Medicare Part D, the new prescription drug benefit is complex, confusing, and a potential looming health crisis for low-income dual eligibles (those on Medi-Cal and Medicare). Dual eligibles will lose Medi-Cal coverage of virtually all prescription drugs starting January 1, 2006. This Alert informs California advocates of the latest developments. 

 

BEFORE DECEMBER 31, 2005:

 

Get 100 Day Fill Covered by Medi-Cal

 

Prior to December 31^st, dual eligibles can ask their doctors for a 100-day prescription fill to help with the transition.  Even if a 30 day supply was dispensed in December, a pharmacist can ask for an override and potentially get the full 100 days (as long as the physician and pharmacist find it appropriate).  See past Alert for more details.

 

This might not be available in managed care plans.  Managed Care or Special Needs Plan that have only a 30-day fill policy can potentially request a change to the 100 day, as well.  Contact Ann Knievel at CMS: ann.knievel@cms.hhs.gov.

 

AFTER JANUARY 1, 2005:

 

Where to Report Problems

 

CMS Region IX Beneficiary Services

 

The Centers for Medicare and Medicaid Services (CMS) Region IX has staff to handle problems and some will be working on January 1^st and 2^nd from 8 am – 4:30 pm.  Staff will also be checking voicemail hourly from 4:30 pm to 9 pm (check hourly).  Staff will be seeking to identify problems, trends and issues to address locally and flag for CMS’ headquarters in Baltimore. CMS urges individuals to call 1-800-MEDICARE and their plans first (all plans must have staff working on those days).

            January 1^st – 2^nd only:

Medicare Advantage related issues: 415 744  3617

            All Other Issues (Part D stand alone plans): 415 744 3628

            January 3^rd on:

            General: 415 744 3602

MA Issues: 415 744 3617

            Other State-Wide Issues: 415 744 3568

 

 

National Senior Citizens Law Center

 

Advocates may contact Jeanne Finberg at 510 663 1055 or jfinberg@nsclc.orgwith problems, updates and concerns.  Client stories that can be shared with the press will also be very important at this time.  Please leave messages with phone numbers of clients who are willing to talk to the press.

 

CMS Contingency Plan for Dual Eligibles:

 

The Center for Medicare and Medicaid Services has clarified that the contingency plan (discussed in the Dec. 9 Alert) only applies to dual eligibles who are not in a Part D plan.  CMS estimates this is either 5,000 or 15,000 of the 6.4 million duals nationally.  Individuals who go to a pharmacy that does not contract with their auto-assigned plan may not be assisted.  These individuals will likely be informed of their plan and sent away to an in-network pharmacy.

 

Not only does it look like duals who are assigned to a Part D plan (but don’t know it) won’t be helped by this contingency process, it may be of limited value to those who it is meant to help – the unassigned duals.  CMS has indicated that dual eligibles who have not been assigned to a Part D plan are still at the mercy of the pharmacy.  Pharmacists, at their discretion, may provide as little as a 3-day supply of drugs.  If a pharmacist only provides a 3-day supply of drugs for a dual eligible, this might not be enough time for the contingency process to assign a dual eligible to a Part D plan.  It is unclear whether an unassigned dual can take advantage of a “first fill” through this contingency process more than once.

 

Part D Transition Plans:

 

All Part D Plans must have a transition plan. According to CMS Guidance, plans are “encouraged” but not required to provide for transition coverage of up to 30 days.  CMS has indicated that all plans have agreed to provide a “first fill” of drugs not currently on plan formularies, to allow time for the transition, but has not provided the transition plans to advocates, or made them available to the public.   DHS has indicated that one or two of the 10 plans available to dual eligibles have only a five day fill.

 

NSCLC and CHA obtained summaries of the transition plans from DHS for all of the drug plan sponsors for the subsidized PDP plans except United and WellCare.  Based on what we’ve been told, we assume that one or both of these plans must have the limited five day fill.

 

Retiree Issues 

 

CMS has stated that it has contacted many employers with dual eligibles in their retiree plans and that the plans do not plan to withhold coverage from individuals who enroll in Part D plans and later disenroll.  CMS appears satisfied that this effort is sufficient; and encourages individuals to send or fax copies of retirement letters to cwindfield-jones@cms.hhs.gov; fax: 410-786-6301.

 

Advocates remain seriously concerned that dual eligibles and others automatically enrolled in plans may unwittingly lose retiree health benefits (all benefits can be lost, not just prescription drug coverage) from many employers.

 

Tricare (a U.S. military retiree plan) is a retirement plan that dual eligibles (and others) can maintain along with a Part D plan. 

