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Medicare Drug Benefit Update: 2006 Enrollment Deadline Less Than 5 Days Away May 11, 2006 As is being widely reported in the press, the initial sign-up period for the new Medicare drug benefit expires on May 15. After Monday, most Medicare beneficiaries that have not signed up for drug coverage will have to wait until next fall and their coverage will not be effective until January 1, 2007. More importantly, Medicare beneficiaries that do not sign up by this May 15 deadline will be forced to pay a financial penalty if they later decide to sign up for coverage (see details on the late enrollment penalty below).
Progress on Medicare Part D Enrollment It is projected that as many as 5.7 million of the 42 million Medicare beneficiaries have not signed up yet. These 5.7 million beneficiaries are split among those who have little or no current drug costs and low-income beneficiaries that stand to gain the most from the program. Both have strong reasons for needing to sign up by May 15. Those with little or no drug costs can get financial protection against future high drug costs and avoid a late enrollment penalty. In addition, since the Medicare drug benefit is an insurance program, enrolling beneficiaries with little or no drug costs helps keep the benefit affordable for those with very high drug costs over time.
No Late Enrollment Penalty for Low-Income Beneficiaries Last week, the Centers for Medicare and Medicaid Services (CMS, the federal agency that administers Medicare) announced that low-income beneficiaries (those at or below about $15,000 in annual income and assets below about $11,500) will NOT face any late enrollment penalty and can enroll anytime after May 15. These Medicare beneficiaries generally qualify for "extra help" (also known as the Low-Income Subsidy, LIS) that offers them deep discounts on monthly premiums, no deductible, and no gap in coverage. These low-income beneficiaries must first apply with Social Security for this "extra help" subsidy.
Details on the Late Enrollment Penalty Medicare beneficiaries with incomes above about $15,000 (150 percent of the federal poverty level) that do not enroll by May 15 will face a financial penalty. This penalty is one percent per month for every month after May 15 that an individual has not signed up. That one percent however, is not based on the premium of the plan an individual chooses. Rather, it is based on the national average premium offered by insurers in the year that coverage starts.
Thus, an individual cannot keep the penalty low by choosing a cheaper policy. Again, since enrollment will not open again until November 15, 2006, the initial minimum penalty will be at least seven percent, on top of increased premium rates for the 2007 plan year. Moreover, the late enrollment penalty stays with a late enrollee for the rest of their life.
It is important to note that in most states, drug benefit coverage is available for as little as $10 to $15 per month and in many states only $5 per month. Further, individuals willing to enroll in Medicare Advantage plans (Medicare HMOs) can access drug coverage at no additional premium in every state. In other words, affordable coverage options are available in most states to avoid being stuck with a late enrollment penalty.
Helpful Links Between
now and May 15, help is available through 1-800-MEDICARE. CMS has announced
that extra operators have been added for the expected surge in applications that
will be coming over the next four days. In addition, the following online links
are recommended: CMS Tip Sheet on Enrollment Deadline (PDF) CMS Fact Sheet on Enrollment Deadline Some Drug Manufacturers Move to Reopen Pharmacy Assistance Programs (PAPs) One of the most challenging problems with the roll-out of the Medicare drug benefit has been disruption to existing programs sponsored by drug manufacturers that offer free or deeply discounted drugs to low-income people. Earlier this year, many of these programs either cut off enrollment, or ended assistance for Medicare beneficiaries. The idea was to encourage Medicare beneficiaries to enroll in Part D coverage and not rely on drug manufacturer PAPs as a substitute for coverage – and thereby expose low-income beneficiaries (especially those between 150 percent of poverty and 300 percent of poverty) to the late enrollment penalty.
In addition, an opinion letter from the HHS Office of Inspector General raised a series of complicated issues involving violations of federal laws governing antitrust and anti-kickback protections with respect to manufacturer-sponsored PAPs. However, in the absence of these PAPs many low-income Medicare beneficiaries have been left worse off under Medicare Part D than they were when they received deeply discounted or free medications. This is especially the case for beneficiaries at or below 150 percent of the federal poverty level that have assets that made them ineligible for the "extra help" subsidy.
