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Medicare Announces More Actions to Assure Dual
Eligibles Get Drugs
Dec. 2, 2005 – In response to a consistent concern
and even a lawsuit by advocacy groups concerned that the poorest of
Medicare beneficiaries will not be covered by the new prescription drug
program that begins on January 1, the Centers for Medicare and Medicaid
Services
has announced new steps to assure coverage for the "dual eligibles."
These are the Medicare beneficiaries that are also eligible for
Medicaid. The responsibility for these senior citizens will shift from
the states to the federal government in 2006.
The major thrust of the CMS effort is to
auto-enroll these six million dual eligibles in the Medicare Part D drug
program prior to the effective date on January 1. Many are concerned,
however, that some will "drop through the crack."
One of the new innovations CMS has announced is a
plan to catch these people at the pharmacy counter and get them
enrolled.
CMS calls this process a point-of-sale solution.
If a beneficiary goes to a pharmacy with
evidence of both Medicaid and Medicare eligibility, but without current
enrollment in a Part D plan, the beneficiary will be able to leave the
pharmacy with their prescriptions and a CMS contractor, Z-Tech Corp. of
Rockville, Md., will immediately follow up to validate
eligibility and facilitate enrollment into a Part D plan.
The coverage for these seniors will be by Wellpoint
Inc. of Indianapolis, which offers Part D plans in all 50 states. CMS is contracting with
Wellpoint to manage a single national account for payment of prescription
drug claims for the "very limited number" of dual eligible beneficiaries
who have not yet been auto-enrolled into a Part D plan at they time they
present a prescription at the pharmacy.
Below is the complete statement issued yesterday by
CMS. (See sidebar links for background stories)
Ensuring an Effective Transition
Of Dual Eligibles From Medicaid To Medicare Part D
Beginning January 1, 2006, responsibility for the
prescription drug coverage for over 6 million low-income Medicare
beneficiaries who also are enrolled in Medicaid shifts from the states
to the federal government consistent with the Medicare Modernization Act
of 2003. These beneficiaries, referred to as the full-benefit dual
eligibles, will qualify for Medicare prescription drug coverage with low
or no premiums and co-payments of a few dollars.
CMS recognizes the enormity of this transition from
Medicaid drug coverage to Medicare and has been working intensively with
many partners in and out of government to ensure that the transition
process for these beneficiaries is as seamless and efficient as
possible. The most important goal of this transition is to ensure
full-benefit dual eligible beneficiaries will get the prescription drug
coverage they need as of January 1, 2006.
CMS is committed to accomplishing the following two
key objectives to ensure a safe and appropriate transition of the dual
eligible population from Medicaid to Medicare Prescription Drug
Coverage:
I.
Providing comprehensive coverage and high quality prescription drug
coverage plans for all people with Medicare, but especially for the
dually eligible population, who often take a number of prescriptions to
manage one or more chronic conditions. To achieve this objective, CMS
has taken the following steps:
A. Robust Formulary Requirements –
CMS developed a set of checks and oversight activities to ensure that
prescription drug plans offer a comprehensive benefit that reflects best
practices in the pharmacy industry, as well as current treatment
standards.
Plan formularies must recognize the special needs of particular types of
beneficiaries, such as mental health patients, those with HIV/AIDS,
those living in nursing homes, people with disabilities, and other
beneficiaries who are stabilized on certain drug regimens.
CMS has reviewed these formularies and benefit structures to verify that
plans are in compliance with the following critical requirements:
1. Multiple drugs in each class – the minimum
statutory requirement is that a formulary must include at least two
drugs in each approved category and class (unless only one drug is
available for a particular category or class). In addition, we have
required that each plan’s formulary include all or substantially all
drugs in each of the following key categories: antidepressants,
antipsychotics, anticonvulsants, anticancer drugs, immunosuppressants
and antiretrovirals for treating HIV/AIDS.
2. Each Medicare prescription drug plan’s
formulary was developed and reviewed by the plan’s pharmacy and
therapeutics committee. Each must be consistent with widely used
industry best practices.
3. CMS compared the prescription drug plans’
use of benefit management tools to the way these tools are used in
existing drug plans to ensure that they are being applied in a
clinically appropriate fashion.
B. Transition Guidance
–
CMS has required each
Medicare prescription drug plan to establish an appropriate transition
process for all new enrollees. All of these transition plans include at
least a one-time fill of a prescription drug excluded from the plan’s
formulary in order to accommodate situations in which a beneficiary
presents at a participating pharmacy with a prescription he or she has
previously filled but that is not on the formulary. Each transition
process addresses the plan sponsor’s method of educating both
beneficiaries and providers to ensure a safe and complete accommodation
of an individual’s medical needs with the plan’s formulary.
Additionally, CMS recommends that this transition process address
unplanned transitions as individuals change treatment settings due to a
change in their level of care.
C. Exceptions
Procedures –
CMS has developed
exceptions procedures designed to ensure that enrollees receive prompt
decisions regarding whether medications are medically necessary. For
example, if an enrollee requests a non-formulary drug, the plan must
make its decision as expeditiously as the enrollee’s health condition
requires after it receives the request, but no later than 24 hours for
an expedited coverage determination or 72 hours for a standard coverage
determination.
D. Protecting Dual
Eligible Residents of Long-Term Care Facilities -
CMS established specific
protections for beneficiaries who live in long-term care facilities and
get their prescriptions from long-term care pharmacies. A condition of
participation requires every plan to provide in-network coverage to all
enrollees who live in any nursing home in its region.
Each plan will be
notified as to which of their enrollees live in a long-term care
setting, which will help the plans and the facilities prepare for any
potential changes to the beneficiary’s drug regimen.
