Post AEP Troubleshooting My Part D plan doesn t cover one or more of my drugs This will be one the most immediate problems you will encounter. There are a variety of reasons that this problem will occur: Client elected a new plan for 2012 during the AEP and the new plan doesn t cover one or more of his or her medications (or covers it but with a prior authorization or step therapy requirement); Client was automatically mapped into a new plan for 2012 and the new plan doesn t cover one or more of his or her medications (or covers it but with a prior authorization or step therapy requirement); Client stayed with his or her 2011 plan (by either conscious or unconscious inaction for 2012 and the 2012 version of the plan doesn t cover one or more of his or her medications (or covers it but with a prior authorization or step therapy requirement); Client elected a new plan mid-year using a SEP and the new plan doesn t cover one or more of his or her medications (or covers it but with a prior authorization or step therapy requirement); The (short term) Solution: Transition Fill A Part D sponsor must provide for an appropriate transition process for new enrollees prescribed Part D drugs that are not on its formulary. Medicare Prescription Drug Benefit Manual Chapter 6 Section 30.4 Regardless of which of the reasons from the previous are the cause of the person not having a drug or drugs covered, the immediate short term solution for them is the transition fill. The transition fill enables a beneficiary to get a one time, 30 day fill (90 days if in LTC institution) when a prescription is not on the Part D plan s formulary or is on the plan s formulary but is subject to drug utilization management limitations (i.e. prior auth requirements or step therapy requirements). Note: A beneficiary doesn t need to have switched Part D plans to qualify for the transition fill, it s enough for the beneficiary to have stayed with his or her current plan or enrolled in his or her very first Part D plan ever.
Who is entitled to the transition fill? The transition fill is available to all Part D beneficiaries who are enrollees in a new plan following the annual enrollment period, newly eligible Medicare beneficiaries, new enrollees switching mid year from one Part D plan to another, enrollees in LTC facilities and current enrollees affected by formulary changes from one contract year to the next. A Part D sponsor s transition process is necessary with respect to: (1) the transition of new enrollees into prescription drug plans following the annual coordinated election period; (2) the transition of newly eligible Medicare beneficiaries from other coverage; (3) the transition of individuals who switch from one plan to another after the start of the contract year; (4) enrollees residing in LTC facilities; and (5) in some cases, current enrollees affected by formulary changes from one contract year to the next. Transition Fill Time Period Transition fills are required during the first 90 days that a beneficiary is enrolled in a plan. This may not correspond with the first 90 days of the calendar year for beneficiaries newly eligible to Medicare or those switching plans mid year. How to obtain a transition fill If the transition fill policy works properly neither you or the beneficiary should have to request a transition fill. When a new enrollee to a Part D plan submits his or her prescriptions to the pharmacist for the very first time under the new plan, the Part D plan should automatically cover all the drugs whether they are on the plan s formulary or not or whether they are subject to drug utilization requirements or not. If this does not happen then contact the plan and request a transition fill on the beneficiary s behalf. If that is unsuccessful, contact your BSSA for further assistance.
Notice of Transition Fill as Important As Transition Fill Itself Providing notice to the beneficiary that they have received the transition fill is as important as the fill itself. Receiving the transition fill is supposed to generate a notice which is mailed to the beneficiary. The notice should inform the beneficiary that he or she has received a one time fill of a drug that is either not on the formulary or subject to PA or step therapy requirements. The notice will also inform the beneficiary of the right to request an exception, complete the appropriate PA/step therapy paperwork or switch to a therapeutically equivalent drug on the plan s formulary. Notice is Critical This notice is important because the purpose of the 30 day transition fill is to give the client and us the time to address the problem causing the drug not to be covered by doing things like requesting an exception, satisfying the prior authorization or step therapy requirements, seeing if the client can switch to a different drug or (often the easiest solution) scrounging up a special enrollment period (SEP) to get the person switched to a different plan for the following month. Lack of Notice Causes Problems In the absence of this notice, the beneficiary simply picks up his or her drugs, they are all covered and the beneficiary logically concludes that all of his or her drugs are covered by the Part D plan. Then, the following month when he or she is out of his or her meds he or she goes to the pharmacy and the meds aren t covered and the transition fill has been used up.