In recent weeks, there has been a flurry of activity as several drug manufacturers have either reopened their old programs, or established new programs. More drug companies are expected to follow suit in the coming days. What is clear however is that standards issued by the HHS Inspector General require that these manufacturer-sponsored PAPs operate completely independent from Part D coverage. In other words, the PAPs are not allowed to coordinate with, or fill in gaps for, Medicare drug coverage. Several of the newly revised and reopened PAPs require an enrollee to demonstrate that they are NOT enrolled in Medicare Part D or have applied for "extra help" and been denied.
Some of these manufacturer-sponsored assistance programs will eventually require a certification on the part of the Medicare beneficiary that: 1) they will not submit a claim to their Medicare drug plan, and 2) they understand that medications provided by the drug company is outside of Part D and cannot count toward meeting the $3,600 catastrophic threshold. Each program is slightly different, so qualified low-income beneficiaries should carefully review eligibility requirements and program rules before applying. Among the companies that have reopened or reestablished their PAPs are Glaxo-Smith-Kline, Eli Lilly, Merck, and Schering Plough. Indoor Pollutants Linked to Asthma Symptoms in Children
Medicare Drug Benefit Update: CMS Issues New Rules on Formulary Changes as Enrollment Deadline Approaches April 28, 2006 On April 27, the federal Centers for Medicare and Medicaid Services (CMS) released new guidelines requiring Medicare drug plans to continue covering medications for any beneficiaries already enrolled in the plan after a plan removes a medication from its list of covered drugs (also known as a formulary). This change is in response to concerns raised by NAMI and other patient advocacy groups about the ability of drug plans to change their formularies -- by removing a drug or imposing higher cost sharing for a specific drug -- in the middle of a plan year, with only 60 days notice. Under the announced change announced, if a drug plan seeks to remove a particular medication, or shift it to a higher tiered co-payment level, the plan would be required to continue covering the drug (at the same co-payment) for any beneficiary prescribed the medication prior to the change, for the rest of the year. By contrast, most plan enrollees (except for extremely low-income individuals dually eligible for Medicare and Medicaid) would have had to wait until the next plan year to switch out of the plan. This would have been especially difficult for someone who selected a drug plan solely on the basis of favorable coverage for a specific drug. With this new rule, enrollees will be assured that when they select a Medicare drug plan, the list of covered drugs, and the cost sharing levels for each drug, will not change throughout the year. Enrollment Period Set to Expire on May 15 This change to the formulary rules comes with the end of the initial enrollment period only two weeks away. This looming deadline has created significant controversy for Medicare beneficiaries that have not yet enrolled. This week, enrollment in the new drug benefit topped 30 million. Many of those that have not enrolled thus far have other coverage. However, an important segment of those that are not enrolled by May 15 will not be able to enroll until next fall and could be subject to a late enrollment penalty once they decide to enter the program (a penalty that compounds over time, and stays with the beneficiary indefinitely). It is important to note that the May 15 enrollment deadline, as well as the late enrollment penalty, do NOT apply to individuals who are dually-eligible for both Medicare and Medicaid. In addition, the enrollment deadline and the late enrollment penalty does not apply to people who are eligible for a separate program that provides subsidies for those who cannot afford Medicare drug coverage on their own (a program known as "Low-Income Subsidy" or "Extra Help"). Individuals must be at, or below, 150% of the federal poverty level (about $15,000) to qualify for this program. Last week, CMS announced that the May 15 deadline had been extended for these beneficiaries. Finally, it is important to note that Medicare beneficiaries that have other drug coverage that is just as good, or better than the Medicare program (known as "creditable coverage") do not have to sign up and will NOT face any late enrollment penalty if they ever decide to enter the program. This includes individuals with retiree health coverage, veterans served by the VA, federal retirees, etc... Medicare beneficiaries with mental illness that have not signed up for drug coverage are strongly encouraged to do so. There are numerous web-based tools designed to assist beneficiaries and their family members in finding the plan that most effectively covers their medications. In most regions of the country, drug coverage is available for as little as $8 to $10 per month. For those uncomfortable using the internet, enrollment information is available at 1-800-MEDICARE. Among the
recommended web-based tools for researching drug plan options are:
Medicare Drug Benefit Update
Medicare Drug Benefit Update: Extended Transition Period Set to Expire on March 31; Prior Authorization and Step Therapy Will Begin on Some Medications March 27, 2006 Initial transition rules for the Medicare Part D drug benefit will expire on March 31, allowing Prescription Drug Plans (PDPs) to begin imposing restrictions on access to some medications on their preferred drug lists (also known as formularies). The transition rules set forth by the Centers for Medicare and Medicaid Services (CMS) have required PDPs to cover any and all medications that were prescribed to an enrollee as of January 1, 2006. Specifically, if a beneficiary was prescribed a medication (including a psychotropic medication) upon enrollment, they were presumed to be stable on that medication and their drug plan was required to cover any refill. This
transition requirement was supposed to have expired at the end of January.
