Medicare Prescription Payment Plan FAQs Update for CY2025
Relevant to: PDP, PDF, COB, Part D
Each week, we scan the latest CMS memos to find the most important ones that apply for PACE programs. Below is a summary of what you need to know.
Disclaimer: The content provided on this site is a summary for informational purposes only, and Grane PBM, Inc. assumes no liability for any errors or omissions in the site’s content. The information does not constitute legal or regulatory advice or replace the original CMS memo. Readers are advised to consult the CMS memo in its entirety and to verify information independently before making any decisions based on this information.
Click here to read the complete guidance on the Medicare Prescription Payment Plan for CY2025
Introduction
The Centers for Medicare & Medicaid Services (CMS) has recently updated its Frequently Asked Questions (FAQs) to aid Part D sponsors and stakeholders in the effective implementation of the Medicare Prescription Payment Plan starting in 2025. Through this initiative, Part D sponsors are mandated to offer enrollees the option to spread their out-of-pocket prescription drug expenses over monthly installments rather than paying in full at the point of sale. This update not only clarifies previous guidances but also introduces new elements to ensure smooth adoption and address potential inquiries from all interested parties.
Key Dates and Deadlines
- Frequently Asked Questions document originally released in the October 1, 2024, HPMS memo
- Final part one guidance for the Medicare Prescription Payment Plan issued on February 29, 2024
- Final part two guidance for the Medicare Prescription Payment Plan issued on July 16, 2024
- New information added to FAQs in November 2024
- Annual Election Period for CY 2025 begins on October 15, 2024
PACE Compliance
This memo outlines updates to the Medicare Prescription Payment Plan for CY2025, and while it is not directly related to Programs of All-Inclusive Care for the Elderly (PACE), any changes in Medicare payment plans might incidentally impact PACE programs due to their interactions with Medicare benefits.
PACE programs must ensure that any changes to Part D prescription drug benefits are incorporated into the individualized care plans tailored to each participant. Given that Medicare changes can affect payment responsibilities or processes, particularly for prescription drugs, it’s crucial for PACE organizations to evaluate if added guidance will alter existing agreements or coverage processes.
If a PACE organization serves Medicare Part D enrollees, it’s important to follow any new procedures for processing claims related to the Medicare Prescription Payment Plan. Coordination with state-specific policies might also be necessary if there are overlaps with State Pharmaceutical Assistance Programs (SPAPs) or other local aid resources.
PACE providers should update their compliance checks and ensure their care coordinators and administrative staff are informed of all changes to adequately manage billing, especially when dealing with out-of-pocket costs spread over a plan year rather than at the point of sale. Documentation should be adjusted as per new guidance outlined in the Medicare Prescription Payment Plan memo.
Although not explicitly mentioned, PACE organizations should consider monitoring CMS releases for any spillover implications of Part D changes on their services and remain prepared to adapt to both policy adjustments and participant care needs as they arise.
Required Actions
1. Make sure all Part D enrollees are informed about the new option to pay OOP costs in monthly amounts over the plan year, instead of at the POS.
2. Review the updated FAQs related to the Medicare Prescription Payment Plan for CY2025 to ensure compliance and smooth implementation.
3. For any questions or clarifications needed, contact MedicarePrescriptionPaymentPlan@cms.hhs.gov as soon as possible.
FAQs
- “What is the Medicare Prescription Payment Plan and when does it start?”
- “Can Part D enrollees receive charitable assistance while participating in the Medicare Prescription Payment Plan?”
- “What happens if a Part D enrollee switches plans mid-year?”
- “Under what circumstances can a Part D sponsor deny a request to participate in the Medicare Prescription Payment Plan?”
- “Are drugs covered through pharmaceutical manufacturer patient assistance programs eligible for the Medicare Prescription Payment Plan?”
Click here to read the complete guidance on the Medicare Prescription Payment Plan for CY2025
