REMICADE® (infliximab) and Medicare

Overview of Medicare1

Medicare is a federal program that provides health insurance coverage to the following types of people:

  • Individuals over age 65 with a work history
  • Individuals with certain disabilities who have been disabled for at least 2 years
  • Individuals diagnosed with end-stage renal disease (ESRD)

While Medicare covers many healthcare needs, it may not cover all of the patient's healthcare costs. The patient may have to pay a monthly premium for Medicare and then pay a coinsurance and deductible for many services.

Medicare Coverage of REMICADE®

Medicare covers most physician-administered drugs like REMICADE® under Medicare Part B. There are comprehensive published Part B coverage policies specific to REMICADE®. Copies of coverage policies (for example, local coverage determinations [LCDs]) are available on your regional Medicare Administrative Contractor's (MAC's) website, which can be found in the Billing section of this website.

Medicare typically places few restrictions on REMICADE® coverage. However, some Medicare policies may limit coverage of REMICADE® to certain diagnoses, such as:

  • Crohn's disease
  • Ulcerative colitis
  • Rheumatoid arthritis
  • Ankylosing spondylitis
  • Psoriatic arthritis
  • Plaque psoriasis

You can check your regional MAC website for coverage policies for REMICADE® or call AccessOne® at 1-888-ACCESS-1 (1-888-222-3771) for more assistance.

The 4 Parts of Medicare1

Medicare is divided into 4 parts: A, B, C, and D. Part A covers facility care such as hospitals, and Part B covers physician and other outpatient services. Part C, which is known as the Medicare Advantage program, allows private managed care plans to administer a patient's Medicare benefits.

Medicare Part D offers prescription drug coverage to anyone enrolled in Medicare Parts A or B. Table 1 provides additional detail regarding the 4 parts of the Medicare program.

Table 1. The 4 Parts of Medicare
Part A
Typically known as the hospital benefit, Part A provides coverage for services such as hospitalizations, hospice care, skilled nursing facility stays, and home health services.
Part B
Part B benefits provide reimbursement for physician services, clinical laboratory services, hospital outpatient services, prescription drugs administered "incident to" a physician's services, durable medical equipment, and some home health services.
Part C
Also known as Medicare Advantage, this benefit provides Medicare Part A and Part B. Some plans may also offer Medicare Part D. These plans are also called Medicare Advantage Prescription Drug Plans.
Part D
Prescription drug coverage for medicines that are usually self-administered or taken orally.

To learn more about the different parts of Medicare, you can call the Medicare program at 1-800-MEDICARE (1-800-633-4227) or visit www.medicare.gov.

Updates to Medicare in 2016

Annual updates to the Medicare program may affect providers and patients in 2016. Updates include changes in patient cost-sharing for Medicare coverage and services.

It will be important to monitor the Medicare program in 2016, because additional changes may go into effect throughout the year. The following are updates to some of the patient costs associated with Medicare in 2016.

Part A (Inpatient Hospital, Skilled Nursing Care)2

Most Medicare beneficiaries do not pay a monthly premium for Part A coverage. However, they may have to pay a deductible for inpatient hospital stays, skilled nursing facility stays, and some home health services. For each benefit period, Medicare pays all covered costs except the Part A deductible. Medicare Part A cost-shares have increased for calendar year 2016. For each benefit period, the patient pays:

  • A total of $1,288 for a hospital stay of 1-60 days
  • For days 61 through 90, the patient is responsible for an additional $322 coinsurance/day
  • For days 91 and beyond, the patient is responsible for an additional $644 coinsurance per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over your lifetime)
  • Beyond lifetime reserve days, the patient is responsible for all costs

Part B (Physician Services, Outpatient Hospital Services, Certain Home Health Services, Durable Medical Equipment)2

In 2016, the monthly fee or premium for Medicare Part B is based on your income. The standard premium for 2016 is $121.80, however, most people who receive Social Security benefits will continue to pay the same Part B premium amount as they paid in 2015 ($104.90). Some people will pay a higher premium if their modified adjusted gross income is more than $85,000 for an individual or $170,000 for a married couple. These amounts change each year. There is also a $166.00 deductible in 2016. After patients meet the deductible, they pay 20% of the Medicare-approved amount for services. Medicare Part B covers 80% of all Medicare-approved services.

Part C (Medicare Advantage)

Because these plans offer a variety of coverage, the patient's cost-share (eg, copay or coinsurance, deductibles, and premiums) can vary from plan to plan. If you are enrolled in a Medicare Advantage plan, you should check with the specific plan to find out what the cost-share will be for 2016.

Part D (Prescription Drug Coverage)

In 2016, people with Medicare Part D will pay an average monthly premium of $34.10.3 After a $360 deductible, patients pay 25% of the next $3,310 in prescription drug costs. Patients will then be in the "donut hole" (also known as the coverage gap), where they will pay 45% of the plan's cost for covered brand medications and 58% of the plan's cost for covered generic medications until they reach $4,850 in out-of-pocket prescription drug costs. This is known as the catastrophic coverage phase. Patients are responsible for 5% of all additional drug costs after reaching the catastrophic coverage phase.4

Medicare Supplemental Coverage1

Most patients who have Medicare also have some type of secondary insurance coverage. This secondary coverage may be an employer-sponsored plan, Medigap plan, or the Medicaid program. These plans offer a wide variety of supplemental coverage to Medicare. For example, Medigap plans may cover some or all of a patient's 20% coinsurance and deductible for administration of REMICADE® provided through Medicare Part B. However, Medigap plans typically do not provide this type of coverage for REMICADE® if it is provided under the Part D prescription drug benefit. Patients enrolled in a Medicare Advantage plan cannot also enroll in a Medigap plan.

Special Notice for Providers: Coding for Disaster Victim Services5

In order to track and facilitate claims processing for disaster victims, CMS established a national modifier and condition code:

CR, Catastrophic/Disaster Related (modifier)
DR, Disaster Related (condition code)

Any provider may use the modifier. MACs use either the modifier or the condition code. The condition code would identify claims that are or may be impacted by specific payer policies related to a national or regional disaster. The modifier indicates a specific Part B service that may be impacted by a policy related to the disaster.

For additional information regarding disaster victim services, please contact Medicare at 1-800-MEDICARE (1-800-633-4227) or visit www.medicare.gov or www.cms.gov.

Additional Information About Medicare Coverage

For more details about the costs of Medicare coverage, please call the Medicare program at 1-800-MEDICARE (1-800-633-4227) or visit www.medicare.gov.

1 CMS. Medicare & You Handbook, 2016. https://www.medicare.gov/Pubs/pdf/10050.pdf. Accessed December 31, 2015.
2 Medicare.gov. Medicare costs at a glance. https://www.medicare.gov/your-medicare-costs/costs-at-a-glance/costs-at-glance.html. Accessed December 31, 2015.
3 CMS. Annual Release of Part D National Average Bid Amount and other Part C & D Bid Information. https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/PartDandMABenchmarks2016.pdf. Accessed December 28, 2015.
4 CMS. Announcement of calendar year (CY) 2016 Medicare Advantage capitation rates and Medicare Advantage and Part D payment policies and final call letter. https://www.cms.gov/medicare/health-plans/medicareadvtgspecratestats/downloads/announcement2016.pdf. Accessed December 31, 2015.
5 CMS. MLN Matters #MM6451. The Use of the CR Modifier and the DR Condition Code on Disaster/Emergency-Related Claims. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM6451.pdf. Accessed November 13, 2015.

February 10, 2016