California Low-Income Health Advocate Alert On Medicare Part D
Thursday, January 26, 2006
- Organization: National Senior Citizens Law Center
January 26, 2006
Medicare Part D, the new prescription drug benefit, is a complex, confusing plan and has created a health crisis for dual eligibles (those on Medicare and Medi-Cal). Dual eligibles lost Medi-Cal coverage of virtually all prescription drugs starting January 1, 2006. This Alert informs California advocates of the latest developments and ways to assist clients who need access to their prescription drugs.
Part D Spells Disaster for Many Dual Eligibles
Since January 1, advocates report that dual eligibles are having serious problems accessing their prescription drugs from Medicare Part D plans. These seniors and people with disabilities no longer have prescription drugs covered by Medicaid and must use the new Part D benefit. The problem is so severe that 25 states, (including California) and the District of Columbia stepped in to provide emergency coverage for the dual eligibles.
The rollout of the Medicare Part D prescription drug benefit starting January 1, 2006 and the corresponding transition in drug coverage for those who are dually eligible for Medicare and Medi-Cal has been extremely problematic. Consumers, advocacy organizations providing direct services to consumers, pharmacists and the media all report that many dual eligibles are not getting their prescription drugs due to a number of problems, including:
• Failure of the process auto-assigning dual eligibles into Part D plans;
• Failure of the CMS' "backup" point of service system;
• Failure of CMS and contractors' databases;
• Inability of consumers and pharmacists to get through to Part D plans and obtain accurate information;
• Failure of Part D plans and contracting pharmacies to honor transition plan "first fill" obligations;
• Pharmacies charging inappropriate cost-sharing for drugs, resulting in duals being unable to afford them; and
• Consumers' inability to file exceptions and appeals with Part D plans.
California cited CMS's computer error rate of 1 in 6 for dual eligibles in mid-January.
California Has Set Up a Temporary Emergency Back-up to the Medicare Part D System
California joined other states across the U.S. and is providing emergency relief for its 1 million dual eligibles. Congratulations to all who joined us to help make this happen!
Under the new, temporary system, pharmacists in California can bill Medi-Cal for prescriptions and co-insurance when the Part D Medicare system does not work. Instructions for pharmacists are located on the Medi-Cal web site, www.medi-cal.ca.gov, at the following link:
http://files.medi-cal.ca.gov/pubsdoco/publications/bulletins/flyers/20060120_emergency_bulletin.pdf.
The DHS bulletin provides specific instructions to pharmacies, telling them to try to bill Medicare first. If they are unable to obtain the necessary information to submit a claim, the claim was improperly denied, or the co-pays are too high, the pharmacist is instructed to bill Medi-Cal.
Note: Under this emergency coverage, Medi-Cal restrictions on accessing drugs are still in effect (e.g., requirement of a TAR for certain drugs, a 6-drug monthly limit, etc.)
Check the Medi-Cal web site for updates and information about the Medi-Cal system. Problems accessing medication should be reported to DHS and/or CMS. First, make sure that the pharmacist knows about and is following the DHS instructions. If so, report any problems to DHS. Problems with the Medicare system can continue to be reported to CMS. If you think a client has a problem with the state (Medi-Cal) code or record, call 1- 866-227-9863.
California relief is very temporary
On January 12, 2006, Governor Arnold Schwarzenegger issued an emergency order enacting a five-day program. On January 20, he signed into law a bill passed by the legislature that will maintain Medi-Cal as the payer of last resort for 15 days, renewable once, providing relief for 1 million dual eligibles.
Please distribute this information broadly to advocates, clients, health care providers and pharmacists
Additional help is necessary.
Concerned clients and/or advocates can let their representatives know that more Part D relief is essential. Advocates are working at the state and federal levels to pursue necessary help for the dual eligibles.
CMS Response to Problems - Too Little, Too Late?
In response to some of the problems described above in the early days of Part D, CMS issued several memos and letters to Part D plans/sponsors in an effort to remind them of their obligations to enrollees.
CMS has officially only acknowledged some "glitches" and continues to report the new benefit as a success. Although CMS has issued a number of documents reiterating the transition plan requirements, it has yet to put an adequate safety net in place.