However, in response to a difficult initial transition period, CMS extended the
transition policy requirement through March 31. More information on the CMS
transition policy is available online, including a
news alert and a
physician Q&A. Under the transition policy, drug plans are supposed to have been providing notices to beneficiaries, doctors, and pharmacists that a specific refill was covered under the transition policy and that the particular medication is either: not on the PDP's formulary (although this should not be occurring with anti-psychotics, antidepressants or anti-convulsants as plans are required to cover "all or substantially all" of these medications), subject to a prior authorization requirement (where the drug plan requires prior clearance before a prescription is filled), subject to a step therapy edit (where the drug plan requires the enrollee to first try a preferred drug alternative), subject to a mandatory generic substitution requirement, or subject to a dosage limitation (the dosage or volume of pills prescribed is above the plans recommended limits).
Most Medicare drug plans have some of these restrictions on access as part of their coverage. A report issued last week by the House Government Reform Committee Minority Staff found that 97 percent of the Medicare drug plans place prior authorization or step therapy on at least one of the 100 most prescribed medications. A copy of this report can be viewed online. In each of these instances (formulary exclusion, prior authorization, step therapy, dosage limitation, etc.), beneficiaries have the ability to seek an "exception" from their drug plan's policy. This is an administrative procedure whereby an enrollee requests that the plan make an exception to the coverage restriction based upon the individual's unique circumstances. Because the grounds for granting an exception are the individual enrollee's clinical status and treatment history, the active involvement of the prescribing physician is essential in the process.
A critical step for some Medicare beneficiaries will be contacting their drug plan and/or their physician to find out if their medications have thus far been refilled in accordance with the plan's transition policy. The rules for Medicare Part D allow drug plans to require that requests for exception be made in writing by the prescribing physician. Each Medicare drug is allowed to have their own written form for exceptions, although CMS has established a model form that has been recommended to all plans. More importantly, Medicare drug plans are required to respond to an exception request within 72 hours – and as quickly as 24 hours in certain emergencies. If an exception is denied, plan enrollees can appeal to an Independent Review Entity (IRE) that is outside of the drug plan's influence. More information on how to seek an exception or seek an administrative appeal is available online.
Overall Part D Enrollment Tops 27 Million The past month has seen a surge in enrollment in the new Medicare drug benefit, with 2 million beneficiaries signing up in the past month. The number of beneficiaries who have individually enrolled now exceeds 7.2 million. The other nearly 20 million enrollees were automatically enrolled through other programs or are retirees whose former employers are receiving subsidies under the program.
Of particular concern are the more than 7 million low-income Medicare beneficiaries projected to be eligible for a generous subsidy (as much as $4,000 annually) in order to afford drug coverage. Thus far, less than 2 million beneficiaries have been signed up for the subsidy. It should be noted that all of these low-income beneficiaries are above Medicaid eligibility and as a result most did not have coverage prior to the new drug benefit. NAMI is currently working with CMS and a broad coalition of national organizations (including the National Council on Aging, AARP, and others) to develop strategies to help reach these beneficiaries before the May 15, 2006 deadline for open enrollment.
Beneficiaries must separately apply for the low-income subsidy (LIS), also known as "extra help" through the Social Security Administration (SSA). The application is available online.
