Last modified: 11 May 2000
DEPARTMENT OF HEALTH & HUMAN SERVICES
Financing Administration
Date
DEC 7 1994
From Director - Office of Program Operations Procedures, BPO
MARVIN M. STOOGENKE, R.PH.
Health Care Financing Administration
Bureau of Program Operations
OPOP/DCPP/ Supplier Procedures Branch
Meadows East Building, Mail Stop G-A-5
Baltimore, Maryland 21207
Phone: (410) 966-9897
FAX: (410) 966-5327 or (410) 966-5882
Memorandum
Refer to; BPO-043
Subject Medicare Extended Coverage of Prescription Drugs Used in
Immunosuppressive Therapy Provided for by the omnibus Budget
To Reconciliation Act of 1993 (OBRA 1993).
Associate Regional Administrators for Medicare
The Omnibus Budget Reconciliation Act (OBRA) of 1986 required
Medicare Part B to cover immunosuppressive drugs for up to one
(1) year after a covered organ or tissue transplant, beginning
January 1, 1987. OBRA 1987 expanded the scope of coverage
from "immunosuppressive drugs" to include "prescription drugs
used in immunosuppressive therapy." OBRA 1993 authorized
phased-in extensions from 12 to 36 months to the period of
Part B coverage for prescription drugs used in
Immunosupposuppressive therapy after the hospital discharge when
a covered transplant has been performed.
Beneficiaries are eligible to receive additional Part B
coverage within 18 months after the discharge date for drugs
furnished in 1995; within 24 months for drugs furnished in
1996; within 30 months for drugs furnished in 1997; and within
36 months'for drugs furnished after 1997. The extension
applies to beneficiaries discharged from the hospital
following a covered transplant procedure as early as
August 1, 1993. The phase-in of the extended coverage periods
created confusion because, in some situations, there were
periods of noncoverage (i.e., gaps) before coverage resumes.
Beneficiaries discharged before August 1, 1993 receive payment
for prescription drugs used in immunosuppressive therapy for 1
year from the date of the hospital discharge.
For example, according to the statute, before 1995, coverage
for prescription drugs used in immunosuppressive therapy is
available for up to one year after discharge. In 1995,
coverage for prescription drugs is extended to 18 months after
discharge. Prescription drugs furnished to a beneficiary who
was discharged on August 1, 1993 includes the initial 12-month
coverage period from August 1, 1993 to July 31, 1994 and
coverage would resume on January 1, 1995 since the discharge
date is within 18 months. Therefore, the beneficiary receives
one additional month of coverage for prescription drugs used
in immunosuppressive therapy.
As a result of the gaps causing confusion, The Social Security
Amendments of 1994 provided a technical correction that
revised 51861(s)(2)(J) to allow the Secretary to administer
this section in such a manner that the months of coverage of
drugs described in such section are provided consecutively, so
long as the total number of months of coverage provided
consecutively is the same as the number of months that would
have been crovided under OBRA 1993. This technical amendment
effectively removed the gap problem.
Beneficiaries whose claims for these services were submitted
prior to January 3, 1995, and were rejected should be
adjusted. In order to correct this problem, notify your
carriers, regional carriers, and fiscal intermediaries to make
retroactive adjustments on a per-beneficiary basis as they are
identified by a supplier, provider, or beneficiary.
Adjustments will be based on the actual date of discharge from
the hospital, thereby limiting the number of beneficiar4es
affected. Changes to the Common Working File (CWF) are
scheduled for implementation on January 3, 1995. Until those
changes are in place, claims may be denied inappropriately for
some beneficiaries. Do not hold claims, however, adjustment
--'Wiil-need to be held until changes can be made to the CWF.
Continue to process and make adjustments as necessary. The
attached phased-in benefit schedule is provided as a guide to
help you in making retroactive adjustments. Process claims
subsequent to January 3, 1995 according to the consecutive-
months rule of the benefit extension.
Direct your carriers, regional carriers, and fiscal
intermediaries to conduct an outreach to beneficiaries,
suppliers, and providers notifying them of the retroactive
adjustments. Please have the contractors complete this
activity by no later than January 31, 1995.
Stewart H. Streimer
Attachment
cc: Regional Administrators
PHASED IN BENEFIT PERIODS FOR IMMUNOSUPPRESSIVE DRUG THERAPY
DISCHARGE COVERERAGE COVERAGE COVERAGE TOTAL
DATE PERIOD PERIOD PERIOD MONTHS OF
ENDS RENEWS ENDS COVERAGE
08/1/93 07/3/94 01/1/95 01/31/95 13
09/l/93 08/31/94 01/1/95 02/28/95 14
10/l/93 09/30/94 01/1/95 03/31/95 15
11/1/93 10/31/94 01/1/95 04/30/95 16
12/l/93 11/30/94 01/1/95 05/31/95 17
0l/l/94 06/30/95 18
02/l/94 07/31/95 01/1/96 01/31/96 19
03/l/94 08/31/95 01/l/96 02/29/96 20
04/l/94 09/30/95 01/1/96 03/31/96 21
03/l/94 10/31/95 01/1/96 04/30/96 22
06/l/94 11/30/95 01/1/96 05/31/96 23
07/l/94 06/30/96 24
09/l/94 07/31/96 0l/l/97 01/31/97 25
09/l/94 08/31/96 0l/l/97 02/28/97 26
10/l/94 09/30/96 0l/l/97 03/31/97 27
11/l/94 10/31/96 0l/l/97 04/30/97 28
12/l/94 11/30/96 0l/l/97 05/31/97 29
01/1/95 06/30/97 30
02/l/95 07/31/97 01/1/98 01/31/98 31
03/l/95 08/31/97 01/l/98 02/29/98 32
04/l/93 09/30/97 01/1/98 03/31/98 33
05/1/95 10/31/97 01/1/98 04/30/98 34
06/l/95 11/30/97 0l/l/98 05/31/98 35
07/l/95 06/30/98 36