The (long term) Solution: Fulfilling drug utilization requirements, requesting exceptions, switching drugs and switching plans Now that the transition fills has bought your client 30 days of covered medication, how do you fix the lack of coverage problem permanently? What s the long term solution? Fulfilling drug utilization requirements; Requesting an exception; Switching to a therapeutically equivalent drug; Switching plans How do I request coverage for a non-formulary drug or fulfill prior authorization, quantity limit or step therapy requirements? The beneficiary s Part D plan website should have the necessary exception request forms that the beneficiary and his or her prescribing physician will need to complete for drugs that require prior authorization and to request exceptions to the formulary, step therapy and quantity limit requirements. I have included samples of these forms from CCRX. Each plan will have their own version of these but since they are required to be based on a CMS Model form they shouldn t vary much in terms of content. What s an exception? An exception is exactly what it sounds like you are requesting an exception to the formulary. I know you don t cover the drug but make an exception for me because medical necessity requires me to take that specific drug. I know you cover the drug but require that step therapy with other drugs be conducted before you cover it. Please make an exception for me because the doctor prescribing the medication for me tried step therapy and it didn t work. Most of the work of completing exception request forms is done by the beneficiary s prescribing physician. An exception request typically requires the physician to explain and document the specific/unique medical circumstances justifying coverage of the drug for the particular beneficiary. Similarly, prior authorization, quantity limit and step therapy requires the physician to provide information which justifies the use of the drug, the need for exceeding the quantity limit or documenting that step therapy was attempted already and didn t work or would not be appropriate. Our role is be to make the beneficiary aware of the availability of the exception and drug management utilization requirements and facilitate the completion of the appropriate forms (send to physician s office along with explanation of it purpose) and submission to the plan.
Switching to a different drug that does the same thing Another way to fix the problem would be to ask the doctor if a therapeutically equivalent drug (for example a generic version if the person is taking a brand name) would be appropriate for the person and then checking to see if its on the formulary. This is probably the least attractive option because presumably the person has been prescribed the drug they have for a particular reason. Switching Plans Another way to fix the problem and sometimes the easiest depending on the beneficiary s circumstances is to simply switch them out of the plan into a new one. You will also likely encounter clients who, for a variety of reasons, missed the opportunity to enroll in a Plan during the AEP or have had their circumstances change such that it is now desirable to get into a Part D plan outside of the AEP. Need A SEP Much of our Part D work outside of the AEP is scrounging up SEP for folks who want to get into or out of Part D or Advantage plans. First, always check to see if the beneficiary is entitled to any type of LIS or if he or she is institutionalized. If so, they are entitled to an ongoing SEP and are easy to fix by enrolling them in a new plan that does cover all their drugs (if there is one) effective the first of the following month. Note: ALL institutionalized individuals are entitled to the ongoing SEP. There is no requirement that they be entitled to Medical Assistance or the LIS.
Other SEPS If the person is not entitled to the LIS and is not institutionalized you can start looking at other SEPS. I have included a longer list of these as an attachment in Tools and SEPs to fix Clients Problems and will introduce the new 5 Star SEP available in 2012 and review some of the more common and useful SEPs for our clients. New SEP for 2012: 5 Star SEP In 2012 there is one new SEP, the SEP to Enroll in an PDP, Advantage Plan or Cost Plan With a Plan Performance Rating of Five (5) Stars. In Wisconsin that means enrolling in an Advantage plan or Cost plan since there are no 5 star PDPs available in WI 5 Star SEP There are 10 Advantage plans (offered by Advocare and Gunderson Lutheran) and 3 cost plans (offered by Dean) with 5 star ratings available in WI. Unfortunately these plans are not available in every county.
