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 on 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 of 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 of 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 once 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 orally, 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 of 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 of 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