|
MEDICARE PART D UPDATE &
QUESTIONNAIRE
As everyone knows, Medicare Part D
went into effect on January 1, 2006. There have been many issues
for people with Medicare and Medicaid (the dual eligibles), who
were to be auto-assigned to a plan. A dual eligible person can
choose a different plan than the one they are auto assigned to.
Since last fall, NYSACRA has been collaborating in a work group
drawn together by OMRDD to share information. On a conference
call today, certain areas were identified for information
gathering on “how things are going?” Please review with the
relevant staff in your agency and get NYSACRA information to help
with our advocacy. The following are some areas of concern:
1. CMS has required drug plans to
extend the transition process through 3/31/06 for drugs not in the
plan formulary. This may provide transition coverage for up to 90
days for some individuals. After March 31st, plans can return to
the 30-day transition requirement for drugs not covered in the
formulary. Although there may be restrictions on certain drugs,
all medically necessary drugs must be available under the Medicare
Prescription Drug Plan benefit, whether they are in the formulary
or not. Drug plans must provide exception and appeal processes
for drugs not in the formulary. Most plans will allow a short
term supply of the non covered drug. If a transition fill is made
by a Plan, they are required to notify the person in writing and
inform the person of the refill process. It is unclear at this
time how this notification will take place. Plans may institute
prior authorization processes, step therapy or initiate exception
requests for refills that follow. No later than 2/15, plans were
supposed to mail out evidence of coverage booklets to Medicare
Part D recipients about: the plans, their rights and the exception
request process. These should be helpful.
Question - Are Plans
honoring transition plans? Are letters being received of
transition
fills? Are providers starting to work on the exception requests?
How many exception requests will you make in a month?
2. OMRDD is developing forms to be
used to help break barriers that have developed around Plans
requesting Power of Attorney before speaking to an individual’s
staff representative. New York has a regulation and the Power of
Attorney is not needed. These forms will be available soon. It
will be important for providers to identify those individuals who
will be able to speak with the Plans on behalf of the consumers.
Question: Are people with disabilities being identified by Plans
as solely able to talk to the PDP (rather than provider on behalf
of the person)? Please identify Plans doing this.
3. In many cases individuals and
providers have been required to pay for medications when Medicare
Part D began if the person was not recognized as in a plan or if
they were not honoring the transition requirement. Individuals and
providers may seek reimbursement to recover any money paid for
prescription fills in excess of the $1/$3 co-payments. You only
have 90 days to seek reimbursement from the Drug Plans.
Question: Have agencies received bills from pharmacies? Have
providers submitted those bills to the Plans for reimbursement?
4.
Providers operating congregate settings other than ICFs have been
required to pay $1 or $3 co-pays for all prescriptions. There was
concern that this would create financial challenges. The same cost
considerations were also raised for those dual eligibles living in
the community.
Question: Do providers have a sense of the cost implications on
their budgets in meeting the co-pay requirements? How are
individuals & families in the community handling this matter?
5. Since January, we have had to
work with a new partner – the insurance industry-in order to
insure that our consumers receive their necessary medications.
Question: What has been your experience working with the plans vis
a vis website, phone or correspondence? Are there any plans that
have been particularly helpful and responsive? Have certain plans
been particularly troublesome? Please let us know. For example,
there have been some particular issues with Silverscript and
Humana.
Question: Have providers received questionnaires from Plans
around change of address, etc. Please don’t throw them away, they
need a response.
6. While there have been
challenges in implementing Medicare Part D, OMRDD and the provider
network have worked diligently to insure individuals are enrolled
in a plan and receive their necessary medications. This could not
have been done without dedicated resources.
Question: Can you calculate the amount of staff time (direct
care/clinical/admin) devoted to the advocacy, education and
implementation efforts during the first 6 weeks of this
transition? How much money has been spent (versus pre Medicare
Part D)?
Question: How are people living in the community and with
families (not in congregate settings) doing with Medicare Part D?
Question: What has been your experience dealing with medical
providers and pharmacists?
It is very important to lodge
any complaints with 1-800-Medicare. They are particularly
interested in hearing about how the transition, exception and
appeals processes are working for the individuals in the plan.
This information/assistance line is compiling complaints and
preparing a report to CMS and to Congress. People become
automatically eligible for Medicare on the 1st day of the 25th
month that they have been receiving Social Security. It is
recommended the process of selecting a drug plan begin 3 months
prior to effective start date to insure timely enrollment.
NYSACRA will keep you posted on
changes and issues related to Medicare Part D. Please contact us
with the above information. It is very important for advocacy
efforts. ANCOR, our national organization, has invited NYSACRA to
participate in discussion designed to help “fix” Medicare Part D
for the dual eligibles. Please get us your thoughts. Contact Ann
Hardiman at 518-449-7551 or by email at
This e-mail address is being protected from spam bots, you need JavaScript enabled to view it
.
PROPOSED NEW YORK “COMMUNITY
CONSUMER”
PRESCRIPTION CO-PAY INITIATIVE
Below is budget language that
NYSACRA strongly supports that was initiated by IAC regarding the
Community Consumer Co-Payment for prescription drugs. It would be
inserted in A. 9554/S.6454 on pg. 232 at line 45. The language
is:
“For assistance with co-payments
for prescription drugs to individuals with developmental
disabilities who reside with their families and are not otherwise
exempt from co-payments under the medical assistance program.”
……………………………………………………………………………$3,780,000
|
