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Physician-Administered Drugs for Dual Eligible Enrollees

The term “dual eligible” is used to describe individuals who are enrolled in both Medicare and Medicaid. States are required to collect rebates on physician-administered drugs.  To collect these rebates, State agencies must submit to the manufacturers the National Drug Codes for all single-source drugs and for the top 20 multiple-source physician-administered drugs.  For dual-eligible enrollees, covered Medicare Part B prescription drugs received in a hospital outpatient setting (which include physician-administered drugs) require a copayment, which Medicaid is generally responsible for paying.  If a State agency paid any portion of a drug claim to the provider, the State agency must then invoice the eligible drugs for rebate and the manufacturer would thus be liable for payment of the rebate. We will determine whether Medicare requirements for processing physician-administered drug claims impact State Medicaid agencies’ ability to correctly invoice Medicaid drug rebates for dual-eligible enrollees. 

Announced or Revised Agency Title Component Report Number(s) Expected Issue Date (FY)
Nov-16 Centers for Medicare & Medicaid Services Physician-Administered Drugs for Dual Eligible Enrollees Office of Audit Services W-00-16-31512 2017

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