December 22, 2005

Medicare Q & A’s

Part V

Nursing Home Plans
The APA office has been asked how many plans are qualified to sign up long term care (LTC) patients.  Only four plans qualified under the discount card program for LTC.  There has been some assumption that those plans were the only ones that qualified to move forward in the final benefit.  This assumption is incorrect.   All plans that qualified under Medicare Part D have LTC provisions.  Each plan formulary must include drugs for LTC facilities.  There are not separate formularies for out-patient and LTC patients.  Some plans may require separate contracts to be an LTC provider.  In these cases, you should have been offered two separate contracts.  The bottom line is that you have to be signed up in the applicable plan for the LTC resident you are serving.

E1 Transmission
If patients come into your pharmacy after January 1, 2006, and do not have a card indicating which plan they are enrolled in or do not know if they are or are not enrolled, you need to be ready to do an E1 transmission to NDC Health to get the correct information.  NDC Health is the TROOP facilitator for CMS and, as such, is the official database of all patient eligibility.  By doing an E1 transmission, you will be able to determine eligibility and enrollment status.  Your software vendor will have to tell you how to do this transmission from your system.  Please contact your software vendor immediately to get E1 transmission instructions.