Medicare Prescription Drug Plan Information –
Part D
Enrollment - Dual Eligibles
• Passive Enrollment Information
• Auto-Enrollment
• Facilitated Enrollment
• Picking a Plan
Enrollment – Others
Low-Income Subsidy Issues
• Link to Low-Income Subsidy Application
• $1-$5 co-pay for low-income individuals guaranteed through Pennsylvania Medicaid. Click here for instructions to pharmacists.
• CMS Guidance to plans on co-pays for LIS eligibles and dual eligibles.
• Final Low-Income Subsidy Regulations
• Senate Bill would eliminate co-pays for dual eligibles on HCBS Waivers and living in Personal Care Homes – s.2409
Drug Coverage
• Transition Plan Requirements for Stand-Alone Drug Plans
• Transition Plan Requirements for Medicare HMOs
• Emergency 5-day Supply of Medication through Pennsylvania Medicaid. Click here for instructions to pharmacists
• $1-$5 co-pay for low-income individuals guaranteed through Pennsylvania Medicaid
Exceptions and Appeals
• Low Income Subsidy Appeals
• Part D Appeals
• Time Frames for Part D Appeals
Self-Help with Medicare Part D
• Links to Model Forms to help you help yourself
Medicare Part D Regulations
• January 2005 – Final Regulations
• PHLP's Comments to October 2004 Proposed Regulations
Part D Fact Sheets and Brochures to Download
Additional Part D Information
• Join PHLP's list serv on Part D
• Join PHLP's mailing list for Senior Health News or Health Law PA News
• View Old documents
ENROLLMENT - DUAL ELIGIBLES
A. PASSIVE ENROLLMENT INFORMATION
URGENT NOTICE FOR PERSONS ON MEDICARE AND MEDICAID WHO ARE IN: Keystone 65, Amerihealth 65, Senior Partners, Gateway Assured, Unison Medicare Advantage, and UPMC for LIFE
Are you being denied prescription medications?
We have reason to believe that up to 2/3rds of medications are being inappropriately denied by one of more of these plans. This is in violation of a legal settlement agreement.
Your pharmacy should be filling all your prescriptions for medications that you were taking before January 1, 2006. This should be happening without question, prior authorization, or problems at least until June 30, 2006. Please contact the Pennsylvania Health Law Project at 1-800-274-3258
· If the pharmacy is not filling prescriptions that you were taking before 1/1/06.
· If the pharmacy filled the prescription(s) once but not again.
· If the plan contacted you to inform you that you could not continue on a particular medication.
· If the plan contacted your doctor to get you switched to another medication.
Are you able to see all of your normal doctors?
We have reason to believe that well more than half of medical services are being inappropriately denied by one or more of these plans. This is in violation of a legal settlement agreement.
You should be able to see all of your Medicare providers, regardless of whether they participate in your Medicare plan. This should happen without question, prior authorization, or problems at least until June 30, 2006. Please contact the Pennsylvania Health Law Project at 1-800-274-3258
· If you have been prevented from seeing a physician or specialist
· If you have been unable to get mental health care
· If you have been unable to get other services from doctors, providers, or facilities that you saw prior to January 1, 2006
Please call the Pennsylvania Health Law Project at (800)274-3258 for assistance and information about how you should be able to access your care until June 30, 2006 and what decisions to make regarding your coverage for after June 30, 2006.
Click here for a printable notice about these transition issues.
• 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: - posted March 2006
• 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. Click here for attestations from the plans regarding the transition – these are the promises being extended until June 30, 2006.
• Additional mechanisms for disenrollment available until June 30, 2006. Disenrollment can be accomplished by:
• Picking another plan to be effective the first of the next month
• 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)
• Faxing written disenrollment requests to the CMS Regional Office at 215-861-4334
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
• 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. Click here to see the individual notice sent.
• 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. Click here to see the provider notice sent.
• 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 in the last 3 months of 2005) if their out-of-network provider will not be joining the HMO's network 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 by June 30, 2006
• 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
• PHLP and CLS file lawsuit against the Centers for Medicare and Medicaid Services over passive enrollment. Click here for the press release . Click here to see the complaint Erb et al v. McClellan, 2:05-cv-06201-JP - posted November 2005
• Assistance in picking the right plan is available for free through the state's APPRISE program at 1-800-783-7067.
• PHLP posts examples of the "Opt Out" letters sent to dual eligible consumers who are in danger of losing their Medicare doctors. – October 2005
• 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 . – September 2005
• 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. - January 2006 B. AUTO-ENROLLMENT
- SPBP and the Chronic Renal Disease programs are autoenrolling memebrs into Medicare Rx plans. In September 2006, the State enrolled Medicare beneficiaries in the Chronic Renal Disease Program (CRDP) and in the Special Pharmaceutical Benefits Program (SPBP) into one of 9 Medicare Part D plans that are currently partnering with the State. The State only intended to auto-enroll individuals who had not joined a Part D plan on their own although some others slipped through. The State enrolled consumers in plans based on the medications they take (that are covered by these two programs) and the pharmacy they use. For both programs, the state will pay the premium for the plan, if the person was auto-enrolled into one of the nine plans. Additionally, the programs will assist with the costs of the medications covered by those programs for any additional cost-sharing. The program will not assist with cost-sharing for any other medications that the person takes.