5 Star Advantage & Cost Plans Available in Wisconsin Advocare H5211: 1)Advocare Essence; 2) Advocare Essence Rx; 3) Advocare Spirit; 4) Advocare Spirit Rx; 5) Advocare Vitality; 6) Advocare Vitality Rx Gunderson Lutheran H562: 7) Gunderson Lutheran Senior Preferred Elite Rx; 8) Gunderson Lutheran Senior Preferred Value Rx; 9) Gunderson Lutheran Senior Preferred Elite; 10) Gunderson Lutheran Senior Preferred Value; HMO HMO Available in 32 Counties: Adams, Ashland, Barron, Bayfield, Burnett, Chippewa, Clark, Douglas, Dunn, Eau Claire, Forest, Iron, Jackson, Juneau, Langlade, Lincoln, Marathon, Monroe, Oneida, Pepin, Portage, Price, Rusk, Sawyer, Shawano, Taylor, Trempealeau, Vilas, Washburn, Waupaca, Waushara, Wood Available in 11 Counties: Buffalo, Crawford, Grant, Jackson, Juneau, La Crosse, Monroe, Richland, Sauk, Trempealeau, Vernon Dean Health Plan, Inc. H5264: 11) DeanCare Gold Basic; 12) DeanCare Gold Enhanced; 13) DeanCare Gold Shared Value COST Available in 8 Counties: Columbia, Dane, Dodge, Grant, Iowa, Jefferson, Rock, Sauk 5 Star SEP Eligible individuals can switch from a PDP, an MA-Only plan, an MA-PD plan, a cost plan or Original Medicare to one of those plans once per year. What s a Cost Plan Works like an Advantage plan in-network. However, unlike an Advantage plan, works outside of the network. Will work as if you have traditional A&B Medicare out of network. You can join even if you only have Part B. If you go to a non-network provider, the services are covered under original Medicare. The beneficiary pays the Medicare Part A and Part B Coinsurance and Deductibles. You can join a Medicare Cost Plan anytime it's accepting new members. You can leave a Medicare Cost Plan anytime and return to the Original Medicare Plan. You can either get your Medicare prescription drug coverage from the plan (if offered), or you can buy a stand-alone Medicare Prescription Drug Plan (Part D) to add prescription drug coverage.
Cost Plan Coordinating SEP Beneficiary s who use the 5 Star SEP to enroll in a 5 star Cost plan (in Wisconsin one of the three Dean plans) have a coordinating SEP to enroll in a PDP or in the cost plan s optional supplemental Part D benefit (if offered). The PDP selected using this coordinating SEP does not have to be 5 Star rated. Coordinating SEP H. SEP for Individuals Using the 5-Star SEP to Enroll in a 5-Star Plan without Part D Coverage Individuals who use the 5-star SEP to enroll in a 5-star Medicare Advantage-only Private Fee-for-Service plan or a 5- star cost plan have a SEP to enroll in a PDP or in the cost plan s optional supplemental Part D benefit, for which they are eligible. The PDP selected using this coordinating SEP does not have to be 5-Star rated. However, individuals may not use this coordinating SEP to disenroll from the plan in which they enrolled using the 5-star SEP. This SEP beings the month the individual uses the 5-Star SEP and continues for two additional months. Dean Cost Plans None of the three 5-star cost plans available in WI (DeanCare Gold Basic, DeanCare Gold Enhanced, DeanCare Gold Shared Value) offer supplementary drug coverage. A person in one of these cost plans will have to enroll in a standalone Part D plan to receive drug coverage.
Who Can Use the 5 Star SEP and When Can They Use it? When can I start enrolling people using the 5 star SEP: December 8 2011. How often can the 5 star SEP be used? One time between December 8 2011 and November 30 2012. Who is eligible to enroll using the 5 star SEP? Anyone who is eligible for Medicare Part D. Even if a person is already enrolled in a 5 Star Plan he or she can use the SEP to switch to another 5 star plan. Example 1 Plan X has an overall rating of 4.5 stars in 2012 and 5 stars for 2013. An individual could use this SEP to request enrollment in Plan X starting on December 8, 2012 for an effective date of January 1, 2013. An individual could not use the SEP to enroll in Plan X for an effective date on or before December 1, 2012, as the enrollment effective dates available during that period are prior to the calendar year for which Plan X has been assigned a 5-star overall rating. Example 2 Plan Y has an overall rating of 5 stars for 2013 but has lost that 5-star rating for 2014. A beneficiary could use this SEP to request enrollment in Plan Y for the first of the following month until November 30, 2013, with the last possible effective date available being December 1, 2013. The beneficiary could not use the SEP to enroll in Plan Y on or after December 1, 2013, as the enrollment effective dates available during that period are after the calendar year for which Plan Y has been assigned a 5-star overall rating.
