MMA Update: New Clients, Problem Resolution, and Part D Deductions - - PowerPoint PPT Presentation

MMA Update: New Clients, Problem Resolution, and Part D Deductions

Medicare Part D Problem Solving

Topics

Background Best Practices Referral Form

Background

Since the implementation of Medicare Part D

• n January 1, 2006, some clients have had

difficulty getting their medications filled at the

• pharmacy. Below are best practices for

resolving the client’s Medicare Part D coverage problems.

Best Practices

Check with the client to find out if she or he cannot

get coverage because the client is not in a plan, or because the client is charged an incorrect copayment.

If the client does not show enrollment in a plan at the

pharmacy, ask the pharmacist to do an E-1 query.

If the client’s enrollment does not show up on the E-1

query, walk the pharmacist through the point-of-sale enrollment process with Wellpoint-Anthem.

Note: This step only works for full dual eligible

clients.

Best Practices Continued

If the client shows enrollment in a plan but at the

incorrect copayment, then:

Find out from the pharmacist if the drug is covered

by the plan. If not, the client’s doctor will need to prescribe a covered drug or file an exception with the plan.

If the drug is covered by the plan, contact the plan

to get the client’s Low-Income Subsidy status updated.

Referral Form

If you cannot resolve the client’s problem through any

• f the steps above, please fax the attached client

referral form to Central Office.

Write “Urgent” at the top of the page if the client is out

• f medications or will be out of medications within three

days.

The fax number is 1-503-373-7274. You can also phone a referral or check a referral by

calling 1-877-585-0007.

Medicare Part D Exceptions and Appeals Process

Topics

Exception Basics Exception Request Prescribing Physician Statement of Support Plan Adjudication Plan Notification Appeals

Exception Basics

All Prescription Drug Plans (PDPs) and Medicare

Advantage Plans with Part D coverage (MA-PDs) must have their exceptions processes in place by January 1, 2006.

The exception process is intended to guarantee

access to medically necessary drugs for each individual enrolled in a Medicare Drug Plan.

Plans must make decisions within 72 hours for

standard exception requests and 24 hours for emergency cases.

Exception Basics Continued

An exception can be filed for a drug that is:

In a covered class of drugs under Medicare Part D; Medically necessary for the client; and Not covered on the plan’s formulary; or Subject to step therapy, quantity limits, or prior

authorization processes.

Exception Request

Only the client, the client’s representative, or the client’s

prescribing physician may file for an exception.

Local staff should assist in the exception process if the client

needs help. If a local staff is acting in the manner described in OAR 407-050-0000 to 407-050-0010 he or she may act as the client’s representative.

Any of these individuals may only initiate an exception after the

client has been denied coverage at the pharmacy.

Any of these individuals may request an exception by filing a

signed, written request. A plan may -- but is not required to -- accept oral requests. If it does not, the plan must explain the procedures to file a written request.

Prescribing Physician Statement of Support

A plan may require a supporting statement

from the prescribing physician before making a decision on the request for an exception.

The plan may require the physician to submit

a written statement and additional supporting medical documentation.

Prescribing Physician Statement of Support Continued

Physicians must indicate that the drug is medically necessary

and other alternatives would not be effective or safe for the client because of at least one of the following:

Uncovered drug: All drugs on the plan’s formulary would not

be as effective as the non-formulary drug, and/or would have adverse effects.

Quantity limit: The quantity allowed under the quantity limit

has been ineffective in treatment or the quantity is likely to be ineffective or to adversely affect the effectiveness of the drug for the client’s condition.

Step therapy: The drug alternative(s) has/have been (or is

likely to be) ineffective in the treatment of the client’s medical condition; or has caused, or is likely to cause, adverse reaction or other harm to the client.

Plan Adjudication

Once the plan begins adjudication, it must inform all

relevant parties within 72 hours after receiving the request or 24 hours for expedited requests.

If a plan requests a written statement of support

and/or other medical documentation from the prescribing physician, then the plan may delay a decision until it receives the requested information.

Plans must give physicians at least 24 hours to

submit the information.

Plan Adjudication Continued

Plans must begin the adjudication process

• nce they receive the physician’s written

statement, even if other medical information is not provided.

If the physician does not submit a written

statement within a “reasonable time,” then the plan may make a decision on the exception at that time.

Plan Notification

If plans grant an exception, they may inform clients or their

representatives orally or in writing. The exception is granted for the rest of the calendar year.

If the plan denies the exception, it must provide written notice,

mailed no later than three calendar days after its decision.

If the prescribing physician is notified of an adverse decision

• rally, plans are not required to notify the physician in writing.

Written denial notification must state the reason for denial,

information regarding appeal rights, a description of both the standard and expedited redetermination processes, and the rest

• f the appeals process.

Appeals

Redetermination Reconsideration Hearing: Medicare Appeals Council (MAC) Federal District Court

Clients With Third Party Insurance

Information

Many clients who have full Medicaid and/or

QMB/SMB/SMF also have other insurance.

This insurance may offer creditable coverage:

prescription drug coverage that is as good or better than coverage offered by Medicare Part D plans.

TriCare or VA benefits

TriCare and VA benefits are creditable

coverage.

These clients can retain TriCare and VA

benefits and enroll in a Medicare Part D plan.

Medicare Advantage Plan for Dual Eligibles

These clients should stay in their plan. Their

plan will have creditable coverage; coverage begins January 1, 2006.

Medicare Advantage Plan that does not serve Dual Eligibles

Clients should check with their Plan. The

Plan may offer creditable prescription drug coverage.

Enrolling in a stand-alone Prescription Drug

Plan may cause them to lose the Medicare Advantage coverage for which they pay.

Group Employer, Union, or Retiree Coverage

Clients should contact their benefits administrator

immediately and find out if they can enroll in a Medicare Part D plan without losing this coverage.

If their plan has creditable coverage, clients should

ask their benefits administrator for written notification

• f creditable coverage if they have no notification.

They may be disenrolled from their third-party

coverage if they enroll in a Medicare Part D plan – even auto-enrolled dual eligibles. If they choose, auto-enrolled clients can disenroll from Part D by calling 1-800-MEDICARE.

Medicare Supplement (“Medigap”) policy

Clients who have an H, I, or J plan can switch

to another Medigap plan offered by their company (such as a C or F plan). Clients will likely save money by switching to another plan.

These clients should enroll in a Medicare Part

D plan. Clients may have their Medigap policy suspended up to 24 months while on Medicaid if they wish to save money on premiums.

Private Insurance Policy

Clients should receive notification for

creditable coverage; clients may request written notification if they do not have it.

Clients should also call the benefits

administrator to find out how their coverage would be affected by Part D enrollment.

OIM/MDC and Pay-In Reductions

OIM MDC Coding

In order to process client copayments for Part

D drugs, please refer to the enclosed IM (SPD-IM-06-017) and its corresponding PT (SPD-PT-06-009).

Who To Call

Questions

Max Brown 503-945-6993

MMA Questions

MMA Problem Solving Referrals:

FAX: (503) 373-7274 1-877-585-0007

Jeff Miller 503-945-6410

OIM/MDC Questions

Brenda Sheppard 503-947-5204

CBC/512 and DD Questions

Sarah Lambert 503-945-6834

Pay-In/Oregon ACCESS Questions