In early September, both programs sent letters out to individuals who were to be auto-enrolled into Part D plans. These letters told members which Part D plan they were being enrolled into. In most cases, this coverage started October 1, 2006. For these individuals, Medicare Part D will be their primary prescription drug coverage and the CRDP or SPBP will be their secondary prescription drug coverage.
Individuals who had other Part D coverage or other
creditable
prescription drug coverage should not have been autoenrolled. Please contact the Pennsylvania Health Law Project helpline if you were autoenrolled and should not have been.
- Beginning in November 2005, full dual eligibles and those who receive the full low-income subsidy will receive YELLOW letters from CMS informing them that they will be enrolled into the Medicare Prescription Drug Plan listed in their YELLOW letter unless they affirmatively elect another plan by December 31, 2005. Click here to see the YELLOW letter.
- Dual eligibles can change plans at any time effective the first of the next month. Plan changes can be made directly through a plan, through 1-800-Medicare, or through www.medicare.gov
C. FACILITATED ENROLLMENT
D. PICKING A PLAN
ENROLLMENT - OTHERS
- Open enrollment ends May 15, 2006. If you do not enroll by then (and are not entitled to a special election period) you cannot enroll until November 15 through December 31, 2006.
- Unless you qualify for a special election period, the plan selected by May 15, 2006 is the plan you will be in until open enrollment, which occurs November 15 through December 31, 2006. If you choose another plan during that time, it will take effect January 1, 2007. You will not be allowed to change Part D plans until such time as you select another plan (which can only be done 11/15 to 12/31 each year – unless you qualify for a special election period).
- For assistance finding the plan that works for you, go to www.medicare.gov plan finder tool, call 1-800-Medicare, or call the state APPRISE program at 1-800-783-7067
LOW-INCOME SUBSIDY ISSUES
DRUG COVERAGE
Transition Plans for Stand Alone Prescription Drug Plans and Medicare HMOs
• 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. – January 2006
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. EXCEPTIONS AND APPEALS
Low-Income Subsidy Appeals:
• Denial, miscategorization, termination, or non-renewal can be appealed
• Appeals must go through the agency the consumer applied with (DPW or SSA)
• Contact us at 1-800-274-3258 or staff@phlp.org to request assistance with an appeal.
Part D Appeals:
• Coverage Determinations
–Refusal to allow enrollee to use a medication that is on the formulary – coverage determination/appeal
–Medication not on formulary – exception appeal
–Medication on high cost-tier of formulary – exception appeal
• Complaints about services – Grievances
Contact us at 1-800-274-3258 or staff@phlp.org to request assistance with an appeal.
Time Frames for Part D Appeals:
• Initial determinations- to be made within 72 hours (expedited cases=24 hours)
• Redeterminations - to be decided within 7 days (expedited cases= 72 hours)
• Independent Review Entity Reconsideration - to be decided within 7 days (expedited cases=72 hours)
• Further appeals may be taken to an Administrative Law Judge for a Fair Hearing.
Other Considerations about Part D Appeals:
• No right to continued benefits pending appeal (this is different from Medical Assistance Appeals)
• A Plan's failure to issue coverage determination or redetermination in a timely manner is considered an adverse decision and must be forwarded to Independent Review Entity within 24 hours
• Representation may be available through PHLP – If you think you have a matter that needs to be appealed, call PHLP's Helpline at 1-800-274-3258.
SELF-HELP WITH MEDICARE PART D
• Guide to appealing Medicare prescription drug denials- from the Health Assistance Partnership (www.healthassistancepatnership.org)
• Model letter to send to plans for reimbursement of for money paid –
• By extra-help/low-income subsidy eligible, when system didn't show them as enrolled in the extra-help/low-income subsidy program
• For non-formulary drug, when plan should have given a one-time fill
Both from the Health Assistance Partnership (www.healthassistancepartnership.org )
• Model exceptions request letter – from the Medicare Rights Center (www.medicarerights.org )
MEDICARE PART D REGULATIONS
PART D FACT SHEETS AND BROCHURES TO DOWNLOAD
ADDITIONAL PART D INFORMATION
• Join PHLP's NEW list serv on Part D (made possible with the support of The Pew Charitable Trusts)– e-mail jnix@phlp.org with subject “join Part D list serv” (for advocates in 5 county Philadelphia area, working with dual eligibles over 60 only)
• Join PHLP's mailing list for Senior Health News or Health Law PA Newse-mail jnix@phlp.org with subject “join SHN (or HLPN) mailing list”
• Request assistance or representation on a Part D problem– e-mail staff@phlp.org
• View Old documents
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'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)
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