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Part D Plan Enrollment

In This Article:

• Enrolling New Duals into Part D Plans - GAO Report
• Extra Help and Medicare Advantage Plans - Who Pays for What?
• Extra Help SEP for Part D Plan Enrollment
• Point-of-Sale Enrollment for Extra Help Beneficiaries
• Pharmacy - Problems & Solutions for Extra Help Beneficiaries at the Pharmacy
• Plan Reassignment and De Minimus Policy – 2008
• Proof of Dual Status – Best Evidence Rule
• Retroactive Transition Period for New Dualsl

Enrolling New Duals into Part D Plans – GAO Report
A report from the U.S. Government Accountability Office (GAO), Medicare Part D: Challenges in Enrolling New Dual-Eligible Beneficiaries (1.25Mb PDF file), contains useful  information about how CMS auto-enrolls new dual-eligible beneficiaries (those enrolled in Medicare and full Medicaid), also called “duals,” into Part D plans and how their transition to Medicare Part D drug coverage actually works.
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As a refresher, people become duals by one of two routes:

• About one-third of new duals first had Medicare and later became eligible for Medicaid.
• About two-thirds had Medicaid first and then aged into Medicare – either by celebrating their 65th birthday or by virtue of having of having received Social Security disability benefits for 25 months.

The GAO report explains many procedures and issues you have probably encountered in your work with new duals. We thought you would find the following aspects of the GAO study relevant to your work:

• Random Assignment of New Duals to Part D Plans

Most of you have worked with duals who were auto-enrolled in plans that did not cover all, or even a majority of their prescribed medications. The GAO report highlights the efforts of some states that have state pharmacy assistance programs (SPAPs). Most notably, Maine and New Jersey reassigned duals to plans based upon comparing their Medicaid-covered prescription usage with Part D plan formulary data. This strategy may be of interest to those of you in other states with SPAPs.

• Processing Time to Auto-Enroll New Duals

The process of auto-enrolling new duals into Part D plans generally takes a minimum of five weeks if all systems work properly. The GAO describes the many information systems that must exchange data to bring about enrollment and to reflect Extra Help/Low-Income Subsidy (LIS) status in the pharmacy system.

The GAO found that some duals paid out-of-pocket to obtain their drugs during that interim period and may be owed reimbursements by their plans. You may know some of these duals, many of whom experienced financial hardship when they paid for the drugs that should have been covered by their plans. The GAO reported that the right to reimbursement is not well-known among duals.

• New Enrollee Transition Prescription Fills
  
  When Medicare beneficiaries join a new plan, they are generally able to obtain at least one refill of prescriptions that are not on the new plan’s formulary or are subject to prior approval by the plan. GAO noted that duals generally do not know what it means to receive a transition fill; they may not be getting, or paying attention to the transition notice (29Kb Word file) that plans must send to their members who receive a transition fill. If new duals do not understand that a transition fill is temporary, they risk losing access to their medication.

• And There's Much More...
  
  There is much more information in the GAO report, including detailed descriptions of auto-assignment processes and automated communications systems that pharmacies can use to access a person’s LIS and Part D plan enrollment status.

• What does this mean for benefits counselors?
  
  The GAO report includes several findings that you can use in your everyday work:

• Random Assignment of New Duals to Part D Plans
  
  Many new duals will continue to need help comparing the formulary of the plan in which they are auto-enrolled with their prescription medications. The data presented in the GAO report suggests that many duals continue to need help evaluating the formularies of other plans with premiums low enough to be fully covered by the LIS.
  
  They also may need counseling on the pros and cons of joining a plan with a higher premium, even though they might need to pay some part of that premium out-of-pocket, in order to get coverage of more of their prescriptions with fewer plan restrictions.

• Processing Time to Auto-Enroll New Duals
  
  You can help duals in your community who may have paid out-of-pocket or borrowed money to pay for prescription fills when their pharmacy lacked access to accurate information about their plan enrollment and/or LIS status.
  
  While CMS has not yet designated a specific procedure for reimbursement requests, you can help duals submit requests that the plan issue a coverage determination for reimbursement of their out-of-pocket payments.
  