1. Pharmacy Transactions
CMS Memo: Information to Assist Pharmacists in Completing Pharmacy Transactions (1/4/06)
http://www.healthassistancepartnership.org/assets/pdfs/Pharmacist-help-letter-1-04-06.pdf
This memo to Part D plans urges plans to "make greater efforts to assist pharmacies in getting the information they need to fill prescriptions on ALL of [their] enrollees." In this memo, CMS admits certain problems, such as pharmacists unable to get through to a Part D plan, pharmacists getting incomplete and inaccurate information from such plans, and that CMS "continue[s] to receive numerous reports that plan [customer service representatives] are not aware of their plan's transition policies and that plans are inappropriately denying some scripts."
CMS states "we need plans to immediately make improvements" in 7 areas, including:
• increasing the capacity of plan customer service representative (CSR) availability (including identifying a technical assistance number);
• providing accurate information through plan CSRs, who, through technical assistance calls, "should be able to provide information on dual eligible and LIS copays …, nursing home copays, and correct information on transitional coverage of non-formulary drugs;"
• reporting/sharing of data with CMS.
LIS Cost-sharing Amounts
Dual eligibles and many others are eligible for the low-income subsidy, which provides for lower cost sharing for LIS -eligible individuals. CMS states:
"[i]f plans are aware that a beneficiary is subsidy-eligible, but do not know the exact subsidy level, they should default the enrollee to a $2/$5 benefit package. If they have no information indicating that the beneficiary is subsidy-eligible, they may default the enrollee to the base non-subsidized benefit package, however -
Even with these defaults in place, Part D plan CSRs who answer pharmacist calls should be trained and prepared to assist pharmacists with overriding default benefit packages in the event that an enrollee presents at a pharmacy with evidence of dual eligibility or an SSA subsidy determination. [underline in original]
In addition, CMS states that a plan can obtain information about an individual's LIS cost-sharing amount from 1-800 MEDICARE, the www.medicare.govweb finder tool, or by "[s]peaking with the beneficiary about an auto-enrollment or SSA letter." [emphasis added].
NOTE: The statement should mean that absent any other proof, a plan must take a beneficiary at his or her word re: eligibility for the LIS.
CMS Memo: Expedited Processes for Application of Cost Sharing for Dually Eligible and Other Low-Income Beneficiaries (1/13/05)
In a subsequent memo, CMS requires plans to ensure that at least one of several articulated procedures "is being effectively implemented when the pharmacy can identify the beneficiary's Part D plan and is seeking confirmation of the beneficiary's low-income subsidy status based upon such information as a Medicaid card, evidence that the prescription was previously filled by the Medicaid program, a CMS letter notifying the beneficiary of auto-assignment, a Social Security Administration letter notifying the beneficiary of eligibility for a low-income subsidy or other similar documentation"
If Someone has a Plan Enrollment Acknowledgement Letter Instead of an Plan ID Card
CMS notes that Part D plan enrollees often receive letters from plans acknowledging their enrollment prior to receiving an actual plan ID card. CMS states that "[p]lans must clearly communicate to their contracted provider networks that these letters must be accepted and used for billing claims in advance of the distribution of plan ID cards." [underline added]
2. Point-of-Sale/Contingency Plans for Unassigned Dual Eligibles
As reported in the 12/9/05 and 12/22/05 Issue Alerts, CMS has set up a contingency process for dual eligibles who have not been automatically assigned to a Part D plan. This process is supposed to both provide duals with a first prescription drug fill and then assign them to a Part D benchmark plan (Wellpoint/Unicare). Advocates, report widespread problems with this process.
Some advocates are, however, reporting success in getting their clients needed drugs by providing pharmacies with copies of the CMS point-of-service process. See: www.cms.hhs.gov/PrescriptionDrugCovGenIn/Downloads/POSFacilitatedEnrollmentWeb.pdf
The Orange County HICAP program also developed a flyer for dual eligibles to take with them to the pharmacy. This form has been adapted by Senior Legal Hotline. If you want a copy, contact them or e-mail oakland@nsclc.org.
CMS has recently issued a revised Point-of-Sale (POS) process for pharmacists to use. In part, this revised instruction sheet lowers the previous 14 step process to 4 steps. www.cms.hhs.gov/states
3. Transition Plans and "First Fills"
As referenced in the 12/22/05 Issue Alert, advocates had difficulty obtaining copies and/or summaries of Part D plans' transition plans that described how they were going to ease the transition of dual eligibles and others into Part D plans that might not cover drug that these individuals are currently taking. Thanks in large part to California's Department of Health Services, advocates obtained summaries of most of the benchmark plans. It appears that at least one Part D sponsor that had planned to provide only a 5 day first fill changed their policy to a 30 day fill (apparently, in part to DHS' efforts).
