NYSACRA

Provider Council Benefit Notes February 28, 2006

Medicare Part D Prescription Drug Benefit


Emergency Coverage
Emergency Medicaid coverage of prescription drugs for "dual eligibles" who are unable to fill their prescriptions through a Medicare Part D Plan will remain in effect until the Commissioner of the NYS Department of Health declares that the current crisis is over. ("Dual eligibles" are people enrolled in Medicaid and Medicare.)

The current plan at State DOH is to end the emergency coverage March 31st. Effective April 1st, the Medicaid "wraparound" program will be operational.

Reimbursement For Excess Co-Payments
CMS, the federal agency which administers Medicare, Medicaid, and the State Children's Health Insurance Program, has instructed the Medicare Part D plans to allow 90 days from the date a prescription is filled to accept and process claims for refunds from individuals who paid more than their proper co-payment. The regular rule is to allow 30 days. The proper co-payment is $1 for generic and $3 for brand name drugs. There is no co-payment for residents of ICFs who have been in the residence for at least a full month.

OMRDD residential providers who have paid more than the co-pay on behalf of a resident will have to pursue recovery directly from the individual's Part D Plan before the temporary 90 day rule expires. We encourage providers to file now for recoveries. We recommend calling the plan first to identify what specific documentation is necessary to process a refund. Providers should keep copies of all paperwork submitted.

Transition Fills
CMS has advised Medicare Part D Plans to extend the "transition fill" policy that was originally established to cover the month of January. This policy has been extended through March 31st. A transition fill occurs when a prescription is submitted for a drug that is either not in the plan's formulary or is in a higher tier. When a transition fill occurs a letter must be issued to the individual which advises that in order to continue receiving the same drug an exception must be requested by the individual's physician. Due to the March 31st deadline, we strongly recommend that our residential providers ensure that doctors are contacted as soon as possible so that exception requests are filed timely.

Newly enrolled Medicare Part D participants are allowed transition fills during their first 30 days in the plan.
Plan Questionnaires
We have been advised that Part D Plans are sending questionnaires to their participants. We recommend that representatives check with each individual's plan before filling in any address confirmation information as the plan may use the information provided to change the individual's mailing address.

Changing Plans
Action to change Part D plans should be taken as early in a month as possible to take into account the time necessary to process a change. As presently designed, a change of plan is effective the 1st day of the month following the change request.

Referring Issues
CMS has asked to be advised about problems individuals are having with their Part D plans. These include any issues relating to filling prescriptions. Problems can be referred using the CMS toll free telephone number 1-800-Medicare (1 800-633-4227). The information provided will be used by CMS to resolve individual problems and also to identify systemic program issues.

Mandatory Managed Care Enrollment/Medicaid Advantage

New York State DOH is implementing two new managed care programs: Mandatory Medicaid Managed Care for persons who receive Supplemental Security Income [SSI] benefits; and Medicaid Advantage. Both programs are currently being implemented in New York City. DOH expects to extend them to other parts of the state in the future.

Mandatory enrollment in Medicaid Managed Care for SSI recipients started in NYC in November 2005 and is expected to continue over the next year. Each month, 2,500 enrollment letters are mailed to NYC SSI recipients. Individuals who are in certified residential programs or are enrolled in Medicaid waivers, such as Care At Home or HCBS are exempt from mandatory enrollment. Individuals with similar characteristics and needs who would qualify for a residential placement or waiver enrollment are also exempt from mandatory enrollment.

This program will primarily impact individuals receiving SSI who live in their own homes and are not enrolled in a waiver program. Individuals who believe they should be exempt can contact the toll free number 1-800-774-4241.

Medicaid Advantage is the name given to a new Medicaid managed care program targeted to serve dual eligibles. Enrollment in this program is voluntary.
Medicaid Coverage Issue

In the Fall of 2004, State DOH changed the manner in which Medicaid applications are processed. The type of Medicaid coverage an individual qualifies for is now tied to the level of disclosure the individual makes concerning current and previously owned resources. To be found eligible for coverage for ICF and HCBS Waiver services, the individual is required to fully disclose the existence of all resources owned during the 3 years prior to the date of the application for Medicaid. This 'look back' period is extended to 5 years if any resources were placed into a trust.

Unfortunately, this process has resulted in many errors as local district social services offices have restricted Medicaid coverage for many individuals who should be eligible for Medicaid coverage for all services, including ICF and HCBS waiver services. OMRDD Revenue Support Field Offices (RSFO) have been working with the NYS State DOH to identify and resolve these cases. Monthly reports are run and shared with DOH which, in turn, contacts the responsible local social services district to ask that the district correct the type of coverage. The RSFOs also work with their DDSOs who in turn notify individual service coordinators who are asked to work with the consumer/advocate on a case-by-case basis to have the local district correct the type of coverage.

Additionally, the local RSFO contacts an individual's waiver provider if the individual's waiver claims will be denied due to restricted Medicaid coverage.

Monthly there are about 20 HCBS waiver enrollees whose waiver claims are denied due to this coding issue. However, DOH is now in the process of activating edits to its billing system which will extend the denial of claims for HCBS waiver services to about 230 individuals monthly. OMRDD and the local RSFOs are continuing contact with State DOH and the local Social Services districts to resolve these coverage issues. Also, State DOH has agreed to issue a new message to the social services districts asking them to correctly establish Medicaid coverage codes for individuals in the OMRDD HCBS Waiver.

Benefit Information On The Internet

We are now posting benefit memoranda and information on the secure portion of the OMRDD website. To access this information, visit the OMRDD website at: www.omr.state.ny.us and click on the button "Information For Providers". Click on "OMRDD Benefit Related Memoranda." The secure portal comes up and the password "provider" is entered to access the benefit information.

We are in the process of adding Medicare Part D material to this site. We will announce this site to service coordinators and providers shortly.If there are any additional questions or concerns, I can be reached by E-mail at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it or by calling [518] 402-4339.