Medicare Hospital Outpatient Prospective Payment System (OPPS) Changes for CY2005 Continued

• Medicare Payment Policy under the Physician Fee Schedule for Calendar year 2005
• Medicare Payment Policy under the Physician Fee Schedule for Calendar year 2005 Continued
• Medicare Hospital Outpatient Prospective Payment System (OPPS) Changes for CY2005
• Medicare Hospital Outpatient Prospective Payment System (OPPS) Changes for CY2005 Continued
• Revisions to the Physician Fee Schedule under Medicare Part B for Calendar Year 2005
• Revisions to the Physician Fee Schedule under Medicare Part B for Calendar Year 2005 Continued
• Revisions to the Physician Fee Schedule under Medicare Part B for Calendar Year 2005 Continued (2)
• Medicare Part A Pass-Through Payment Update CY2005

The CY2005 payment rates and beneficiary co-pay amounts for blood clotting factors and IVIG therapies are listed below:

Alpha1–Proteinase inhibitor (A1PI)

Alpha1 products are categorized under the OPPS as Single Indication Orphan Therapies. As such, CMS has the discretion to use a reimbursement methodology they deem appropriate for this category. In CY2005, these therapies will be subjected to a reimbursement based upon the higher of 88 percent of AWP or 106 percent of the average sales price (ASP). CMS has acknowledged in their final rule that due to the fact that two new therapies were introduced in CY2003, their original calculations may have created unanticipated access issues. The listed payment rate for CY2005 is currently identical to the CY2004 level of $3.43 per 10mg. Moving forward, CMS will use a volume weighted average of the AWP for all three (3) therapies currently on the market to calculate a reimbursement rate. This figure will be updated quarterly if deemed necessary throughout CY2005.

As you will notice, CMS is still relying on AWP figures to calculate and report reimbursement payment rates under OPPS for CY2005. As we transition into CY2006, as mandated in the MMA, CMS will set payment rate based on actual hospital acquisition costs. CMS has begun collecting data, and will continue to survey hospitals throughout CY2005 for the acquisition costs of recombinant and plasma-derived therapies in order to set reimbursement payment rates for CY2006. Any questions or concerns related to this article can be directed to ZLB Behring’s Toll-Free Reimbursement Answerline at 1-800-676-4266.

REFERENCES

Department of Health and Human Services. Centers for Medicare and Medicaid Services; 42 CFR Part 419; CMS-1427-FC. RIN 0938-AM75: Changes to the Hospital Outpatient Prospective Payment System and Calendar Year 2005 Payment Rates. Medicare Prescription Drug Improvement and Modernization Act of 2003 (Public Law 108-173); Section 621

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