Example 3 Cost Plan Z has an overall rating of 5 stars for 2012. Cost plan Z does not offer a supplementary drug benefit. If a beneficiary enrolls in Cost plan z, the beneficiary can then enroll in any of the 29 standalone PDPs available in WI in 2012 using the 5 Star Part D coordinating SEP. Text of 5 star SEP I have included the full text of the 5 star SEP in the attached Tools and SEPs to Fix Clients Problems. 13. SEP to Enroll in an MA Plan or PDP With a Plan Performance Rating of Five (5) Stars A Part D eligible individual may enroll in an MA plan or PDP with a Plan Performance Rating of five (5) stars during the year in which that plan has the 5-star overall rating, provided the enrollee meets the other requirements to enroll in that plan (e.g., living within the service area as well as requirements regarding end-stage renal disease). As overall ratings are assigned for the plan contract year (January through December), possible enrollment effective dates are the first of the month from January 1 to December 1 during the year for which the plan has been assigned an overall rating of 5 stars. An individual may only use this SEP one time between December 8 of the year prior to the year in which the plan sponsor has been granted a 5-star overall rating and November 30 of the year in which the sponsor has been granted a 5-star overall rating. The enrollment effective date is the first of the month following the month in which the plan receives the enrollment request. SEP Plan Non Renewal The SEP for plan non renewal applies to PDPs and Advantage plan enrollees in companies who have elected to no longer offer their PDP or Advantage plan in the member s service area effective January 1, 2012. Unlike 2011, there were relatively few Advantage plans and PDPs that did not renew for 2012. In Wisconsin this SEP would apply to individuals enrolled the Bravo and Sterling PDPs and in Advantage plans that are not renewing for plan year 2012 which vary by county. These individuals have from December 8 until February 29 to enroll in a new plan if they did not already enroll in a new plan during the AEP. Remember that individuals who enroll in January will have an effective date of February 1 and individuals who enroll in February will have an effective date of March 1.
Advantage Plan Disenrollment Period Another enrollment period (a disenrollment period) that will be available shortly after the end of the AEP is the Advantage Plan Disenrollment Period (MAPD) which runs from Jan 1 through February 14. The MADP allows for the disenrollment from an Advantage plan to return to original Medicare. An individual is not required to have enrolled in the advantage plan during the AEP to use the MADP to get out of the plan. If the individual is in an advantage plan, for whatever reason, he or she can get out using the MADP. If the individual did enroll in an advantage plan during the most recent AEP, the MADP provides him or her with a very short amount of time to try the advantage plan out and get out of it if he or she does not like it. MADP Coordinating PDP SEP Individuals using the MADP are also entitled to a coordinating Part D SEP that allows them to get into a Part D plan. It doesn t matter if the advantage plan the person is disenrolling from had drug coverage or not, the person gets the SEP for a standalone PDP. With the exception of a MA-only PFFS plans, the beneficiary can effectuate the disenrollment from the advantage plan by simply enrolling in the PDP. SPAP SEP Another useful SEP for our population is the SEP for Individuals Who Belong to a Qualified State Pharmaceutical Assistance Plan (SPAP) or Who Lose Eligibility for a SPAP. This SEP is available to our SeniorCare level 2b and 3 enrollees (also enrollees of the chronic renal disease program, cystic fibrosis program, HIRSP and hemophilia home care program). If a person is not already in SeniorCare and their income would put them at level 2b or 3, they can buy a SEP for the $30 SeniorCare annual enrollment fee that will allows them to enroll, switch or drop a Part D plan. The SEP is available once per calendar year and ends with the first election of the calendar year using this SEP.
What Does the SPAP SEP Allow A Beneficiary to Do A 2b or 3 SeniorCare enrollee can use this SEP to: Go from original Medicare to a PDP or MA-PD plan; Go from a PDP to a different PDP or MA-PD plan; Go from an MA-PD to a different MA-PD or PDP plan; Go from an MA only plan (no prescription drug coverage) to a PDP or MA-PD plan SEP to Disenroll from Part D to Enroll in or Maintain Other Creditable Coverage This SEP is available to anyone who currently has, or can enroll in, any kind of non Part D creditable coverage (employer drug coverage, VA, Tricare etc..). For our purposes, this SEP is most frequently used when that other creditable coverage is SeniorCare. Unlike the SPAP SEP, anyone (levels 1, 2a, 2b and 3) enrolled in SC qualifies for the other creditable coverage SEP. It allows a beneficiary to disenroll from their Part D or MA-PD plan to enroll in or maintain other creditable coverage. Unlike the SPAP SEP, it does not allow enrollment into a Part D plan, only disenrollment. Individuals enrolled in an MA-PD plan who have or are enrolling in other creditable coverage may use this SEP to disenroll from the MA-PD plan by enrolling in an MA-only plan. For the $30 annual enrollment fee anyone enrolling in or already in SeniorCare can get out of their Part D plan. Other SEPS I ve provided a fuller list of the more frequently encountered SEPs in the Tools and SEP to Fix Clients Problems document in your materials. As always, if you are looking for a SEP for a client, contact your supervising attorney for assistance.