Medicare Drug Benefit Update: CMS Renews Critical Beneficiary Protections for 2007, Drug Plans Must Continue to Offer Broad Coverage of Medications to Treat Mental Illness March 9, 2006
Last week the federal Centers for Medicare and Medicaid Services (CMS), the federal agency responsible for Medicare, issued guidelines that renew protections that require drug plans to offer broad coverage of psychotropic medications and cover all prescriptions of new plan enrollees. These protections are currently in place and will be renewed through 2008. Renewal of Formulary Guidance
The guidance that CMS renewed for 2007 requires Medicare drug plans to cover "all or substantially all" medications in six therapeutic categories including anti-psychotics, antidepressants, and anticonvulsants. This guidance was set forth last year for the initial year of the program and will now stay in effect for the 2007 plan year. This means that Medicare drug plans will not be able to completely exclude medications to treat mental illness from their preferred drug lists (also known as formularies). Further, these same guidelines also limit the ability of plans to impose restrictive policies such as prior authorization and step therapy for medications in these protected classes.
Read NAMI's comments on the new formulary guidance Renewal of Transition Guidance A separate guidance to Medicare drug plans issued last week by CMS requires them to cover all medications prescribed to a new enrollee for their initial 30-day period of enrollment. This transition guidance specifically mandates that a drug plan must immediately refill any prescription in the initial coverage period, so long as the beneficiary was prescribed the drug prior to enrollment (whether the specific medication is within the six protected classes or not). This guidance has been in effect since January 1 of this year and continues through March 31, 2006. For the 2007 plan year (which will begin on January 1, 2007) the transition refill requirement will again apply to any new enrollee or existing Medicare beneficiary who switches to a new plan. Read NAMI's comments on the new transition guidance Recent CMS Part D Drug Benefit Notices
Last week, CMS issued new notices covering a range of issues related to the new Medicare drug benefit. These notices are designed to help frontline providers -- including physicians and Community Mental Health Centers (CMHCs) -- better navigate the new benefit. Among these are factsheets that:
Help doctors assist their patients access seamless coverage and seek exceptions to access medications not on a plan's formulary or subject to an access restriction (prior authorization & step therapy). Click here to view the physician factsheet.
Help agencies that serve homeless individuals access the new benefit. Click here to view the homeless factsheet.
Provide updated guidance on immediate coverage at the beginning of the month for dual eligibles who switch plans. Click here to view this guidance.
Finally, earlier this week CMS issued a warning for beneficiaries on avoiding a recently uncovered scam that induces beneficiaries to sign up for a fraudulent drug plan. Click here to view the anti-fraud announcement.
Medicare Drug Benefit Update: Consumer and Family Tip Sheet Available to Help Dual Eligibles Address Coverage Problems; Bills Introduced in Congress to Address Gaps February 15, 2006 The Medicare Part D drug benefit is now 45 days old and while many of the problems that plagued the early days of the benefit have been addressed, some problems persist. Of particular concern to NAMI are coverage gaps faced by low-income beneficiaries with severe mental illness who are concurrently (dually) eligible for both Medicare and Medicaid. More than 22 states are currently using Medicaid to cover medications for dual eligibles. But since the beginning of February, a number of states have suspended temporary coverage for dual eligibles in order to press pharmacies to first seek payment from Medicare drug plans and only use state Medicaid as a payor of last resort. As noted in an E-News last week, the Centers for Medicare and Medicaid Services (CMS) extended transition guidance that requires Medicare drug plans to cover all medications prescribed to dual eligibles through at least March 31, 2006. Tip Sheets for Consumers and Families Perhaps the biggest challenge facing the new drug benefit in these early days is the persistent gap between the coverage and transition obligations imposed on drug plans by CMS and what drug plans and pharmacies are doing in the real world. It is no surprise to many NAMI members that the standards that CMS has required of drug plans and pharmacies with regard to coverage for dual eligibles is not always being followed where it really matters (i.e. where a consumer is at a pharmacy counter being told "no.") In order to help alleviate these problems and provide consumers and families with the tools they need to maintain continuity of care, NAMI has developed a simple one-page listing of the obligations required for all Medicare drug plans serving dual eligibles. This "tip