The following information was provided by the Pennsylvania Health Law Project (PHLP) to the Medicare Rx Coalition.
- The managed care organizations to which dual eligible individuals were passively enrolled (Keystone 65 Complete, Senior Partners, Amerihealth 65, Gateway, Unison, and UPMC for Life) are required to allow passively enrolled dual eligibles to continue to see out-of-network doctors without referrals or prior authorizations. Additionally, they are required to allow passively enrolled dual eligibles to continue to obtain any medication they were able to have under the Medicaid formulary without prior authorization or requirements for generic substitutions. These requirements are in place for at least the first 90 days of the year. Attestation statements signed by plan representatives committing them to the requirements are available at www.phlp.org/New%20Medicare%20Law%20Pdf%20Files/Plan%20attestation%20transitions.pdf. A letter from the Centers for Medicare and Medicaid Services (CMS) that explains the process is available at www.phlp.org/New%20Medicare%20Law%20Pdf%20Files/Transition%20policy%20reminder%201%2006%2006%20FINAL.pdf.
- The PHLP
requests that they be contacted if problems are identified regarding transition.
Contact can be made via email to ahalperin@phlp.org
or by completing and faxing the PHLP
survey. In instances where passively enrolled individuals are having
severe problems with accessing care under the transition requirements and
want or need to enroll in a different plan sooner than February 1 (the earliest
date they can disenroll simply by selecting a new plan), CMS has been processing
requests for retroactive disenrollments to original Medicare and into a
prescription drug plan (PDP) back to January 1 for PHLP on a case-by-case
basis.
• As part of the process for transitioning new enrollees into their plans, all Prescription Drug Plans (PDPs) are to cover off-formulary drugs with an initial 30-day supply (www.phlp.org/New%20Medicare%20Law%20Pdf%20Files/Transition%20policy%20reminder%201%2006%2006%20FINAL.pdf.) In addition, the Department of Public Welfare (DPW) has authorized an emergency five-day supply fill under Medicaid where the pharmacist is unable to get approvals for Medicare coverage (www.dpw.state.pa.us/Disable/MedicarePartD/003674234.htm.) - The PHLP continues to find problems with dual eligibles that are not identified as having the low-income subsidy. Plans generally wait for the corrected data to come directly from CMS. CMS has directed the plans to have customer service staff available to instruct pharmacists to override the computer message that a person must pay the full amount when the pharmacist is presented with information that the person has both Medicare and Medicaid (www.phlp.org/New%20Medicare%20Law%20Pdf%20Files/Pharmacist%20help%20letter%201%2004%2006.pdf.) In addition, DPW has agreed to guarantee the low co-payment amounts for dual eligibles (www.dpw.state.pa.us/Disable/MedicarePartD/003674234.htm.)
- The PHLP has found that many pharmacies do not know about, or are unable to process, the Point-of-Sale/Wellpoint option. Persons who are dual eligible and should have been auto-enrolled into a stand alone PDP but were not, can get their prescriptions filled through the Wellpoint contingency plan. Information on this option can be found on the CMS web site (http://questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std_adp.php?p_faqid=6248.)
PCPA Members may contact Betty Simmonds at PCPA with questions.
