to an ESRD patient.
  • Instruct home dialysis patients currently under Method II about any changes in the arrangements for ESRD-related home dialysis supplies and that patients no longer have any financial obligation to suppliers for ESRD-related supplies on or after January 1, 2011. 

 
ESRD patients may obtain covered Part D non-ESRD-related prescription drugs from a network pharmacy or an out-of-network pharmacy in accordance with Part D rules.

For more information visit:  http://www.cms.gov/MLNMattersArticles/downloads/MM7064.pdf

Also, remeber beginning January 1, 2011 a home-based dialysis patient must have one face-to-face visit with a provider per month.  Visit our prior blog post for details.

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