  Since no specific procedure has been established by CMS for plans to accept such reimbursement requests, you can ask your clients’ plans if they have a streamlined protocol for processing reimbursement requests. Alternatively, these can be submitted to Part D plans as requests for coverage determinations.
  
  You can find helpful information about Part D coverage determinations here — scroll down to Exceptions and Appeals.

• New Enrollee Transition Prescription Fills
  
  You can educate duals and your community about transition policies and the options open to duals to get their prescribed medications that are not on plan formularies or to which access is limited by prior approval and other utilization management requirements. You can also advocate with plans for consistent and timely mailing of transition notices to duals who obtain transition fills.

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Extra Help SEP for Part D Plan Enrollment
CMS has extended a continuous Special Enrollment Period (SEP) to all beneficiaries dually entitled to Medicare and any kind of Medicaid. View the CMS PDP Enrollment Manual provision expanding the SEP here.

Now all such beneficiaries may:

• Enroll in a Part D plan,
• Switch to another plan, or
• Drop Part D coverage (if, for example they acquire other creditable drug coverage)

at any time, effective the first day of the following month.

The extended SEP was effective as of June 2007. and extends at least through 2008.

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Best Available Evidence Rule (Updated August 18, 2008)

Background
Extra Help errors or missing data in CMS’ and Part D plans’ electronic records systems can cause problems for Extra Help beneficiaries at the pharmacy – when correct co-payment information does not show up on the electronic pharmacy information system, Extra Help beneficiaries often get charged too much for their needed medications. These problems can be especially problematic because often low-income beneficiaries simply cannot afford to pay out-of-pocket until the underlying issues are resolved.

Use of the Best Available Evidence Rule can help Extra Help beneficiaries to get their prescriptions filled promptly even when CMS and plan electronic systems don’t correctly reflect their Extra Help status. Use of the rule can also help get the systems corrected so that future problems can – hopefully – be avoided.  

When your clients present certain types of documents that prove Medicaid entitlement to their pharmacist, or directly to their Part D plan, the Part D plan should then promptly make it possible for the pharmacy to give them their prescriptions and charge only the appropriate Extra Help co-payments. These documents are called best available evidence.

The Details of the Best Available Evidence Process

The Best Available Evidence rule applies to errors or missing data in CMS and Part D plan systems regarding Extra Help levels for people with Medicare and Medicaid (duals).  Part D plans can verify Extra Help status by reviewing certain types of documentation of Medicaid status or institutional living arrangement. CMS uses the Best Available Evidence Rule to direct Part D plans to override imposition of standard cost sharing so that duals are not charged amounts in excess of the correct Extra Help co-payments when they seek to fill their prescriptions when the system fails to accurately reflect reduced Extra Help co-payment levels. Likewise, full duals residing in nursing homes should not be charged any co-payments for their drugs as soon as they have resided there for a full calendar month and the Best Available Evidence Rule can be used to prove their institutional status.

Evidence That Qualifies as Best Available Evidence

There is specific evidence Part D plans should accept to verify Medicaid status and/or institutional status*.

Best Available Evidence of Medicaid entitlement is:

A dated Medicaid card with the person’s name on it showing current entitlement;

A signed and dated note from the state Medicaid agency that documents contact with the verifying entitlement;

A print out, screen shot or copy of electronic eligibility data; or

Other documentation from the Medicaid agency.

Best Available Evidence of institutional status* is:

*Regarding institutional status, remember that full duals are the only Medicare beneficiaries who have resided in long-term care facility for at least one full calendar month are the only Medicare beneficiaries with no out-of-pocket expenses for their drugs. So correcting errors regarding institutional status can make a very big difference for residents.

Documentation from a long-term care facility showing Medicaid reimbursement, (this is generally called a remittance invoice);

Documentary verification from the state Medicaid agency of institutional status for at least one calendar month; or

A screen shot of either a remittance or state Medicaid agency documentation.

