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CMS Clarifies Medicare Part D Transition
February 3, 2006

The Centers for Medicare and Medicaid Services (CMS) has issued a clarification regarding the transition period for implementation of Medicare Part D and dually eligible beneficiaries who were passively enrolled in Special Needs Plans (SNPs). Providers can continue to provide Medicare-covered services to these individuals and receive payment even if they are not in the SNP’s provider network. The SNP is required to pay the provider the Medicare fee-for-service (FFS) rate or the billed charge, whichever is lower, for any Medicare covered services provided between January 1 and March 31. Providers should contact the SNP to request enrollment in the provider network.

SNPs in Pennsylvania have all agreed to the transition plan that honors prescriptions from non-network providers and directs payment for out-of network services through March 31. Delays or denials of medications at point-of-sale due to prior authorization requirements are not permitted. The January 26 clarification memorandum states “…a passive enrollee’s Part D-covered maintenance drugs that were available under the Medicaid managed care plan will remain available to the enrollee through the Plan during the transition period.” CMS encourages providers to contact the SNPs for questions about transition policies or becoming enrolled in the plans’ provider networks. Providers may also contact the CMS Philadelphia Regional Office if they continue to have problems (215-861-4226).

CMS will distribute another notice to beneficiaries who were enrolled in SNPs that explains enrollment options and plan transition policies. Dually eligible individuals are permitted to disenroll from the SNP at any time and return to FFS Medicare or enroll in a different Medicare managed care plan. They can disenroll by contacting the individual SNP or by contacting Medicare at 800-MEDICARE. Medicare staff can help the beneficiary enroll in another plan or in a Medicare Prescription Drug Plan.

Contact information for SNPs in Pennsylvania:
AmeriHealth 65
Member Services: 800-645-3965
Provider Services: 888-850-9200

Gateway Health Plan
Member Services: 800-685-5209
Provider Services: 800-685-5205

Health Partners
Member Services General: 800-553-0784
Medicare Specific: 888-667-7367
Provider Services: 888-850-9200

Keystone 65 Complete
Member Services: 800-645-3965
Provider Services: 888-991-9023

Unison Health Plan
Member Services: 800-290-4009
Provider Services: 800-600-9007

UPMC Health Plan
Members and Providers: 800-606-8648

The complete CMS memorandum is available. Contact Betty Simmonds with questions.

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