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MEDICARE PART D UPDATE
Starting on January
1, 2006, Medicare, not Medicaid, will be the primary payor of
drugs for individuals that are dual eligible (that is a person
with Medicare and Medicaid coverage). The Centers for Medicare
and Medicaid Services (CMS) have randomly auto-assigned dual
eligibles to 15 different prescription drug plans (PDP). If you do
nothing, you will be automatically enrolled in the CMS assigned
plan on January 1, 2006. CMS letters of auto assignment have gone
out and were printed on yellow paper for easy identification. The
letter tells recipients which plan they have been assigned to.
OMRDD is able to provide agencies a list of their dual eligibles
by contacting Kevin Patricia at OMRDD at 518-402-4339. He will
ask you to put the request in writing. This will help agencies
cross check whether individuals are in the “system” as dual
eligible.
CMS has a
contingency plan that will allow a pharmacy to provide up to 14
days of medication if a dual eligible slips through the crack and
is not auto-assigned a plan. Many agencies have begun the tedious
job of checking the plan formularies through the plan-finder with
the medications taken by individuals that they serve, to find the
plan best for the individual. A dual eligible can change plans at
any time. Right now, as you investigate plans and what each plan
provides you should know that plans are changing as they compete
with each other. Dual eligibles will be required to pay a
co-payment ($1 generics and $3 for brand and specialty drugs).
Individuals in ICFs and nursing homes, falling under long term
care, have no co-payments. Co-payments can be waived by a
pharmacy on an individual, unadvertised basis. Many provider
agencies have developed relationships with their pharmacy vendors
and they can be helpful when looking at plans for the individuals
we serve. They very likely have contracted with the some or all
of the 15 prescription drug plans (PDP) in New York. It is
important to talk to your pharmacies about their situation.
Remember that individuals with Medicaid must continue to keep
their Medicaid card to pay for other services provided through
Medicaid, such as some over-the-counter health items and for
medical appointments.
New York is one of
two states that will be providing a wraparound benefit. Medicaid
will provide additional wraparound benefit for drugs not covered
by the PCP. This will occur after the prescriber has requested an
exception request with PDP and has received a denial. After the
denial, a call must be made to get a Medicare Verification System
number before the pharmacist can submit it to Medicaid for
payment. More about this new wraparound information can be found
on NYSACRA’s website under Medicare Part D, DOH December Medicaid
Update.
NYSACRA will provide
a Medicare Part D training with Margaret Raustiala on December 12,
2005, Holiday Inn Turf, 205 Wolf Road, Albany, NY, 9:30-12:30.
Contact NYSACRA to register at 518-449-7551.
Helpful websites
include:
www.health.state.ny.us;
www.medicare.gov; www.thedesk.info/PartD and on NYSACRA’s
website at
www.nysacra.org/nysacra/medicare.htm. |
