Medicare RX Update Archive 2006
Click on the date to read that date's Medicare RX Update.
Sign up for the PHARMACY_MMA-L list to receive the Medicare Rx UpdateApril 4, 2006
CMS Releases the 2007 "Call Letters"...
May 22, 2006
CMS Administrator applauds the strong partnership between CMS and pharmacists...
May 25, 2006
CY 2007 Medicare Marketing Guidelines Update - Issued for Public Comment
May 26, 2006
There is less than one year left to get your NPI...don't risk disruption to your cash flow!
June 14, 2006
Plans pledge timely payment and willingness to work towards EFT...
June 20, 2006
Information for Pharmacists Calling Medicare ...September 12, 2006
Planning Medicare Part D Awareness...for 2007October 6, 2006
LIS re-determination letters are in the mail...October 16, 2006
2007 Medicare drug information now available on the CMS Drug Plan Finder tool…October 25, 2006
Medicare pharmacy-specific PSA video available now …December 1, 2006
Reminder: Special Pharmacy Training is Monday…December 12, 2006
Many Low-Income Patients Still Need Assistance…Friday December 15, 2006
Proposed rule on Medicaid AMP released...Wednesday December 20, 2006
'Tis the season. to prepare for the start of the January 2007 plan yearFriday December 22, 2006
January preparation. The best medicine for beneficiaries.
CMS Releases the 2007 "Call Letters"...
With a strong commitment to continuous quality improvement in the Medicare prescription drug program, CMS today issued instructions to and expectations of the prescription drug plans as the plans prepare their bids for 2007. In addition to operational enhancements, Plans have made this year, CMS is requiring Plans to continue to streamline their Part D operations to avoid unnecessary administrative burdens on pharmacists and other providers and special attention will be paid to key operational areas which impact customer satisfaction and successful delivery of the benefit, including:
Effective Data Systems.
CMS expects that successful plans will follow best practices for timely and accurate processing and verification of enrollment and copay information, particularly in the case of plans serving beneficiaries eligible for Medicare andMedicaid.Effective Customer Service
CMS is conducting routine surveys to determine plan compliance with Part D standards concerning call abandonment rates and percentage of calls answered within 30 seconds. Complaint rates related to customer service are an important consideration for future participation by a plan.
Transition Guidance Compliance
In addition to providing the transition supply of non-formulary drugs for 30 days in the retail setting and 90 days in the long term care setting, PDP sponsors must also inform their enrollees of the following key information:
- The transition supply is temporary
- Enrollees need to work with their plan and physician to switch to a therapeutically appropriate on-formulary drug
- They have a right to request a formulary exception if they or their physician believe a non formulary drug is medically necessary, and
- How to access the exceptions and appeals
procedures.
Strengthen Relationships with Providers through Avoiding Excessive Burdens in the Exceptions and Appeals Process
Sponsors should develop a "one stop" shopping area on their website that provides ready
access to all of the transition, prior authorization, exception and appeals information and forms that enrollees and their providers need.
Strengthen Relationships with Pharmacists through Effective Pharmacy Support
PDP sponsors must comply with contractual agreements with their participating pharmacies. CMS has been and will continue to investigate and track pharmacists' complaints about plan compliance with their pharmacy contracts. PDP sponsors are also expected to implement best practices in pharmacy transactions, including the use of consistent transaction codes and secondary messages when a requested prescription fill is denied. Plans must comply with CMS guidance on cobranding, to ensure that beneficiaries receive accurate information about the broad range of pharmacies available to serve them.
CMS will review each PDP sponsor's compliance with all requirements of the program to determine whether contract renewal is warranted. While many plans are performing well or are achieving significant improvements in key areas of beneficiary service and support, CMS may consider non-renewal if there has been a substantial failure to comply with program requirements.To read the CMS fact sheet for additional information click here.
A full copy of the Call Letter may be found here.
S. Lawrence Kocot
Senior Advisor to the Administrator
Centers for Medicare and Medicaid Services (CMS)
Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201
Monday, May 22
CMS Administrator applauds the strong partnership between CMS and pharmacists...At an afternoon speech at NCPA's 38th Legislation and Government Conference, CMS Administrator, Dr. Mark McClellan reflected on where we've been...and where we are going with Part D, the DRA and the PQA.
"Pharmacy perspectives are now an essential and integral part of our agency, just as prescription drugs are an absolutely essential part of modern medicine and now, for the first time, an integral part of Medicare... The implementation of the drug benefit was a once-in-a-lifetime challenge for all of us, but the heightened level of interaction between CMS and our nation's pharmacists is here to stay."
... but Deficit Reduction Act (DRA) implementation was the topic of the day.
Dr. McClellan told a capacity crowd that, " Pharmacists have made it clear to us that unless AMPs are defined and calculated accurately...AMPs will not accurately reflect prices available to retail pharmacies. We know that an imprecise definition of AMP, especially if publicly posted, will be misleading to state Medicaid directors and others who will use this as a reference point for setting pharmacy reimbursement. We also recognize that pharmacists are especially concerned about the DRA provision that calls for AMPs to be posted beginning on July 1, 2006, because the more specific definition of AMP would not be reflected in the current AMP data as reported by manufacturers."
"Consequently, I am announcing today that CMS will not publicly release the current AMP figures. They just aren't the right numbers to use. We do expect to share pricing information with the states, as we do confidentially with other types of drug pricing data, but only for purposes of helping them set up their billing systems appropriately and not for the purposes of setting reimbursements. Instead, we are focusing our efforts on developing a proposed regulation that will assure an accurate and effective AMP calculation ahead of implementation of the drug payment reforms."
S. Lawrence Kocot
Senior Advisor to the Administrator
Centers for Medicare and Medicaid Services (CMS)
Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201
CY 2007 Medicare Marketing Guidelines Update - Issued for Public Comment
The Centers for Medicare & Medicaid Services is issuing for a one week public comment period the draft, updated Medicare Marketing Guidelines (found here) for Medicare Advantage (MA), Medicare Advantage Prescription Drug Plans (MA-PD), Prescription Drug Plans (PDP) and 1876 Cost Plans, last updated on November 1, 2005.
Comments on the updated marketing guidelines must be received by CMS no later than 5:00 p.m. Eastern Time, Wednesday, May 31, 2006.Comments must be submitted via e-mail to marketing@cms.hhs.gov with "CY 07 Marketing
Guidelines Comments" in the subject line of the email.
S. Lawrence Kocot
Senior Advisor to the Administrator
Centers for Medicare and Medicaid Services (CMS)
Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201
Friday, May 26, 2006
There is less than one year left to get your NPI...don't risk disruption to your cash flow!
The National Provider Identifier (NPI) will be your standard unique identifier for electronically billing HIPAA covered entities. HIPAA requires the NPI to be used by health plans (e.g., Medicare, Medicaid, PDPs and other private health insurers), health care clearinghouses and health care providers that conduct electronic transactions, including pharmacists. NPIs will be required on all electronic claims sent on and after May 23, 2007. Every health
care provider should obtain an NPI!
Getting your NPI is the first step in the process of meeting the compliance date. Once you have your NPI, you may need to modify your existing business processes to accommodate use of the NPI. You will also need to share your NPI with other health care providers with whom you do business.
Health care providers may obtain their NPI by applying on-line here or requesting a paper application by calling the NPI Enumerator at 1-800-465-3203, or applying for a bulk enumeration, which allows an Electronic File Interchange Organization (EFIO) approved by CMS to obtain a number of providers' NPI.
Learn more about NPI and how to apply by clicking here. A Countdown Clock is now available on this page to remind health care providers of the number of days left before the compliance date...you may also want to bookmark this page as new information and resources will continue to be posted. Please click here to see the press release.
Question of the Week:
CMS instructed Part D plans on May 5, 2006 that they are required to use the "best available data" to make changes to their systems when they have knowledge that a dual eligible beneficiary's cost sharing level is not correct.
What does CMS mean by best available data?
Part D plans have flexibility to develop their own procedures for determining whether best available information is sufficient to change or update their systems to reflect appropriate cost sharing levels for dual eligibles. For example, with respect to dual eligibles who are community residents, a Part D plan may rely on the beneficiary showing the contracted pharmacy a current Medicaid card or on information provided by a state Medicaid office as proof of low-income subsidy status. Since the Part D plan will not know the exact subsidy level for the dual eligible beneficiary, it should default the enrollee to a $2/$5 benefit package.
For full benefit dual eligibles who are residents of long term care (LTC) facilities, a plan may develop procedures that rely on attestations from LTC pharmacy and facility personnel that certain residents who are enrollees of the plan are Medicaid eligible, have been or are expected to be residents of the facility for a full calendar month, and are under a Medicaid-covered stay.For LTC facility residents, Part D plans should rely on information that clearly indicates the elements necessary to confirm Medicaid eligibility and LTC facility admission dates for purposes of establishing a full calendar month of LTC facility residency. This could include location codes on billing transactions from the LTC pharmacies, in conjunction with the institutional attestations necessary to confirm Medicaid eligibility and LTC facility admission dates for a Medicaid-covered inpatient stay.
As part of their procedures, Part D plans should keep appropriate records in order to reconcile low-income subsidy payments with CMS after the end of the contract year.
S. Lawrence Kocot
Senior Advisor to the Administrator
Centers for Medicare and Medicaid Services (CMS)
Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201
June 14, 2006
Plans pledge timely payment and willingness to work towards EFT...
To ensure that pharmacy payment processes work as efficiently as possible in Medicare, the Board of Directors of America's Health Insurance Plans (AHIP) issued a new statement of policy saying that: " ... the industry will work with pharmaceutical benefit managers (PBMs) to ensure that payment for clean claims is transmitted via mail or electronic funds transfer at least twice per month and no later than 30 days after the claims are submitted by the pharmacy. In
addition, the industry will work with PBMs and the pharmacy community to promote the availability and utilization of EFT."
Note: This generally means that payment for the oldest claim submitted will be transmitted in no more than 30 days, so in a 15 day billing cycle, payment for the last claim received will be transmitted in no more than 15 days from receipt by the plan.
Click here to view the AHIP press release.
Question of the week:
Will beneficiaries be able to obtain early refills on their Part D medications that were lost or misplaced during a declared emergency?
Answer:
We expect that Part D plans would guarantee immediate refills of Part D medications to any beneficiary located in an "emergency area" defined as the area in which there has been a Stafford Act or National Emergencies Act declaration and a public health emergency declaration. In addition, we would expect all " refill too soon edits" to be removed beginning with any voluntary or mandatory state or federal evacuations and lasting for the period of the
emergency declaration. Additionally, with the possibility of only a limited number of operational pharmacies, limitations on transportation and travel and the disruption of US Mail, we expect plans to allow the beneficiary to obtain the maximum plan extended day supply, if requested and available at time of refill.
This question is available by clicking here.
S. Lawrence Kocot
Senior Advisor to the Administrator
Centers for Medicare and Medicaid Services (CMS)
Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201
June 20, 2006
Information for Pharmacists Calling Medicare ...
As you know, the special contact phone line for pharmacists (1-866-835-7595) will no longer be available after June 23. CMS originally created the pharmacist contact line at the startup of the Medicare Prescription Drug Benefit...when data was less likely to reflect accurate beneficiary information and Plans were experiencing high call volumes. Since January, the average wait time on Plan customer service numbers has decreased dramatically and the number of daily calls to the CMS pharmacist contact line has decreased by more than 80%.
Beginning on June 24, pharmacists who call 1-866-835-7595 will be redirected to the 1-800 Medicare interactive voice response system...where they will have access to the same information and service as they do today. Callers to 1-800-Medicare reach a Call Service Representative (CSR) with little or no wait times.
Medicare Part D Plans should continue to be the first pharmacy contact for nearly all questions... including formulary and cost sharing issues, payment inquiries and other contracting questions. If the pharmacist does not receive appropriate information from the
Plan, or would like to file a complaint, they should contact 1-800-Medicare or their CMS Regional Office. Additionally, pharmacists should continue to call 1-800-Medicare (1-800 633-4227) to determine Medicare eligibility or to obtain enrollment information if it cannot be obtained from the patient or through the E1 query.
S. Lawrence Kocot
Senior Advisor to the Administrator
Centers for Medicare and Medicaid Services (CMS)
Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201
Planning Medicare Part D Awareness … for 2007
Tomorrow, Secretary Leavitt and Administrator McClellan will kickoff our Fall Medicare Awareness campaign, entitled, “My Health, My Medicare.” Our goal is to reach all Medicare beneficiaries to make sure they know about Medicare’s Preventive Services. However, the campaign is also designed to create awareness about the coming open enrollment period for Medicare Part D.
This campaign presents an opportunity for pharmacies to partner with CMS to discuss the many benefits of Medicare during annual flu shot events and other beneficiary outreach activities as we all prepare for Medicare Part D open enrollment, November 15 - December 31. A brief timeline of upcoming important events for pharmacists are attached (EOY Timelines.ppt). Specifically, pharmacies will want to be aware of the following events as beneficiaries will likely ask their pharmacist about what they receive:
LIS Re-determination. The MMA requires CMS and SSA to determine whether beneficiaries who qualified for low-income subsidies (LIS) in 2006 will again qualify in 2007. Beneficiaries who don’t automatically qualify for the LIS in 2007 will receive a letter from CMS that explains their pending loss of LIS eligibility and includes an application and an enclosed postage-paid return envelope. CMS will also send a letter to individuals who continue to qualify for the LIS in 2007, but will have a change in their co-pay level. Pharmacists will likely get requests for help from beneficiaries in returning forms pertaining to their LIS. Beneficiaries who no longer automatically qualify for extra help will receive the attached letter (Final un-redeemed letter 08-18-06.pdf) on blue paper beginning next week.
Annual Notice of Change (ANOC). Part D Plans may begin sending ANOCs on October 1 and all Plans must ensure that members receive the ANOC with the Summary of Benefits (SB) by October 31, 2006. The ANOCs include specific changes in Medicare plan benefits, plan premiums and plan rules effective January 1, 2007. In particular, the model ANOCs contain information specific to the Medicare Part D benefit, open enrollment period limitations and important information for beneficiaries receiving extra help. Most Plans must include an abridged or comprehensive formulary with the mailing of their ANOC and SB. Plans have been strongly encouraged to use model documents, which can be found here. This is a good opportunity for pharmacists to review formulary and other changes with beneficiaries to make sure the plan continues to be the best plan for the beneficiary.
Plan Marketing. Plans will begin disseminating 2007 marketing materials on October 1. All 2007 plan information, including pharmacy networks, will be available in the Medicare Prescription Drug Plan Finder on October 12.
Beneficiary Reassignment. Dual eligible beneficiaries who are enrolled in either plans that are above their regional 2007 benchmark or plans that are dropping out of Part D entirely will be reassigned into a plan that is below the benchmark. CMS will mail notices to beneficiaries that are being reassigned during the week of October 30. We will be sure to include a copy of the model letter to beneficiaries as soon as it is available to the public.Early Enrollment
All beneficiaries who are enrolling in or changing PDPs should be encouraged to do so as early as possible, but no later than December 8th to ensure that the beneficiary, Plans, pharmacies and CMS all have the correct Plan and subsidy level information in the system and ready for use by January 1.CMS will be providing more information and materials to assist pharmacies with outreach in the coming weeks. With your help, we can make sure all beneficiaries get the information they need to make the right choice about their Medicare benefits. We look forward to working with you as we prepare for open enrollment.
S. Lawrence Kocot
Senior Advisor to the Administrator
Centers for Medicare and Medicaid Services (CMS)
Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201
Friday, October 06, 2006
LIS re-determination letters are in the mail...Beginning last week, CMS began sending letters to those beneficiaries no longer automatically eligible for the Low Income Subsidy (LIS) in 2007. Along with the letters, these beneficiaries are receiving a LIS application and should be encouraged to apply for the LIS in 2007. Additionally, beneficiaries who will have a change in their subsidy level are receiving a separate notice informing them of the change.
Pharmacists are encouraged to help beneficiaries fill out the LIS applications or they can also refer them to the Social Security Administration by calling 1-800-772-1213 (TTY users should call 1-800-325-0778) or visiting http://www.ssa.gov/medicareoutreach2/index.htm.
And important messaging is coming to a newspaper near you...
People with Medicare should complete the simple Medicare Rx enrollment check-up when considering their Prescription Drug Plan options for 2007. CMS will be placing drop-in article (see FinalEnrollmentDropIN10206.pdf) which focuses on Plan cost, coverage and customer service, in newspapers and other publications around the country...and beneficiaries are sure to ask pharmacists for more information.
