Medicare Prescription Drug Plan Information –
Part D
• The Pennsylvania Health Law Project, Community Legal Services of Philadelphia, and the Center for Medicare Advocacy have reached a verbal settlement agreement with the Centers for Medicare and Medicaid Services in the Erb v. McClellan litigation on behalf of the over 110,000 individuals with Medicare and Medicaid who were passively enrolled into a Medicare HMO. These are the agreed terms of the verbal settlement that are now being reduced to writing:
1. An extension of the transition period – during which passively enrolled individuals can continue to see out-of-network providers and not have to obtain referrals or prior authorizations and can continue to obtain off-formulary drugs they were taking before January 1 without prior authorizations or other obstacles – until June 30, 2006. ALL passively enrolled individuals need to make a decision by June 30 about whether to stay in the HMO or disenroll. If in doubt about whether the HMO will cover the providers and medications the individual relies on, we recommend that the individual disenroll.
2. Additional mechanisms for disenrollment available until June 30, 2006. Disenrollment can be accomplished by:
a. Picking another plan to be effective the first of the next month
b. Calling 1-800-Medicare and asking to be disenrolled effective either the first of the next month (prospective disenrollment) or the first of the current month (retroactive disenrollment)
c. Faxing written disenrollment requests to the CMS Regional Office (direct fax number to follow)
Note that those who request disenrollment will receive confirmation of their disenrollment request within 7 days and will be held harmless for any charges resulting from delays in processing of their disenrollment
3. Passively enrolled dual eligibles will receive a written notice from CMS in the next week informing them of the extension of the transition period and of their options for disenrollment or evaluating whether to remain in the plan.
4. Providers that bill Medicare will receive a notice and information from CMS on the extension of the transition period and how to counsel their patients
5. The Medicare HMOs into which dual eligibles were passively enrolled must contact all enrollees who have been using out-of-network providers (through the transition plan) and inform them that the provider will not be joining the plan and thus the individual must choose another form of coverage or another provider
6. All problems should be reported to the Pennsylvania Health Law Project (800)274-3258 or ahalperin@phlp.org or Community Legal Services at (215)227-2400 x. 2418 or kcostello@clsphila.org so that we can convey them to CMS for monitoring and enforcement
7. Assistance in picking the right plan is available for free through the state's APPRISE program at 1-800-783-7067.
• All passively enrolled individuals can disenroll from the Medicare HMO they have been put in. They can disenroll retroactively (back to 1/1/06 or even 2/1/06) and have it be coupled with retroactive enrollment into a stand-alone drug plan or they can disenroll by electing a new plan (PDP) to take effect on March 1, 2006. Both of these steps can be done by calling the 1-800-Medicare line. .
• Transition plans for PDPs extended an additional 60 days. Beneficiaries should be able to receive medications that they have been taking until March 31, 2006. Click here for the announcement from CMS (see page 5 for details on the transition extension) • CMS issues notices to Medicare providers stating that they are requiring Special Need Plans to have transition plans that allow dual eligibles who were passively enrolled to see their providers until March 31, 2006 and requiring that dual eligibles have access to the medications they were receiving under Medical Assistance. Click here for the notice to providers that outlines these requirements. • CMS releases directives to Medicare prescription drug plans regarding excessive copays for dual eligibles and formulary transitions. CMS is requiring plans to ensure that dual eligibles are not charged the standard deductibles and copayments and that consumers are able to receive a temporary supply of medications during the transition. Click here for the directive on copayments. Click here for the directive on formulary transition.
• Pennsylvania will cover Medicare prescription drug copayments over $5 for people with Medicare and Medical Assistance. Many dual eligibles were supposed to have copayments of $1, $3 or $5 but are being charged excessive copays because their low-income subsidy (extra help) has not come through yet. Pennsylvania will cover the excessive copays until the low-income subsidies come through. Click here to see a press release announcing the plan. Click here for the instructions to pharmacists from DPW.
• CMS releases transition policy memo, reminding plans that delaying or denying an initial fill of medications is not consistant with the CMS policy. Click here to see the memo.
• CMS releases memo to help pharmacists complete transitions and assist dual eligible consumers. Click here for the memo to pharmacists. Click here for a question and answer sheet about dual eligibles.
•CMS requires passive enrollment plans to allow dual eligibles to see any Medicare Participating Provider and pay them FFS rate for first 90 days. CMS also requires passive enrollment plans to fill any prescription dual eligible could fill under Medicaid HMO formulary for first 90 days. Click here for attestations from the plans regarding the transition.
• Were you passively enrolled into a Medicare HMO and having problems? Do you know someone else who was? Tell us about it! Please fill out this passive enrollment questionnaire and send it back to us via fax at 215-625-3879. Click here for the questionnaire in PDF. Click here for the questionnaire in Word.
• Low income subsidy regulations released. Click here for the regulations. • PHLP notices for dual eligibles on what to do regarding their prescription coverage, before December 31, 2005:
Click here for Fee for Service notice in pdf. Click here for Fee for Service notice in Word.
Click here for SouthWest Region HMO notice in pdf. Click here for SouthWest Region HMO notice in Word.
Click here for SouthEast Region HMO notice in pdf. Click here for SouthEast Region HMO notice in Word.
Click here for Lehigh-Capital Region HMO notice in pdf. Click here for Lehigh-Capital Region HMO notice in Word.
• PHLP posts examples of the "Opt Out" letters sent to dual eligible consumers who are in danger of losing their Medicare doctors.
• Dual Eligible recipients could lose doctors, other health care providers on Jan. 1, 2006. Click here for letter of protest to CMS and a transition plan letter to health plans.
Fact sheets on the Medicare Prescription Drug Benefit:
• April 2005 Senior Health News- All about the Medicare Prescription Drug Benefit. Click here for the newsletter.
• August 2005 Senior Health News- Medicare Prescription Drug Benefit updates. Click here for the newsletter. • Timeline of Important Dates for Consumers – May 2005 (in pdf)
• Link to Final Medicare Prescription Drug Plan Regulations Released by CMS – January 2005 (in pdf)
• PHLP's Comments on the Proposed SSA Lower-Income Subsidy Forms – December 2004
• Publication: Consumer's Guide to Medicare Discount Cards (for consumers with disabilities in SW Pennsylvania)
• PHLP's Comments on the Proposed Medicare Rx Regulations – October 2004
Medicare Coverage for Persons Who Also Have Medicaid
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