WRINGING HANDS BRING IN THE NEW
YEAR FOR DUAL ELIGIBLES:
WHAT People with Medicare And
Medicaid Should Expect From Medicare Part D After January 1, 2006
This New Year may bring more
confusion than joy to the more than 6 million beneficiaries with both Medicare
and Medicaid (“dual eligibles”) who will lose their Medicaid prescription drug
coverage and be switched to Medicare’s Part D coverage on January 1, 2006.
Though the Centers for Medicare & Medicaid Services (CMS) announced contingency
plans for those who fall through the cracks and gave assurances that the
transition will go smoothly, dually eligible beneficiaries, their caretakers,
and advocates are concerned that many will not be able to get the drugs they
need this January.
The Center for Medicare
Advocacy suggests several questions dual eligibles should ask, and several steps
they can take, in order to ensure the smoothest transition possible:
Which Plan Am I Enrolled?
possible, all beneficiaries should have their prescriptions refilled before
January 1, 2006.
Dual eligibles should have received a yellow letter telling them the plan in
which they have been enrolled and giving them contact information for the
plan. If they have not chosen a different drug plan, they should retain the
letter and the contact information in the same place as they keep numbers
for the doctor and pharmacy.
NOTE: Everyone who enrolls in a Part D plan will receive an Evidence of
Coverage (EOC) document that gives pertinent plans’ phone numbers and
procedures. CMS has indicated that plans will not begin to mail out the EOC
until the end of January.
pharmacy should be able to assist someone in determining the plan in which
he or she has been enrolled. The pharmacy can submit an electronic “E1”
query to a special Medicare contractor to get the information. The pharmacy
may also call 1-800-MEDICARE or use
the beneficiary chooses a plan on his or her own, because s/he was not
auto-enrolled, or because s/he is choosing to change plans, the beneficiary
should verify that the new plan is a “standard” plan, and that its premium
is below the “benchmark” premium for the region. Medicare’s low-income
subsidy will not fully subsidize premiums and cost sharing for plans
that are “enhanced,” even if the plan premium is below the benchmark, and it
will not fully cover costs for plans that have premiums above the
benchmark. Thus, dual eligibles could face unexpected costs if they choose
a non-standard plan.
the Center for Medicare Advocacy’s December 8, 2005 Weekly Alert for
information to help duals who “fell through the cracks” and were not
auto-assigned. Beneficiaries should bring their Medicare and Medicaid cards
to the pharmacy with them. If they don’t have their Medicare card, they can
bring a Medicare Summary Notice or other evidence of Medicare coverage. If
they have used the pharmacy before to get drugs covered by Medicaid, the
pharmacy may have their Medicaid information on file.
NOTE: Advocates should also check with their local communities. Some
cities and community mental health centers have established a process to provide
prescriptions to duals who are denied drug coverage.
Should I Do About My Retiree Health Insurance?
Beneficiaries who have received information from their employer stating that
they will lose retiree health coverage if they enroll in a Part D plan
should contact their former employer immediately. According to CMS, some
former employers are being more flexible, especially in situations where
dependent family members will lose their health coverage if the dual
eligible retiree keeps Part D. Some employers are giving their retirees
more time to determine whether they want to give up all of their retiree
health coverage in exchange for Part D. Others are allowing their retirees
a one-time return to the retiree health plan. Still others are allowing the
retiree’s dependents to keep their retiree health benefits if the retiree
enrolls in a Part D plan.
NOTE: Each employer can set its own policies, and not all employers are
Suppose My Drug Is Not on My Plan’s Formulary?
Medicare Part D regulations require each Part D plan to have a transition
policy to cover non-formulary drugs for people when they first enroll in the
plan. Thus, duals should not be turned away from their pharmacy without
any medication. The regulations do not set out a specific time frame,
but non-binding CMS policy guidance recommends providing a 30 day
supply of the drug for most people and a 90-180 day supply for nursing home
residents. Most plans to which duals have been auto-assigned will provide a
30-day supply of drugs, though not necessarily a 90-day supply for nursing
home residents. The exception appears to be plans sponsored by PacifiCare,
which will only provide a 15-day supply. A CMS summary of PDP transition
policies may be found at
a beneficiary requires a drug that is excluded from coverage under
Medicare Part D, the state Medicaid program may still pay for that drug. A
list of the general categories of excluded drugs that each state will pay
for may be found at
the beneficiary knows or believes that one or several of his or her drugs
are not on the formulary, but that the drug is covered under Part D, the
beneficiary should speak with his or her doctor as soon as possible. The
beneficiary, the doctor, or the beneficiary’s appointed representative can
file an “Exception” with the plan to ask that the drug be covered. This
process can take time and should be done as early as possible.
NOTE: Detailed information about each plan’s Exception process will be
included in the Evidence of Coverage document that plans are to mail to their
enrollees. Beneficiaries will generally not be given this information at the
pharmacy counter if the pharmacy determines that a drug will not be covered.
Rather, they will need to call the plan to find out how to file the Exception.
A beneficiary may request an Exception at the time of this initial inquiry, but
the plan will not begin processing the Exception request until the doctor
submits a supporting statement.
Copyright © Center for Medicare Advocacy, Inc.