CMS subsequently distributed a summary of all the PDP transition plans in CA (12/22/05 PDP Transition Policy Draft Summary). According to CMS, Part D plans in CA have various "first fill" policies (for non-formulary drugs) that range from a 15 day supply offered by PacifiCare to 60 days offered by some plans; and some plans have an "open formulary."
CMS Memo: Pharmacy Transition Policies (1/6/06)
http://www.healthassistancepartnership.org/assets/pdfs/Transition-policy-reminder-1-06-06-FINAL.pdf
Advocates report, and CMS acknowledges, serious problems with plans adhering to their transition processes, including "numerous reports that plan customer service representatives (CSRs) are not aware of their plan's transition policies" and "reports that plans are inappropriately denying some prescriptions because the plan has not provided transition override instructions to pharmacists." In addition, CMS notes the "use of potentially burdensome prior authorization and step edit requirements that are preventing access by beneficiaries to needed first prescriptions at the point-of-sale." While CMS does not prohibit this practice outright, it states: "as a general matter, prior authorization and step edits should be suppressed so as to not prevent an enrollee from receiving their medications under a transition period."
CMS Memo: Further Clarification of Formulary Transition Policies (1/13/06)
CMS notes that "delaying or denying the filling of initial prescriptions for new enrollees at point-of-sale because of prior authorization/edit requirements is not consistent with the intent of CMS' transition policy." CMS requires Part D plans to:
n establish an expedited process for pharmacists to obtain authorization to override any edits that would apply in the absence of their transition policies;
n provide customer service representatives (CSRs) on pharmacy help lines who have the authority to make or obtain quick decisions on the application of transition policies;
n enable CSRs to "operationalize" approved claims through the claims processing system in real-time in order to permit the pharmacy to electronically submit the claim and have it accepted.
CMS Memo: Letter to Partners (1/13/06)
http://www.cms.hhs.gov/Partnerships/Downloads/PartnerLetter113.pdf
In this memo, CMS outlines steps is has taken to try to address some of the problems with the implementation of Part D. CMS states that it is reviewing process and systems to review and address enrollment process and infrastructure issues, working with the states, ("to limit their financial exposure in the event that the cost sharing information is erroneous"), requesting plans to have expedited processes for cost sharing approvals with new resources to assist pharmacists in obtaining needed approvals and authorizations, and establishing special troubleshooting CMS caseworkers across the country.
CMS letter to the Part D plan sponsors urges (but not does appear to obligate) them to work with CMS a number of "collaborative next steps":
- provide a toll free pharmacy hotline and provide a toll-free number and appropriate exception information to physicians/providers;
- strengthen transition policies with expedited systems to handle utilization management requests in real time (i.e., while the individual is still at the pharmacy);
- "use sound judgement to extend [30 day transition coverage] in special situations where a longer transition may be required for sound medical reasons
- provide timely written notice and clear guidance to individuals who receive transition coverage about 1) the temporary nature of the transition and the need to work with physicians for substitutes, 2) the right to request an exception and how to do so;
- provide expedited procedures to approve Low-Income Subsidy cost sharing at the pharmacy for no more than $2/$5 co-payments ($0 for institutionalized individuals)
- abide by guidance and regulations relating to disenrollment individuals for failure to pay premiums; wait for CMS notification of actual premiums before sending a bill or disenrolling an individual for lack of payment.
Other CMS Info:
Medicare Call Center Pharmacy Helpline: # 1-866-835-7595
On 1/6/06, CMS reported that the Medicare Call Center's Pharmacy Helpline call handling capacity has been increased by 30 fold and the line is now available 24 hours a day/ 7 days a week.
The following link has a number of CMS documents relating to the implementation of Part D, including transition plan summaries, pharmacist Q&As and a description of the point of service process for unassigned dual eligibiles: www.cms.hhs.gov/PrescriptionDrugCovGenIn/
On 12/30/05, CMS released a "chart of potential situations beneficiaries, especially full benefit dual eligible beneficiaries, may encounter. This list of scenarios is designed to assist you and your colleagues to quickly respond to any inquiries or problems you may receive. Please distribute the scenarios as you think appropriate." The scenarios are in the Prescription Drug Coverage section of CMS' website at http://www.cms.hhs.gov/partnerships/downloads/whatif1.pdf
CMS noted that if states/advocates "encounter situations not covered in this chart, please send those to the CMS Regional Office Part D Assistance Center for your state at the email address listed below. As these new scenarios are submitted and answered, they will be added to those that are currently in the chart, so check back often. The contact info for California (Region IX) is Ro9drugteam@cms.hhs.gov
Note: Health Assistance Partnership (HAP) has helpful material posted on their website re: Part D implementation issues, including copies of many of the above-referenced CMS documents. See: http://www.healthassi stancepartnership.org/medicare/resource-center/medicare-modernization-act-of-2003/first-aid-kit.html.