 

Good News for Medically Needy/SOC

 

CMS and DHS have informed us that owing to an error elsewhere in the country, 40,000 individuals who have NOT met their share of cost since February 2005 have been deemed eligible for the Low-Income Subsidy.  These are individuals who are on Medi-Cal but haven’t spent down for some time.  For 2006 only they will receive the LIS (this is a group not statutorily entitled to the LIS).  If they do not enroll in a plan before May 15, they will be facilitated into a plan, along with others in Medicare Savings Programs.  Encourage these individuals to sign up for a Part D plan now since the costs are subsidized.  This only applies to those who were on the DHS Part B buy in list at the time the information was transmitted to CMS earlier this year.

 

Medicare Advantage Updates:

 

Kaiser Permanente has a “KP Foundation” to pay for the Medicare Advantage premiums of dual eligibles.  Kaiser has said that this will extend to dual eligibles who have not met their share of cost.  It will not, however, cover the Part D portion of the premium for individuals whose Part D premium is not fully covered by the Low Income Subsidy.

 

CMS has stated that other Medicare Advantage plans have not received permission to waive premiums.  Some Secure Horizons/Pacificare representatives have stated that Secure Horizons will not collect from duals who do not pay.

 

New Auto Assignment Glitch – Out of State?

 

CMS has reported a serious problem with dual enrollments.  People may have been enrolled in an out of state plan.  Because CMS uses Social Security Administration address files for its auto assignments, in a “very small” but unspecified number of cases, the SSA address is not the actual address.  This is usually the case when someone is in a nursing home (and uses a relative’s address) or has a representative payee.

 

In these cases, if the daughter of the nursing home resident or the representative payee lives in a different state from the dual, the dual would have been auto assigned to a plan in the wrong region. Advocates should assist these duals in choosing an appropriate plan in their region.

 

Overview of Enrollment/Disenrollment:

 

NSCLC has recently produced an “Overview of CMS’ Guidance on Eligibility, Enrollment and Disenrollment for Medicare Part D Low Income Populations,” available at http://nsclc.org/. This provides a review of the various methods of enrollment and disenrollment detailed by CMS.

 

Problems with CMS WebTool and Enrollments Continue

 

The online CMS Prescription Drug Finder tool (at www.Medicare.gov) continues to be incomplete (e.g., not all drugs covered by plans are listed yet) and at times has included erroneous information (e.g., pricing information).  CMS has been unable to state a date when the formulary finder tool will be complete and accurate, despite the fact that individuals are already choosing and enrolling in plans.  We understand that there are many delays in the enrollment process including delays in confirmation of enrollment in a plan, delays in new plan information showing up on CMS’s webtool, as well as delays in obtaining plan ID cards.  CMS acknowledges that some information was and is wrong and will correct problems that are identified.  This is, of course, very difficult for duals who must rely on the plan finder now.  Please report errors, inaccurate and incomplete information.

 

Client Stories Needed: 

 

NSCLC is attempting to focus greater attention on the impact of Medicare Part D on low-income seniors and individuals with disabilities. Please help us by identifying and sharing client stories and contacts. We need provider stories and clients who are willing to speak directly with the press or are willing to have the facts of their situation shared. Please use the form available at http://www.nsclc.org/news/05/11/partd_stories.htm. The new fax number is 510 663 1051.

 

NSCLC Oakland has Moved!

 

NSCLC Oakland is at a new location. The phone and email are the same. The fax number and address have changed. Please change your records.

 

More information about Medicare Part D is posted on www.calmedicare.org, and on main page and California page of the NSCLC website, which you can view at www.nsclc.org.  We will continually post new training materials as this program develops.  Other helpful websites: Center for Medicare Advocacy at www.medicareadvocacy.org; Health Consumer Alliance at www.healthconsumer.org; Families USA at www.familiesusa.org; Medicare Rights Center at www.medicarerights.org; California Health Advocates at www.cahealthadvocates.org; California HealthCare Foundation at www.chcf.org/topics/healthinsurance/drugbenefit; Health Assistance Partnership at www.healthassistancepartnership.org;  and Kaiser Family Foundation at www.kff.org/medicare.

 

More information on Medicare Part D, including the December 9, 2005 Alert and other past Alerts, can be found at the www.nsclc.orgwebsite, at www.cahealthadvocates.org/cmc/index.html.

The Dec. 9 Alert is available at:  http://www.nsclc.org/news/05/12/partd_alert120605.doc

The Nov. 9 Alert is available at: http://www.nsclc.org/news/05/11/partdCA_alert111005.htm

 

For more information call or email NSCLC or CHA: