Medicare Part D for NYS Full Benefit Duals

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Medicare Part D for NYS Full Benefit Duals

• December, 2005

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Part D NYS Key Areas To Be Addressed

• Continue appropriate treatment and care for Full
  Duals
• Establish Wrap-around, Assure Medicare is Primary
  Payor
• Address Financial Impacts of Clawback and
  Wrap-around
• Outreach and Education for Full Duals

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Continue Appropriate Care for Full Benefit Duals

• Changes in the pharmacy benefits for duals
• From fee-for-service to enrolling in a commercial
  plan
• From multiple pharmacies to a network
• Limits and restrictions on use of drugs
• Encouraging prescribers to use alternative drugs
• Transition process relies on good information
  about complex topics

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Plans and Plan Assignment

• CMS has auto-assigned randomly to benchmark
  plans (15 options)
• Recipient can choose another plan at any time
• Additional premium due if non-benchmark chosen
• Duals must be enrolled to maintain Medicaid
  coverage

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New York Stand-Alone Prescription Drug Plans
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Comparing Plans

• Formulary
• PA, Quantity Limits, Tiers
• Co-pay for duals limited to 1/3
• Pharmacy Networks
• Preferred pharmacies
• Using a non-participating pharmacy
• Benchmark plan options in NYS

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Key Transition Issues

• Medicaid continues coverage of excluded drugs
• bezodiazapines, barbiturates, some OTCs
• Need to pay small co-pay for Part D drug
• State has no authority to pay co-pays for Part
  D
• Clinical and fraud/abuse risk for 90-day supply

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Transition Supplies

• Plans to provide transition supply for those
  already stabilized on drugs
• 30-90 day supply
• Transition time to initiate approval process if
  required

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Transition SuppliesContd

• Coverage continued for specific drugs when
  recipient stabilized antidepressant,
  antipsychotic, anticonvulsant, anticancer,
  immunosuppressant and HIV/AIDS
• Transition and emergency supplies for NH
  residents

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Establish Wrap-around, Assure Medicare is Primary
Payor

• NYS one of only two in nation to provide
  wrap-around assistance
• State-only costs for this coverage
• Double payments by NYS for
• Clawback
• Wrap-around benefit
• Use of Medicare must be maximized

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Wrap-around, Contd

• If pharmacist attempts to bill Medicaid for a
  dual for Part D covered drugs, claims will
  initially be denied by Medicaid
• Claims submitted to Part D plan for payment
• If denied, prescriber or recipient must request a
  coverage determination (exception)

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Wrap-around, Contd

• If exception request denied by plan, Medicaid may
  cover medication.
• Prescriber to confirm to NYS Medicaid that
  exception process was used, and coverage denied
  by plan, using Medicare Verification System (MVS)
• Electronic phone in system to confirm denial by
  Medicare
• MVS can be issued at time of call

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Wrap-around, Contd

• Medicare verification number must be on
  prescription to allow Medicaid payment under
  wrap-around
• Pharmacy submits claims with MVS number
• Valid coverage determinations related to medical
  necessity only

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Operation of MVS

• Prescriber or their agent must phone
• Electronic system available 24/7
• Prescriber is confirming plan has denied an
  exception request
• Single call for MVS and Medicaid PA processes

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Plan Exceptions and Appeals

• MMA requires plans to have exception processes to
  challenge the lack of coverage for a particular
  drug.
• A beneficiary, their physician, or their
  appointed representative, should contact the plan
  first if their drug is not covered to request an
  exception
• Plans must grant exceptions when they determine
  that it is medically appropriate to do so
• If the plan denies the exception, the beneficiary
  can further appeal (five levels)

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Hot Topics and Recent Developments

• Exceptions to the requirement to join Part D
• Not immediately implemented
• Exception process to allow recipients to
  affirmatively decline Part D when loss of third
  party coverage is not cost effective
• Denial notice, 60 days to respond
• When in doubt, decline

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Hot Topics, cont.

• Plan enrollment at the counter for duals who
  were not autoassigned. (photo id)
• MVS instructions to providers
• Medicaid Update released
• Hearing rights
• CMS Planfinder includes current assignment
• Improved pharmacy access to current enrollment
  information

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Financial Impact of Clawback and Wrap-around

• State makes clawback payments monthly for
  coverage of each dual recipient
• Increased costs to State for Part D
• Inequitable calculation of clawback results in
  excess payments
• Additional State-only costs for wrap-around
• Assure maximum use of Medicare Part D benefit

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Outreach and Education for Full Duals

• Helpful and clear education efforts required for
  full benefit duals
• National outreach stresses LIS, not duals
• Need frequent and useful messages
• National messages may not fit NYS
• Must be enrolled in a plan or loss of full
  Medicaid coverage
• Excluded drugs vs. limited wrap-around

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NYS Efforts to Increase Awareness

• Letters to recipients
• Enrollment Letter
• Notice of benefit change
• Includes exception for third party coverage
• Includes fair hearing rights
• Additional letters to spenddown and MSP
  populations

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NYS Outreach (cont.)

• Pharmacist education
• Other provider education
• HIICAP and LDSS support
• Advocate education and assistance
• Brochures/flyers for recipients
• DOH website

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Questions and Answers