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Upcoming Change to Medicare Enrollment Requirement for Medicare Parts C and D Providers


The Centers for Medicare & Medicaid Services (CMS) has announced a change in the requirement that providers and suppliers contracting with Medicare Advantage (MA) plans (Medicare Part C), and those who prescribe drugs covered by Medicare Part D programs, must be enrolled in Medicare.

Effective January 1, 2019, the regulations specify that CMS rely on a “Preclusion List”  to eliminate those providers, prescribers and suppliers who are ineligible to provide services or items under the programs.

The requirement that prescribers be enrolled in Medicare if they want to prescribe medications for covered Part D drugs goes back to 2014. Then in 2016 CMS implemented another rule that mandated that all providers and suppliers furnishing health care services or items to MA plan members be enrolled in Medicare by 2019.

Impact of the Medicare Advantage Final Rule

In the MA Final Rule, released on April 2, this requirement is eliminated. The new regulations prohibit MA plans from paying for services provided by health care providers and suppliers that are included in a “Preclusion List,” and also require that a pharmacy claim for a Part D drug be rejected if the prescriber is on the “Preclusion List.”

The “Preclusion List” will be compiled by CMS and will be separate and distinct from the OIG Exclusion List. Basically, those on the “Preclusion List” will be providers and suppliers who are currently revoked from Medicare orwho have engaged in behavior that might have caused revocation, and those whose conduct is detrimental to the best interests of Medicare as determined by CMS.

The impact of the new rule should be positive, including greater flexibility to those providers, suppliers and prescribers not enrolled in Medicare by allowing them to provide services to MA plan members. The burden of enrollment will be somewhat eased as well.

Let Us Manage All Your Payer Enrollment Services

If you require medical credentialing and payer enrollment needs for your practice or medical facility, please contact 1st Assistant. Our experienced and dedicated specialists will provide all credentialing and enrollment services quickly and will monitor your account for ongoing updates and re-attestations. Heidi Henderson, our company owner and President, is eager to meet you and discuss your payer enrollment needs. Please call us at 512.201.2668 or contact us via the website.

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