sheet" also has FAQs explaining cost sharing requirements (including circumstances under which cost sharing can be waived) and the process for getting a drug that is not on a drug plan's preferred list or is subject to a restriction such as prior authorization. NAMI affiliate leaders are especially encouraged to download this document and make it available to consumers and families. NAMI National staff will periodically update this document since CMS is expected to issue new guidance in the coming weeks and months. Download the Medicare Drug Plan Tip Sheet CMS Issues Recommendation on Plan Switching for Dual Eligibles Because dual eligibles were automatically enrolled – on a random basis – into Medicare Part D plans, they are the only beneficiaries that have the ability to switch plans during the year (all other Medicare beneficiaries have to wait until the beginning of the following plan year). A major problem occurred in early January for dual eligibles that elected to switch plans in late December – in most cases, their status as a dual eligible was not relayed to the new plan in which they enrolled in a timely fashion. As a result, they were charged co-payments far in excess of the required $1 for a generic drug, $3 for a brand-name prescription. In some instances, these dual eligibles were sent bills for monthly premiums they were not responsible for. In order to avoid these problems going forward, CMS has put out guidance recommending that dual eligibles NOT switch drug plans late in the month in order to avoid a coverage gap at the beginning of the following month. While attempts are being made to address the computer problems that delay effective enrollment for duals switching plans, the recommended course of action is to make the election to switch plans early in the month. The CMS guidance on dual eligible plan switching can be viewed here. Bills Introduced in Congress to Address Cost Sharing for Duals and Benzodiazepine Coverage Since the beginning of the year, a broad range of legislation has been introduced in the House and Senate to address concerns with the new Medicare drug benefit. They range from proposals to completely suspend the benefit to replacing the new program with a government managed program. It is unlikely that any legislative proposal for major changes to the Part D benefit will get through Congress in 2006. The Bush Administration remains firmly opposed to any major structural reforms, much less the scrapping of the entire benefit. At the same time, there is some receptivity on the part of congressional leaders to addressing distinct problems with the new benefit while keeping the basic structure of the program in place. Two specific bipartisan proposals that may have a chance in 2006 are cost sharing for certain dual eligibles and the mandatory exclusion of benzodiazepines. Duals Cost Sharing (S 2234) – The proposal introduced by Senators Gordon Smith (R-OR) and Jeff Bingaman (D-NM) would require Medicare drug plans to waive cost sharing for dual eligibles in certain community-based residential programs such licensed group homes and other residential treatment settings (just as the law currently requires for dual eligibles in nursing homes and psychiatric hospitals). Benzodiazepine Coverage (HR 3151) – The proposal introduced by Representatives Ben Cardin (D-MD) and Jim Ramstad (R-MN) would repeal the current requirement for Medicare drug plans to exclude coverage of medications known as benzodiazepines (klonopin, ativan, xanax, etc.) and allow drug plans to cover them at their discretion. It should be noted that the vast majority of states are covering these medications for dual eligibles as allowed by CMS. NAMI strongly supports both S 2234 and HR 3151. Copies of NAMI's letters of support for S 2234 and HR 3151 can be viewed here. NAMI will continue to monitor developments in Congress on legislation to amend Medicare Part D.
Transition Protections Extended Through March 31 February 3, 2006 The Centers for Medicare and Medicaid Services (CMS) announced yesterday that it is extending, for an additional 60 days, a requirement for drug plans to automatically cover medications prescribed to dual eligibles as of January 1. The requirement mandates that all Medicare drug plans and pharmacies provide refills of any medication prescribed to a low-income beneficiary eligible for both Medicare and Medicaid, so long as the medication was prescribed prior to January 1. This transition plan requirement is compulsory regardless of whether or not a medication is on the drug plan’s formulary or subject to an access restriction such as prior authorization or step therapy (a new medication prescribed after January 1 is not part of this requirement). The additional 60 days will provide more time for dual eligibles to apply for exceptions from plan restrictions or switch to a different plan that covers their medications on a more comprehensive basis. It will also help ensure that vulnerable beneficiaries face no break in their continuity of care and are not forced to pay more than $3 for a brand name medication or $1 for a generic.
