December 9, 2005

 

Medicare Q & A’s

Part IV

 

Coverage Problems For Dual Eligibles

CMS has acknowledged that there may be a few Dual Eligible patients that will “fall through the crack” and present at a pharmacy in early January and have no coverage.  Two vendors have been chosen to address this problem.  One is referred to as an “Enrollment Contractor” (Z-Tech) that can verify dual eligibility status and transfer needed info to the pharmacy.  The second is referred to as the “POS Contractor” (Wellpoint) and will be able to sign up these non-covered dual eligibles into one of their plan.  Click here to find the details of how this is done.   We are not happy with the solution to this problem and the fact that only one vendor can sign up these non-covered dual eligibles.  Certainly, any dual eligible can change plans every 30 days, but there may have to be medication changes to meet formulary that will have to be reversed the next month if the dual eligible changes plans.  We think it would be better if you could help the dual eligible to sign up for the plan that will be best for them for the rest of the year.  We are still working on this and hope to have more info at a later time.  This problem just reinforces why you need to identify your dual eligible patients and make sure that each of them has proactively signed up on the right plan for them.

 

Penalty For Late Sign-up

The 1% per month penalty that will be assessed to patients that don’t sign up on a Medicare Part D plan when they have no coverage or “non-creditable” coverage will be based on the national average of the premiums of all plans and not the premium of the plan that they are signing up on.  For instance, if a senior signs up on a plan with a $30 premium and the national average for all plans is $50, then the senior would be penalized 1% per month based on $50 rather than the $30 of the chosen plan – a 50 cent per month penalty rather than a 30 cent per month penalty.  Of course, this penalty accumulates for every month that the senior does not have “creditable” coverage and will be applied year after year.

 

Phenylpropanolamine Update

All drugs containing phenylpropanolamine have been recalled immediately.  Click here to find a list of these products. 

 

Medicare Website vs. CCRx Website

We have received reports from pharmacists that discrepancies exist about cost and coverage information between the Medicare Website and the CCRx  Website.  Drug coverage, formulary issues, patient costs, and other applicable factors should be verified if patients tell you that they have been to the Medicare Website.  Of course, many state and federal agencies as well as private services helping seniors sign up are depending on the Medicare Website and may no always have accurate information.  Just another FYI for you to be concerned about!

 

Long Term Care Emergency Boxes

Question:  Does each provider for a Long Term Care (LTC) facility have to maintain a separate emergency box in the facility?  According to CMS, the answer is NO.  Multiple providers for a home may work out an agreement about who is responsible for the emergency box.  For instance, one pharmacy may be responsible one year and another pharmacy the next year, etc.  However, if a drug is administered out of an emergency box that has to be billed to the patient, then the pharmacy that services that patient will need to bill for payment of that med to the appropriate plan or payer and replace the product to the emergency box.

 

Dual Eligible Auto Assignment

Question:  Is the auto-assignment of all dual eligible patients complete?  According to sources at MemberHealth, all of the dual eligibles are assigned, therefore it is safe to send in an assignment to a plan that the patient proactively enrolled in.  The new enrollment will supersede the auto-assignment.  Because the original plan may not know that the plan has been changed, the patient may continue to get materials from the original plan that was auto-assigned.  Therefore, even though it is not necessary, it may be advantageous to inform the first auto-assigned plan about the new sign-up just to save confusion for the patient.

 

IEP vs. AEP

Question:  Can patients who are NOT dual eligibles or LTC patients change their plan one time before March 15?  All low income assistance (LIS) seniors and standard plan seniors are intended to choose only one plan per year.  However, there can be a one time change this first year and I will try to explain it.  I’m sorry but this is very complicated. 

 

Each patient has an Initial Enrollment Period (IEP) and an Annual Enrollment Period (AEP).  The IEP is defined as the initial period in which a patient can sign-up for a Medicare Part D plan the first time.  The first IEP runs from November 15, 2005 through May 15, 2006.  The patient has one sign-up coming during the AEP, also.  This first year the AEP and the IEP happen run concurrently- November 15, 2005 through May 15, 2006.  Let’s say a senior signs up for a plan Dec. 1, 2005.  This satisfies the senior’s IEP and he/she has no more right to sign-up again under that provision.  However, let’s say that in March 2006 the patient is not satisfied with their plan.  We have been informed by CMS that the patient still has the right to one sign-up under the AEP.  This sign-up would supersede the earlier Dec. 1 sign-up and will satisfy the AEP sign-up privilege.  This in essence allows for a change, but it will only apply during this Nov. 15, 2005 through May 15, 2006 time period because the two run together.  In the future the IEP will not occur again for a patient unless special circumstances occur (i.e., moving to another state, entering a long-term care facility, etc.).  The bottom line is that before May 15, 2006, if you have a patient that wants to change his/her plan, he/she can probably do so once because of the concurrence of the IEP and AEP.

 

LTC Any Willing Provider and Freedom of Choice Issues

There has been much discussion and concern about pharmacies being told that they cannot provide for local nursing homes in the past couple of weeks.  We have been told by CMS representatives that they will get us clear documentation on the facts.  We have had daily conversations with CMS and still do not have the answers in writing.  I will provide those answers as soon as I get them.  I know the importance of this and will be communicating to you as soon as possible.