Key Points about Best Available Evidence

Part D plans must accept Best Available Evidence that pharmacies convey via e-mail or fax and that originally comes from Medicaid agencies or long-term care facilities to verify and correct Extra Help status;

Plans must have live help desks available to assist pharmacies to transmit best available evidence documentation;

Plans are required to place edits in their electronic systems in order to correct errors and allow their pharmacies to fill prescriptions at the correct Extra Help cost-sharing level either immediately, or as soon as possible;

Plans must request the assistance of CMS in gathering evidence of the Medicaid entitlement of their members who state they have both Medicare and Medicaid, but are unable to present proof of their Medicaid status;

People with Extra Help who have less than a three day supply of their medications should receive expedited assistance from CMS and the Part D plan to prove their Medicaid entitlement, establish their Extra Help status and fill their prescriptions by paying no more than the applicable Extra Help co-payments.

Resolving the Underlying Errors

Resolution of Extra Help status errors can take time. When Part D plans are informed of an Extra Help error, CMS directs them to check the CMS system to make sure the system incorrectly reflects Extra Help status. The plans are instructed to wait before submitting corrections between 30 and 60 days because the CMS system might correct itself automatically with updated information. Plans are instructed to submit corrections only once and then wait for CMS to inform the plan that the correction has been input manually.

Pending correction, CMS requires Part D plans to give its 1-800 customer help call centers and pharmacy help lines prepared to triage and address dire need cases in which Extra Help plan members have less than a three day supply of their medications and need prescriptions filled at the correct co-payment level.

New Developments Improve Best Available Evidence Rule

CMS has reminded plans that adherence to the Best Available Evidence Rule is mandatory. Plans must accept documentary proof of Extra Help status when submitted by your client, a family member, your client’s pharmacist, advocate or representative. Once plans have the Best Available Evidence, they must immediately make your clients’ on-formulary prescriptions available and see to it that the pharmacy charges no more than the applicable Extra Help co-payment. View the August 4, 2008 CMS Memorandum on Best Available Evidence here.

If your client gets Extra Help because of having both Medicare and Medicaid, but cannot document her Extra Help status, your client’s plan must provide CM S with detailed information, and the CMS Regional Offices will work through state Medicaid offices to verify her Extra Help status.

Plans must have in place methods for your client, you, or the pharmacist to submit Best Available Evidence, or to request help from CMS in getting that proof through your state Medicaid agency.

Part D plans are required to ascertain whether or not your client will run out of their medication within less than three days. If your client is about to run out, CMS will expedite its efforts to verify Extra Help status. When CM S notifies the plan of your client’s Extra Help status, the plan must tell your client within one business day and must make sure your client can fill her prescriptions paying no more than the applicable Extra Help co-payments.

Best Available Evidence Rule Reiterated in November 2007

In November 2007, CMS reiterated the Best Available Evidence requirement that plans accept certain documents from beneficiaries or network pharmacies as evidence of dual status or nursing home residence.  CMS has informed plans that it will be monitoring plan compliance with this rule.  Here is the text of the latest CMS guidance on the Best Available Evidence Rule.

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Point-of-Sale Enrollment for Extra Help Beneficiaries

When there is no record of Extra Help beneficiaries’ enrollment in a Part D plan, these individuals can end up at the pharmacy counter only to be informed by the pharmacist that their prescriptions cannot be filled due to the lack of plan enrollment. The Point-of-Sale solutioncan help these beneficiaries get their prescriptions filled immediately. Through Point-of-Sale, pharmacists may use their electronic system to instantaneously enroll Extra Help beneficiaries into a Unicare Prescription Drug Plan (PDP) run by WellPoint. Extra Help beneficiaries can then have their prescriptions for Part D drugs filled on the spot.

Even if their prescriptions are limited by prior approval or other utilization management requirements, beneficiaries will get a transition fill and can then speak to their physician about other appropriate drugs, submitting exception requests, or they can arrange to switch plans for the following month using their continuous Extra Help special enrollment period.

The Point-of-Sale process is essentially a process of elimination in four simple steps for the pharmacy.

Step 1: The pharmacist asks beneficiaries for their plan ID card or other proof of plan enrollment, such as an enrollment acknowledgement letter. These documents contain the information called "4-Rx" that pharmacists need to submit claims using their electronic systems.