Because a large
number of long-term care residents are full-benefit dual eligibles, it
is important for the transition process that plans employ to account for
any issues associated with filling the first prescription of a
non-formulary drug.
CMS has also developed ways to assist long-term care
facilities in identifying the plan in which their dual eligible
residents are enrolled to allow for early accommodations to new
formularies, if necessary. In addition to using the web-based
Prescription Plan Finder tool at www. Medicare.gov for individual
resident inquiries, long-term care facilities without Internet access or
who need Medicare prescription drug plan enrollment information for
multiple residents can now do so via a special CMS fax-based procedure.
II. Ensuring
continuity of prescription drug coverage and care for the dual
eligibles.
A. Outreach & Partnerships –
CMS has conducted targeted education and
outreach to ensure dual eligible beneficiaries are aware of the upcoming
changes to their prescription drug coverage, including the transition in
coverage, auto-enrollment, and their individual rights. CMS is
conducting an integrated education effort incorporating both paid and
earned multi-media, direct mail, and extensive grassroots operations
organized down to the county level. This effort is run in cooperation
with thousands of trained traditional and non-traditional partners
across the country, including other federal agencies, state and local
governments, pharmacists, nursing homes and other health care providers,
faith-based organizations, and community based organizations.
B. Auto-enrollment –
To ensure that there is no
lapse in prescription drug coverage for full dual eligibles; CMS will
make sure that full-benefit dual eligibles are enrolled in a Medicare
prescription drug plan by January 1, 2006.
In November, anyone who was a
dual eligible for even one month beginning in March, 2005 received a
letter which informed them of their new plan and the option to choose
another plan.
Dual eligible individuals also will have the opportunity
to switch plans at any time.
This ensures continuity of care when
Medicaid prescription drug coverage ends, while also retaining the
personal right to select a plan that best meets their needs.
If a
beneficiary is unaware of the plan in which they have been auto-assigned
he/she can call 1-800-MEDICARE or look at the “Medicare Prescription
Drug Plan Finder” on
www.medicare.gov.
In the future, we will identify and auto-enroll
those about to become full-benefit dual eligibles prior to the end of
their Medicaid coverage to ensure a seamless transition on an on-going
basis. This includes those Medicaid beneficiaries who will age into
Medicare, or who will reach the end of the 24-month Medicare disability
waiting period.
C. Targeted Assistance –
CMS will have special
protocols and specially trained operators and case work coordinators
ready to provide dual-eligibles focused assistance in January for any
questions or concerns that may arise. We will track any issues and act
on them quickly. CMS will work closely with States and with our many
partners around the country to ensure that dual eligibles have a smooth
transition to Medicare drug coverage.
D. Collaboration with States –
CMS is committed to
working with States on an ongoing and collaborative basis to ensure both
the immediate need of a smooth transition for their current dual
eligible residents is met and a continuing basis ensuring a successful
transition for Medicaid beneficiaries who age into Medicare, the newly
dually eligible individuals.
This work commenced in August 2004 with
convening of the State Issues Workgroup which included representatives
from State Medicaid Agencies, the Social Security Administration and
CMS. In addition to the ongoing efforts of the State Issue Workgroup,
CMS engaged the States in a series of summits, conference calls and
workshops to discuss and work through the implementation issues of the MMA. Finally, CMS has worked especially closely with states on ensuring
their monthly data feed identifying full-benefit dual eligible
individuals to CMS is complete and accurate. CMS has a nationally
recognized expert in Medicaid data validate each state’s monthly feed,
and the number matched consistently exceeds 99%.
E. Automatic Eligibility Checks and Coordination of
Benefits in Pharmacies –
In unprecedented coordination with all segments
of the pharmacy and prescription drug payer industries, CMS has
participated in the development of an automated Part D eligibility query
and coordination of benefits (COB) process. The new eligibility
capability will allow pharmacies to use existing pharmacy systems to
identify a Medicare beneficiary’s plan billing information, which will
save pharmacists time and money in processing prescriptions for Medicare
beneficiaries. This billing information will also allow pharmacists to
immediately coordinate benefits with any other coverages the beneficiary
may have through other payers, even if the beneficiary does not present
the plan ID card or is even aware that he/she has been auto-enrolled
into a Part D plan. These services will be open and accessible by all
pharmacies regardless of the network or pharmacy management system they
use.
F. Point of Sale Protection –
CMS is making its
best effort to identify and auto-enroll all dual-eligible beneficiaries
prior to the effective date of their Part D eligibility. However, it is
possible that some beneficiaries may go to pharmacies before they have
been auto-enrolled in a Part D plan. For this reason, CMS has developed
a process for a point-of-sale solution to ensure full dual eligible
individuals experience no coverage gap when Part D coverage commences.
If a beneficiary presents at a pharmacy with
evidence of both Medicaid and Medicare eligibility, but without current
enrollment in a Part D plan, the beneficiary will be able to leave the
pharmacy with their prescriptions and a CMS contractor, which will be
announced later today, will immediately follow up to validate
eligibility and facilitate enrollment into a Part D plan.
CMS and its contractor will provide a uniform and
straightforward set of instructions that all pharmacists can follow no
matter which plan network they are in or where they are in the country.
To achieve this objective, CMS is contracting with a single national
plan to manage a single national account for payment of prescription
drug claims for the very limited number of dual eligible beneficiaries
who have not yet been auto-enrolled into a Part D plan at they time they
present a prescription at the pharmacy.
For further detail about this additional component
of the dual transition work plan please click here:
http://www.cms.hhs.gov/media/press/files/122005/de-timeline.zip
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