The SPARC Act and Compliance with Medicare Advantage plans PART D prescription drugs

Haro v. Sebelius- Medicare Conditional Payment CollectionIn September, Congressman Tim Murphy (R-PA) and Congressman Ron Kind (D-WI) introduced bipartisan legislation into the U.S. House of Representatives to improve the Medicare Secondary Payer (MSP) Act as it pertains to the Medicare Prescription Drug (Part D) program. The Secondary Payer Advancement, Rationalization and Clarification (SPARC) Act (H.R. 6120) would clarify the Part D Medicare Secondary Payer (MSP) provisions with specific parameters to follow when resolving claims that involve Medicare beneficiaries who have related claims that were paid by Medicare Part D insurance plans.

The SPARC Act is anticipated to diminish the ambiguity associated with the Medicare Secondary Payer (MSP) claim compliance process and allow for efficient repayment of amounts owed from claims to be paid directly to the Medicare Part D Prescription Drug Plans (PDPs). Since the MSP provisions of the Social Security Act prohibit Medicare from making payment where payment has already been made or can reasonably be expected to be made by a primary plan, the payments made by the Part D plan are paid conditionally, with the expectation that the conditional payments would be reimbursed, once primary payment responsibility is demonstrated by accepting ongoing responsibility for medical (ORM) expenses and/or by settlement, judgment or award.

Current Medicare beneficiaries with workers’ compensation, no-fault, and/or liability claims experience uncertainty and delays in settling claims, because it is difficult to find out how much money has to be repaid to Part D Plans upon settlement. As such, the Part D plans are not promptly reimbursed for medications prescribed to Medicare beneficiaries that are related to the treatment of their injuries.

  • Expedited repayment procedures proposed by the SPARC Act are designed to avoid wasting claim, judicial, governmental and taxpayer resources, not to mention the Medicare Trust Fund. The SPARC Act would:
  • Require the Centers for Medicare and Medicaid Service (CMS), to convey settlement information to Part D Plans, coordinating benefits within 15 days of receipt
  • Require Part D drug plans to instruct pharmacies to bill entities that have accepted ORM benefits
  • Prevent Part D plans from paying for prescription medication when other plans are responsible

If the SPARC Act passes, it is expected to enable Medicare beneficiaries to settle claims sooner. It will also enable insurers to resolve claims quicker, with greater certainty, and the Part D Prescription Drug Plans, as well as the Medicare Trust Fund, will be efficiently reimbursed.

The bill, however, doesn’t specify how workers’ compensation insurers should account for the shifting of pharmacy costs to Medicare post settlement. It seems that injured workers would want apportion a part of the total settlement amount toward related prescription costs needed in the future; however, the SPARC Act, as written, would make workers’ compensation insurers responsible for prescriptions reimbursement until the settlement of a Medicare beneficiary’s workers’ compensation claim. Afterward, Medicare’s Part D plan would become the primary payer, thus eliminating the need for the workers’ compensation Medicare Set-Aside (WCMSA) arrangement to allocate for prescription drugs otherwise covered by the Part D plan. Regardless, many state workers’ compensation statutes may still require prescriptions to be allocated in the WCMSAs even if SPARC Act is enacted.

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.