LINET Another problem that you will likely encounter are individuals entitled to the low income subsidy who are not enrolled in a Part D plan. To get them immediate access to their drugs you can use Limited Income Net (LINET) which is administered by Humana. LINET is also used to get retroactive LIS coverage for Medicaid entitled individuals. If a Medicare beneficiary can demonstrate that they are eligible for Medicaid or the LIS and they are not enrolled in a Part D plan, the pharmacist can submit the claim to LINET. Dual eligibles who need retroactive coverage and all other LIS beneficiaries who need coverage immediately are temporarily enrolled via LINET into this one prescription drug plan without formulary restrictions, prior authorizations, step therapy, network pharmacy restrictions and claim filing deadlines. LINET Once enrolled in LINET, the beneficiary will receive a 90 day supply of his or her medications and he or she will automatically be enrolled into a low cost plan the second full month after becoming LINET eligible. For example, beneficiaries processing the first claim using LINET on January 14 would be members in LINET for January and February and would the be assigned to a Part D plan effective March 1. If you encounter pharmacists who are unfamiliar with it you can provide them with the below materials to instruct them how to bill LINET: LINET Quick Reference Sheet (NEW) LINET Tip Sheet for Pharmacy Providers LINET Questions and Answers for Pharmacy Providers LINET Four Steps for Pharmacists LINET for people at the Pharmacy Counter The LINET Program for People with Retroactive Medicaid and SSI Eligibility. What if the beneficiary is eligible for the LIS, is not in a Part D plan but LINET won t work? Remember LINET will only work if the LIS entitled beneficiary is not enrolled in a Part D plan. However sometimes it doesn t work anyway. There are two main reasons for this: 1) the person opted out of the Part D auto-enrollment process with Medicare. This often occurs because the enrollee has SeniorCare, wants to keep it and doesn t want to keep being auto-enrolled in Part D plans; 2) a person is in an Advantage plan without drug coverage or has private insurance with drug coverage. LINET will not work because it does not want to inadvertently disenroll a beneficiary from their existing coverage.
Solutions 1) Call 1-800 Medicare and opt back in. Use the actual phrase opt in when speaking with Medicare Rep 2) disenroll from the Advantage plan; 3) after consulting with the HR department, determining the effect of enrolling in Part D plan on retiree health coverage and drug coverage and explaining that effect to the client, assist the client in disenrolling from the retiree drug coverage. What if the LIS eligible person is enrolled in a Part D but the subsidy isn t showing up? Use Best Available Evidence A second useful tool that you should be familiar with is the Best Available Evidence (BAE) policy. This policy will useful when you have a client who is in a Part D plan and entitled to the low income subsidy but that subsidy status is not showing up when the person goes to get their medications filled. This tends to happen when someone is newly eligible for the LIS or someone on LIS switches from one plan to another or there is simply a mistake and the person s LIS status disappears. The best available evidence policy enables you to prove the LIS status of your client to a Part D plan and the policy requires Part D plan to accept the evidence that you provide establishing a member s LIS eligibility. Best Available Evidence The Best Available Evidence can be a Medicaid card, a CAREs notices, an LIS award letter, a state document/print-off showing Medicaid eligibility or any other documentation that would demonstrate LIS or dual eligibility. There is typically very little problem in obtaining adequate best available evidence for a client. The problem usually comes in getting the plan to recognize the best available evidence, understand its legal obligations with regard to it and supply the client with the appropriate LIS cost-sharing in a timely fashion. Once a beneficiary provides this evidence to the plan, the plan is obligated to update its system to reflect cost-sharing levels at the higher level of LIS cost sharing ($2.60 and $6.50 in 2012).
