CMS delays enforcement of Medicare Part D rule

The Centers for Medicare & Medicaid Services announced that it is delaying enforcement of the requirements in 42 CFR § 423.120(c)(6) for the Medicare Advantage and prescription drug benefit (Medicare Part D) programs until Dec. 1, 2015.

In May, CMS finalized (CMS-4159-F), a rule aimed at combating fraud and abuse in the Part D program. Under 42 CFR § 423.120(c)(6), physicians, and when applicable other eligible healthcare professionals who write prescriptions for Part D drugs, must either be enrolled in an approved status or have a valid opt-out affidavit on file with their Part B Medicare Administrative contractors. That provision was to take effect June 1, 2015.

Although enforcement of that specific requirement has been delayed, providers still must be in compliance by no later than June 1, 2015 to ensure that their Medicare Administrative contractors have sufficient time to process the applications or opt-out affidavits and avoid prescription drug claims from being denied.

Providers may submit their application electronically using the Internet-based Provider Enrollment, Chain, and Ownership System or by completing the paper CMS-855I or CMS-855O application, which is available at

CMS-4159-F also is designed to do the following:

  • Improve payment accuracy
  • Expand prevention and health improvement incentives
  • Increase price transparency for network pharmacies
  • Allow for the revocation of Medicare enrollment for abusive prescribing practices and patterns
  • Allows CMS, anti-fraud contractors and other oversight agencies to request and collect information directly from those entities that contract or subcontract with Part D sponsors to administer the Medicare prescription drug benefit
  • Expand Part D data sharing

Click here to read more about the delay.

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The Health Law Offices of Anthony C. Vitale