CMS Announces Plans to Reimburse States for Costs of Coverage Gap for Dual Eligibles January 25, 2006 The federal Centers for Medicare and Medicaid Services (CMS) announced plans to provide reimbursement to states that have elected to cover costs associated with gaps in coverage during the transition to the new Medicare drug benefit. Since the new Medicare Part D drug benefit went into effect on January 1, more than 23 states have provided reimbursement for a range of gaps in coverage, particularly for low-income individuals dually eligible for both Medicare and Medicaid. This has included state coverage for medications excluded from Medicare drug plan formularies and payment for cost sharing above the limited $1/$3 co-payments that dual eligibles should be charged under the benefit. This has resulted in states paying for prescription costs that should have been paid for by private sector Part D drug plans. CMS is undertaking the following steps to help states recover these costs:
This initiative to help states to recover the costs of covering medications will run through February 15. By then, CMS hopes that drug plans will be covering medications for dual eligibles as required. HHS Secretary Leavitt has made clear that this date will be extended if problems persist. CMS will be asking states to agree to turn off their state reimbursement system and return to the Medicare Part D system by February 15. Click here to view a copy of the CMS announcement. Medicare Drug Plans Issue Inaccurate Premium Notices to Dual Eligibles In the past week, there have been increasing reports of Medicare drug plans sending notices of payment due for monthly premiums to dual eligible beneficiaries. Such premium notices contradict CMS policy, since low-income beneficiaries who are dually eligible for Medicare and Medicaid should NOT be charged premiums for enrollment in the new drug benefit. Unfortunately, because of administrative problems, some dual eligibles were enrolled in drug plans without their status as dual eligibles being confirmed. As a result they have been incorrectly charged deductibles and subjected to higher cost sharing. CMS has been working aggressively to fix these problems. While in many instances these problems have been resolved, the mailing of monthly premium bills provides another challenge for dual eligibles in this initial transition period. It is critically important that dual eligibles receiving premium notices do NOT make any payments to their drug plan. Instead they should contact the plan directly to verify their dual eligible status as well as reminding the drug plan of their obligation to offer drug coverage with no deductible and cost sharing limited to $3 for a brand name drug and $1 for a generic drug. During the transition period, these drug plans are also required to provide for an initial 30-day refill of any medication previously prescribed to a dual eligible.
Medicare Part D Update: President Bush Directs Drug Plans To Provide an Automatic 30-Day Supply of Medications January 17, 2006 In order to address continuing problems with the implementation of the new Medicare drug benefit program, the Bush Administration has ordered prescription drug plans to provide a 30-day supply of any drug that a low-income beneficiary (including a dual eligible) was previously taking, for no more than $5 for each covered drug ($2 if the medication is generic). As part of transition rules set forth by the federal Centers for Medicare and Medicaid Services (CMS) last year, drug plans were supposed to be making this emergency 30-day transition supply available starting January 1. However, many retail pharmacists and drug plans either did not know about this requirement, or were not complying with it. This directive from the President should help ensure that drug plans and pharmacists begin meeting their responsibility to ensure that no dual eligible walks away from the pharmacy counter without his/her prescription being filled. This order follows two weeks of uncertainty for some Medicare beneficiaries, particularly low-income beneficiaries who are dually eligible for both Medicare and Medicaid. A major problem has been computer systems that verify plan enrollment, but not the individual's status as dual eligible. As a result, many of these beneficiaries are being charged vastly more than the $1/$3 co-payment they were supposed to be charged. As a result of these
problems, as many as 20 states (including How Is the Medicare Drug Benefit Working for You? Last week NAMI launched a toll-free hotline and e-mail response system to help individual consumers work through problems with the transition to the new Medicare drug benefit. For more information, click here. Click here to view the January 13 update on implementation from CMS Administrator Mark McClellan
Medicare Prescription Drug Plan Provided by the National Association on Mental Illness Medicare Drug Benefit Went Live on January 1; Tips to Ensure Smooth Transition More than two years after Congress passed legislation authorizing a new prescription drug benefit in Medicare, the program goes into effect on Sunday, January 1. There are growing concerns about how the initial period of transition to the new benefit will work. For more than 18 months, the federal government and the private drug plans that will be administering the new program have been working to ensure that coverage is seamless from the outset. Despite all the planning, problems are expected during the initial roll-out next week, given that 21 million elderly and disabled beneficiaries should be covered by the program as of January 1. A Few Last Minute Tips and Reminders There should be no gap in coverage for individuals who are dually eligible for both Medicare and Medicaid (see details below);
Make sure to bring any enrollment information you have been sent by Medicare to your local pharmacy when filling a prescription after January 1 (if you have not been sent enrollment information, bring your Medicare enrollment number with you); Retail pharmacists are required to have computer software that can instantaneously verify eligibility and plan enrollment;
A Medicare beneficiary can enroll in a drug plan up through December 31 and have their enrollment be effective on January 1;
Even though the benefit begins on January 1, the "open enrollment" period runs through May 15, 2006 (allowing Medicare beneficiaries to enroll in a plan with no penalty); Help with enrollment and plan selection is available 24-7 through 1/800-MEDICARE and www.medicare.gov
Transition for Dual Eligibles Of particular concern to NAMI are the 6.3 million Medicare beneficiaries who are also eligible for Medicaid – the so-called dual eligibles. For these individuals (as many 1/3 of whom have a mental illness), participation in the new Medicare drug benefit is mandatory and coverage of prescriptions under their state Medicaid programs will end as of midnight December 31.