Best Available Evidence Fax or scan a copy of the BAE guidance and memo (included at the end of these materials) explaining the BAE policy along with the best available evidence you have to the plan. Don t let the plan persuade you that they cannot provide the cost sharing until their system has been updated in three days or whenever, the guidance makes clear that they are to provide the cost sharing as soon as they receive it: Update sponsor systems to reflect the correct LIS status based upon BAE documentation, override the standard cost-sharing, and maintain an exceptions process for the beneficiary to obviate the need to require the re-submission of documentation each month pending the correction of the beneficiary s LIS status in CMS systems. Part D sponsors will be required to update their systems within 48-72 hours of their receipt of BAE documentation. The requirement that Part D sponsors update their systems within 48-72 hours is in addition to the requirement that Part D sponsors provide access to covered Part D drugs as soon as BAE is presented to them. Best Available Evidence If you get a plan that is either refusing to recognize the evidence or provide the LIS cost sharing or is dragging its feet in processing the request, contact the plan s designated BAE contact person: http://www.cms.gov/prescriptiondrugcovcontra/17_best_av ailable_evidence_policy.asp#topofpage If that doesn t solve the problem, contact your supervising attorney and we will get CMS Region 5 involved. In my experience, getting Region 5 involved tends to expedite the recognition and processing of BAE on the plan s part. New for 2012: Reinstatement Following Disenrollment for Failure To Pay Part D/Advantage Premiums Finally, I just wanted to remind you of another new right effective January 1, 2012: Good Cause Reinstatement for Beneficiaries Disenrolled from Advantage Plan or PDP for Failure to Pay Premiums There is a new good cause right to request reinstatement for individuals who have been disenrolled from their Advantage or PDP for failure to pay premiums. (The guidance is in your handouts).
Good Cause Reinstatement If an individual has been involuntarily disenrolled for a failure to pay premiums he or she may request reinstatement into the plan by CMS under the following circumstances: 1. The person requests reinstatement with CMS within the first 60 days of the disenrollment effective date; 2. CMS determines that the individual meets the good cause criteria specified 3. The individual pays all owed plan premiums in full within the three month grace period (both past due amounts and the premium amounts that accrue for the months during the request for reinstatement). Good Cause Reinstatement Reinstatement for good cause is provided only in rare circumstance in which the beneficiary or his/her authorized representative was unable to make timely payment due to circumstances over which they had no control and they could not reasonably have been expected for foresee. According to the guidance, examples of circumstances that may constitute good cause include: Federal government error caused the payments to be missed or late; Prolonged illness, hospitalization or institutionalization of the beneficiary; Death or serious illness of spouse or other family member; or Loss of the beneficiary s home or severe impact by fire, or other exceptional circumstance -outside the beneficiary s control (e.g. affected individual resides in a federal disaster area). Good Cause Reinstatement Examples of circumstances that would not constitute good cause include: Allegation that bills or warning notices were not received due to unreported change of address, out of town for vacation, visiting out of town family, etc; Authorized representative did not pay timely on member s behalf; Lack of understanding of the ramifications of not paying plan premiums or Part D-IRMAA; Could not afford to pay premiums at the time of delinquency/disenrollment
Good Cause Reinstatement To request a good cause determination, the beneficiary must call 1-800-Medicare within 60 days of the effective date of their disenrollment due to failure to pay premiums. If the beneficiary calls the plan and indicates that they had a good reason for failing to pay the premium, the plan is required to inform them to call 1-800-Medicare. Once the request is made with CMS via 1-800-Medicare a CMS caseworker will contact the beneficiary. CMS will then make a decision and, if favorable, inform the plan who will, in turn, inform the beneficiary of the repayment process (i.e., all premiums due the last day of the third month following effective date of disenrollment) Once the beneficiary makes the repayments, he or she will be reinstated back to date he or she was disenrolled so his or her coverage will be continuous. If the decision is unfavorable the beneficiary will not be reinstated (or if the decision is favorable and the beneficiary fails to pay all premiums owed within the three month time frame). There does not appear to be an appeal right if the CMS decision for reinstatement is unfavorable or if the beneficiary fails to pay all premiums owed within the three month time frame.