Step 2: Pharmacists can also submit an "E1" query through their electronic systems to obtain existing plan enrollment information. If no plan enrollment verification is available, the pharmacist goes on to Step 3.

Step 3: Now the pharmacist requests best available evidence

of Medicare and Medicaid or Extra Help status. The pharmacist asks for beneficiaries' Medicare and Medicaid cards or other best available evidence. For Point-of-Sale, evidence of Medicare status includes a recent Medicare Summary Notice. For Medicaid, evidence includes a recent history by the pharmacy of billing Medicaid or a copy of an award letter that indicates current coverage.

Step 4: With evidence of Medicare and Extra Help coverage, the pharmacist may submit a Point-of-Sale enrollment through the electronic system, enabling the pharmacist to fill all Part D-covered prescriptions and bill the WellPoint Unicare plan.

Key Points about Point of Sale Enrollment

The Point-of-Sale solution is not required of pharmacists. They may use it; they cannot be compelled to use it.

In the past, many pharmacists were reluctant to use Point-of-Sale because if it was later determined that the individual was in a Part D plan, or was not eligible for Extra Help, WellPoint would reverse the claim, leaving the pharmacy to figure out which Part D plan to bill, or to collect directly from the customer if she was found to not be eligible for Extra Help and Point-of-Sale enrollment.

As of 2008, pharmacy claims under Point-of-Sale enrollment are no longer reversed.  This means pharmacies are no longer at financial risk if they use Point-of-Sale enrollment to help their Extra Help customers.  WellPoint is now responsible for assuring that claims are appropriately adjudicated.

Many pharmacies, especially small, non-chain pharmacies remain under-educated about Point-of-Sale enrollment and how it can be so helpful to their customers. Conveying this information to pharmacists in your community can be very helpful for your Extra Help clients.

New Developments in Auto-enrollment of New Duals (August 2008)

Auto-enrollment of people who become dually entitled to Medicare and Medicaid has been speeded up. States are now able to submit their data files to CMS more frequently than once monthly and once received by CMS, these new cases are now processed within one business day of receipt. CMS and WellPoint, the Point of Sale enrollment contractor, are working to educate pharmacies and encourage them to make better use of the Point of Sale enrollment option when it is needed. The Point of Sale enrollment procedure remains optional for pharmacists, however, pharmacists have not been held at financial risk if it turns out that somebody who was enrolled using POS was in a plan, or was not actually eligible for Extra Help for the past year. WellPoint ascertains whoever should have paid for any prescriptions filled using POS, whether that is another Part D plan, or an individual who turns out not to have been eligible for Extra Help.

Since the first step in the Point of Sale procedure is often using the Best Available Evidence Rule to verify Extra Help status, the improvements to both processes should make it easier for you to assist your Extra Help clients to promptly fill their prescriptions.

 

Retroactive Transition Period for New Duals

CMS requires Part D plans to implement a special retroactive transition period of up to seven months during which the plan must cover all prescriptions the new dual was taking prior to the Medicaid award. This retroactive transition period is necessary because often Medicaid awards are retroactive by three months if the applicant was otherwise eligible for Medicaid during those months prior to the Medicaid eligibility determination. Moreover, it is not uncommon for Medicaid eligibility decisions to be delayed by many months.

The retroactive transition period would enable Part D rather than Medicaid to cover the costs of drugs provided to new duals during the months before they knew Medicaid had been granted. The retroactive period might extend back to the previous calendar year.

Here is the memorandum from CMS mandating the seven month retroactive transition period: CMS Memo to Part D Plan Sponsors (57Kb PDF file)

A new auto-enrollment notice was simultaneously implemented by CMS with an explanation of the retroactive transition period.

Revised Auto-Enrollment Notice

CMS sends this Part D plan auto-enrollment notice to people with Medicare who are subsequently found entitled to Medicaid. This notice explains the seven month retroactive transition rule and directs people who are newly dually entitled to both Medicare and Medicaid to contact their plan for more information.