To ensure seamless coverage, dual eligibles have been automatically enrolled in a new Medicare drug plan and that plan must offer immediate coverage. Most dual eligibles received an auto-enrollment notice from Medicare in November. Dual eligibles are strongly encouraged to hold on to this letter and bring it with them to their pharmacist starting January 1. However, even without the letter from Medicare, all retail pharmacists are supposed to be able to instantly verify plan enrollment. In other words, while the enrollment letter or enrollment card can be helpful, what really matters is electronic verification at the pharmacy counter.
Obligations of the Medicare Drug Plans Serving Dual Eligibles The Medicare drug plans that dual eligibles have been enrolled in are required to meet the following standards:
They must offer drug coverage to dual eligibles at no monthly premium, no annual deducible, and no gap in coverage;
They can NOT impose cost sharing on dual eligible that exceeds $1 for a generic drug, or $3 for a brand-name drug (cost sharing is waived for dual eligibles in nursing homes, Institutes of Mental Disease (IMDs), public psychiatric hospitals, etc.);
They must cover all the drugs prescribed for a dual eligible prior to January 1 (i.e., if a dual eligible was prescribed a medication prior to January 1, it must be immediately covered); They must cover "all or substantially all" of the medications commonly prescribed to treat mental illness, including "all or substantially all" anti-psychotics, anti-depressants; and anti-convulsants; They can NOT cover medications known as benzodiazepines (e.g., klonopin, ativan, xanax), although nearly every state Medicaid program has elected to cover these medications for dual eligibles;
They must allow a dual eligible to switch to a different drug plan at any time (so long as the plan is at, or below, the average "benchmark" plan in the region; and They must respond quickly (within 72 hours) for a request from a beneficiary and their doctor for an exception to any restriction in their coverage (e.g., to cover a medication that is not on the plan's preferred drug list or to waive a prior authorization requirement).
A few last minute concerns on the transition for dual eligible beneficiaries What happens to dual eligibles that have not been auto-enrolled or have not been notified of auto-enrollment prior to January 1?
No government program has ever transitioned 6.3 million people without a mistake and the new Medicare drug program is unlikely to be an exception. Some dual eligibles have not been auto-enrolled (due to the discrepancies between state and federal lists) or have not received enrollment notices (inaccurate mailing addresses, clerical errors, etc.). To deal with such cases, the Centers for Medicare and Medicaid Services (CMS – the federal agency that administers Medicare) has set up a "Point of Sale" system that will allow a dual eligible to immediately get their prescriptions filled and initiate immediate auto-enrollment.
How will the "Point of Sale" System Operate? A dual eligible presents proof of eligibility in both programs. This can be their Medicare enrollment number and any proof that they are Medicaid eligible (Medicaid card, letter from Social Security declaring SSI eligibility, even asking the pharmacist to check on the computer to see that Medicaid paid for a prescription prior to January 1). Once the beneficiary demonstrates proof of eligibility for both programs, the pharmacy is required to fill the prescription and charge only $1 for a generic drug and $3 for a brand name drug. The pharmacist is also required to initiate enrollment by alerting a national vendor, who will verify the individual's dual eligibility status and auto-enroll them in a national plan. All of this is designed to take place at the pharmacy counter so that the dual eligible is able to get the prescriptions filled immediately and ensure rapid enrollment in a Medicare drug plan.