Sign-on Letter to CMS
On behalf of various advocacy organizations, National Senior Citizens Law Center and the Center for Medicare Advocacy sent a letter to CMS detailing the problems that dual eligibles are having and asking for immediate relief. Over ninety organizations have now signed on to the letter, originally sent out on January 11. You can find the letter at http://www.nsclc.org/news/06/01/cmsletter_011206.pdf. We are continuing to release the letter with additional sign-ons . We have refined our specific request for action to include three specific points. We are now requesting that CMS immediately:
· Alert all pharmacists who fill prescriptions for Medicare beneficiaries for dual eligibles that they will be reimbursed, regardless of whether or not they can verify coverage or subsidy eligibility.
· Assure states that they can continue Medicaid coverage for their dually eligible residents and be reimbursed for such payments.
· Assure that all individuals who identify themselves as eligible for the full low-income subsidy pay co-payments of no more than $1 for generic drugs and $3 for non-preferred brand name drugs.
CMS has taken a number of steps to improve its systems, but it has not yet taken the necessary steps to protect the dual eligibles. It has not assured pharmacists that they will be paid in full if they provide medicine to dual eligibles. CMS has agreed to reimburse the states for efforts to ensure that dual eligibiles access their medications, a complete reversal from it's earlier position that it had no authority to take such an action. We hope that the agency will take further action that will address problems at the pharmacy level. We believe that for our clients to be able to walk away from the pharmacy with their medically necessary prescriptions, CMS must promise the pharmacists that they be paid.
If you would like your organization to sign on to the letter (and have authority), please e-mail both jfinberg@nsclc.org and oakland@nsclc.org.
Keep Those Stories Coming
Specific details on the problems that the dual eligibles are facing are extremely important to keep a statewide and national focus on the problems and to bring about the changes needed at the state and federal levels. California's temporary bail out may last only 15-30 days. To get more permanent relief and a working program for dual eligibles to access needed drugs, we need to keep our client stories in the press. Please help us by identifying clients or their family members who are willing and able to talk to the press, and those whose stories can be told through advocates. Send stories and contacts to jfinberg@nsclc.org or oakland@nsclc.org.
NSCLC Oakland has Moved!
NSCLC Oakland is at a new location. The phone and e-mail are the same. The fax number and address have changed. Please change your records to the following:
National Senior Citizens Law Center
1330 Broadway, Suite 525
Oakland, California 94612
Tel. 510 663-1055
Fax 510 663-1051
Reporting Problems
DHS-problems with state system (or emergency system)
· No new lines have been set up to handle problems with Medicare Part D, but regular DHS numbers are in effect and should be used to make officials aware of any remaining problems.
· Beneficiaries can call 1-800-541-5555. Press 1 for English
2 for Spanish,
then 11 for English, then 13 for Medi-Cal beneficiaries.
CMS-problems with federal system
- 1-800-MEDICARE or specific plan number
- If that is not satisfactory, call CMS Regional Office for customer service:
General: 415 744 3602
MA Issues: 415 744 3617
Other State-Wide Issues: 415 744 3568
and e-mail Lucy Saldana (lsaldana@cms.hhs.gov) and to have a written report of this issue.
- Pharmacist line: 1-866-835-7595
More information on Medicare Part can be found on our websites. The Dec. 22 Alert is available at http://www.nsclc.org/issues_health_medicareD_CA.html:
For more information call or email NSCLC or CHA:
National Senior Citizens Law Center
Jeanne Finberg
Katharine Hsiao
510 663-1055
California Health Advocates
David Lipschutz
dlipschutz@cahealthadvocates.org
213 381-3670
This Alert is provided by the National Senior Citizens Law Center in partnership with California Health Advocates with support from The California Endowment
More information about Medicare Part D is posted on:
- www.calmedicare.org
- The NSCLC main page at www.nsclc.org and the "Medicare Part D in California" page, linked from the main page, at www.nsclc.org/issues_health_medicareD_CA.html. We will continually post new training materials as this program develops.
- 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;
- Kaiser Family Foundation at www.kff.org/medicare