The notice also explains that people who have other creditable drug coverage that they want to keep may decline Part D in order to stay with their other coverage. Keep in mind that Extra Help won’t work with non-Part D drug coverage.

Plan Reassignment and De Minimus Policy -

NOTE: There will be no de minimus policy in 2009. Approxinmately one in seven Extra Help beneficiaries will be reassigned to new plans with premiums at or under the applicable Regional Low-Income Benchmark premium for 2009.

Plan Reassignment

CMS will continue to re-assign full premium Extra Help beneficiaries who remained in the Prescription Drug Plan (PDP) that CMS originally enrolled them into different Part D plans under one of three circumstances:

• The plan premium in 2009 will be more than the applicable low income premium benchmark,
• The plan was a standard plan in 2008 but will offer enhanced benefits in 2009.
• Enhanced benefits consist of coverage in the coverage gap (doughnut hole), coverage of drugs that are not usually excluded from Part D coverage, such as barbiturates or weight loss or weight gain medications, or a reduction to the deductible or to copayments.  The Medicare Modernization Act does not allow coverage of these enhanced benefits by the Extra Help premium or cost-sharing subsidies.
• The plan is not going to participate in Part D in 2009.

Extra Help beneficiaries who will be reassigned to a different plan will receive blue letters in October or early November 2008.

Extra Help beneficiaries who selected their own plan or who were enrolled in a plan by a State Pharmacy Assistance Program (SPAP) will not be reassigned even if their current plan will have a higher premium in 2009. They will receive a tan-colored "Choosers" letter explaining that they will have to pay a portion of their plan premium unless they switch to a standard plan with a premium under the low income benchmark premium.

These decisions are complex. For example, some Extra Help beneficiaries may wish to consider the option of staying in their 2008 plan even if they'd pay a portion of the premium in 2008 if plan covers the drugs they take and the part of the premium they'd pay will not be very much.  Others will want to make sure they are in a plan to which they will not have to pay a premium in 2009.

You can find more information about plan reassignment on MyMedicareCommunity.

2009 Low Income Benchmark Premium Amounts were released in August 2008.

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Extra Help and Medicare Advantage Plans - Who Pays for What?
Medicare Advantage plans can charge premiums to enrollees in order to cover a part of the costs of delivering Medicare Parts A and B services, as well as any extra benefits that members receive that are not covered by Medicare. These extra benefits are called mandatory supplemental benefits. In addition, Medicare Advantage plans can offer other optional supplemental benefits that are generally funded by an additional Medicare Advantage plan premium. Members decide whether or not to elect to receive these extra services.

Medicare Savings Program (MSP) recipients, as well as other dual eligibles, need to understand the extent to which Medicaid pays for Medicare Advantage premiums, deductibles, co-pays and/or co-insurance, in order to avoid making choices that will cost them more money. Therefore, it is critical that you understand and be able to clearly explain to your clients the rules about how and when the MSPs pay for Medicare Advantage plan beneficiary out-of-pocket costs. Knowing these rules means that you can help your clients with limited financial means to weigh the pros and cons of Medicare Advantage enrollment.

We've prepared this chart to explain the rules that govern how Medicaid pays some of the Medicare Advantage out-of-pocket beneficiary costs for MSP recipients. Different rules apply to each of the MSPs, and the rules also vary based upon the type of Medicare Advantage cost-sharing.

• Summary of Medicare Savings Program Eligibility and Coverage
• Medicare Savings Programs and Medicare Advantage Out-of-Pocket Cost Sharing

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Pharmacy - Problems and Solutions for Extra Help Beneficiaries at the Pharmacy
When Extra Help beneficiaries present prescriptions at the pharmacy after having recently switched plans, cannot recall which plan they have, or do not have proof of plan enrollment and/or dual status filling the prescription can be problematic.

This Frequently Asked Questions document for pharmacists from CMS addresses how to handle these and other problems Extra Help beneficiaries sometimes encounter when trying to fill prescriptions. It describes the E 1 Query, whereby pharmacists use their electronic billing system to verify plan and Extra Help status in order to submit claims and fill prescriptions.

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