Are pharmacies required to collect the $1/$3 cost sharing from dual eligible beneficiaries? Sort of. The law appears to require that dual eligibles meet their cost sharing obligations ($1 for a generic drug, $3 for a brand name drug). However, the regulations specifically mention that a retail pharmacist can, at their discretion, waive cost sharing for a dual eligible. However, a retail pharmacist cannot establish a blanket policy to waive cost sharing for all dual eligibles, nor can they advertise their willingness to forgo cost sharing for dual eligibles. As a result, some pharmacies may be reluctant to waive cost sharing. At the same time, nothing prevents a pharmacist from allowing a third party – including a family member or friend from making co-payments on the dual eligible's behalf.
Are all pharmacies participating in the new Medicare drug benefit? Yes. However, not every pharmacy – whether a chain drug store or an independent retailer – is part of every drug plan's pharmacy network. The law requires every Medicare drug plan to have an adequate pharmacy network – based on geographic proximity to plan enrollees (including dual eligibles). Drug plans are also required to disclose to enrollees the pharmacies that are in their network. Dual eligibles can switch drug plans at any time if they wish to move to a plan that includes a specific pharmacy.
Will Medicare beneficiaries who reside in IMDs, group homes, supportive housing programs, or other congregate settings that offer on-site pharmacies (or have agreements with a pharmacy) be able to continue to get their medications as before? In some cases, yes. As noted above, every drug plan will have its own pharmacy network. Unfortunately, this does not mean that most Medicare drug plans have established contracts or relationships with in-house pharmacies in IMDs, group homes, board and care homes, supportive housing, etc. It is critically important for CMHCs, public mental health agencies, and non-profits that manage supportive housing programs to know which plans their dual eligible tenants have been enrolled in and to reach out to these plans and insist that their pharmacies be included in each drug plan's network.
CMS has provided guidance to every Medicare drug plan encouraging them to do this. There is no legal or regulatory barrier preventing in-house pharmacies from continuing to provide medications to their residents who are dual eligible beneficiaries. It just requires them to deal with a new entity (a Medicare drug plan), as opposed to Medicaid or the state mental health authority. NAMI is especially concerned that Medicare drug plans have not done the work necessary to ensure that systems that have traditionally worked to provide medications to dual eligibles with mental illness can continue to do so under the drug benefit. This may be further complicated by difficulties that CMHC administrators, case managers, and other treatment professionals have been experiencing in finding out which plans the consumers they serve have been enrolled in.
Are
there other web-based resources with information on Medicare Part D enrollment? http://www.cms.hhs.gov/partnerships/downloads/whatif1.pdf http://www.cms.hhs.gov/center/partner.asp
NEW WEB-BASED TOOL HELPS PEOPLE WITH DEVELOPMENTAL DISABILITIES For more than six million dual-eligibles, their Medicaid prescription drug coverage will end as of December 31, 2005 and be replaced on January 1, 2006 by the new Medicare Part D coverage, provided by private prescription drug plans (called PDPs). The new Web-based tool provides answers to many of the complex questions, such as: * Who is a Dual Eligible? Find the answer here. http://www.thedesk.info/PartD/dualEligibles.htm * Is Medicare prescription drug coverage voluntary? Can a dual eligible decide not to participate in it? Here's the answer. http://www.thedesk.info/PartD/differencesFromMedicaid.htm * What are the key differences between Medicaid prescription drug coverage and the new Medicare Prescription Drug Plans (PDPs)? The answer. * What are the key things to think about when choosing a PDP? Find the answer by clicking here. http://www.thedesk.info/PartD/choosingaPDP.htm Scam
Alert Medicare
pamphlets appeared in Parade magazine on Sept. CMS has identified an error in the printed area-specific versions of the Medicare Issues
Approval to Plans Offering Coverage |
