Billing Insulin Furnished Through an External Infusion Pump May 1, 2023 and After

Effective July 1, 2023, Medicare Part B coinsurance must not exceed $35 for a monthly supply of insulin covered under the Durable Medical Equipment (DME) benefit. This provision applies only to beneficiaries who use insulin delivered through DME insulin pumps.

Payments to suppliers and pharmacies will be adjusted to account for the balance of the reduced coinsurance. Suppliers will continue to receive the Medicare payment amount for the insulin (average sales price plus 6%) minus any applicable coinsurance, which is capped at $35 for a one-month supply or $105 for a three-month supply. If there’s more than one claim for the same month, the coinsurance cap will apply to the first claim processed.

Do not bill for insulin supplies for July or subsequent months before July 2023. System updates are required to ensure beneficiaries are not charged more than the $35 maximum allowed for the month of July.

New Modifiers:

  • JK - Short Descriptor: One-month supply or less of drug/biological
  • JL - Short Descriptor: Three-month supply of drug/biological

The following table shows when to use the modifiers.

Claim Submission Month Modifier Billing Insulin Administered
through DME		 Modifier Utilization Date
April 2023 JK, JL Not required March 1, 2023: DOS January 1, 2023 and after
May 2023 JK One-month supply March 1, 2023: DOS January 1, 2023 and after
June 2023 JK One-month supply March 1, 2023: DOS January 1, 2023 and after
July 2023 JK or JL One-month or three-month supply April 1, 2023: DOS May 1, 2023 and after

 

Note: If the from date of service is in May or June 2023, suppliers must only bill a one-month supply and append the JK modifier. If the JL modifier is billed with a date of service of May or June the claim will be returned as un-processable. For the transition into July implementation, suppliers must wait to bill the supply for July until on or after July 1, 2023 or the claim will be returned as un-processable.

For more information, please refer to the Billing Medicare Part B for Insulin with New Limits on Monthly Coinsurance- Fact Sheet MLN4443820.

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