Remember, if your pharmacy customers are satisfied with their current coverage, they do not have to do anything. However, if they want to review other plan options, Medicare will have its 2007 Plan Finder tool available in the next several days; also, pharmacists are permitted to assist beneficiaries with objective information about plan options. Additionally, beneficiaries can call 1-800-Medicare or visit www.Medicare.gov to enroll...and of course they can always call specific plans to request more information. Finally, if your customer is going to change coverage, please advise them to enroll early. Completing enrollment by Dec 8th will help ensure that the enrollment information is processed and data is in the system for a positive pharmacy experience on January 1st.
S. Lawrence Kocot
Senior Advisor to the Administrator
Centers for Medicare and Medicaid Services (CMS)
Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201
Monday, October 16, 2006
2007 Medicare drug information now available on the CMS Drug Plan Finder tool…CMS announced Friday that Medicare has made enhancements to www.medicare.gov that will provide new help for people with Medicare prescription drug coverage who want to consider changing plans. The changes will make it easier for beneficiaries to get personalized information about their coverage options and costs for 2007. With the enhancements to the website, beneficiaries who want to find out more about their Medicare drug plan choices can do so before open enrollment begins on November 15.
A recorded Webinar is also available to help people learn more. Click here to view “Navigating the Medicare Prescription Drug Plan Finder.” This short tutorial walks you through the Drug Plan Finder and highlights the changes for 2007.Medicare & You 2007 handbooks are now available…
The general “Medicare & You 2007” handbook is also now available here to help people with Medicare review their coverage options and prepare to enroll in a new plan if they choose. This official government handbook contains important information about what’s new, health plans, prescription drug plans, and rights for people with Medicare. You can find 48 geographic-specific versions of the handbook here, with drug and health plan comparison charts for particular states or regions. Partners and beneficiaries will receive their Handbooks by the end of October.
Special Enrollment Period for People who no longer qualify for extra help…
CMS expects Part D plan sponsors to reach out by phone or mail to every member who will no longer qualify automatically for extra help beginning in 2007 to encourage them to apply and help them through the process (click here for background). In support of this effort, CMS is identifying for each Part D sponsor those individuals who CMS is notifying by mail, and providing an outbound script (Attachment F) and model notice (Attachment G) for plans to use. We have also attached a set of Questions and Answers on this topic (Attachment H).
Additionally, CMS is granting a one-time Special Enrollment Period beginning January 1, 2007 through March 31, 2007 to allow any individual who no longer qualifies for LIS to make one Part D enrollment election. (See background file: Plan LIS Guidance—HPMS note.pdf)
NPI: Get It, Share It, Use It…
CMS will host a discussion about how the NPI relates to pharmacists on the next Pharmacy Open Door Forum on November 7, 2006. In the interim, we have several other resources available including the transcript for the 9/26 NPI Roundtable and requirements that are specific to Medicare providers in Module 5 of the NPI training package. Additionally, registration is open for the WEDI audiocast “NPI 101 – And We’re Off! Getting Up To Speed On NPI” to be held on October 25th from 2-3:30 PM ET. Please note; there is a cost to participate in the audiocast. As always, more information and education on the NPI can be found at the CMS NPI page. Providers can apply for an NPI online or can call the NPI enumerator to request a paper application at 1-800-465-3203. Getting an NPI is free…not having one can be costly.
S. Lawrence Kocot
Senior Advisor to the Administrator
Centers for Medicare and Medicaid Services (CMS)
Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201
Wednesday, October 25, 2006
Medicare pharmacy-specific PSA video available now …
With flu shot campaigns in full swing and open enrollment just around the corner, CMS is preparing outreach and education tools specifically designed for use by pharmacists and pharmacies. A Public Service Announcement (PSA) encouraging beneficiaries to ask their pharmacist about Medicare preventive services and enrollment into a prescription drug plan is available now. Please visit www.cms.hhs.gov/pharmacy to view the PSA as well as a quick reference document on Medicare Preventive Services and several flu-shot posters. A limited number of copies of the PSA are available for pharmacists to play in store. To obtain a copy, pharmacists can contact either the National Community Pharmacists Association (NCPA) at stacey.swartz@ncpanet.org, the National Association of Chain Drug Stores (NACDS) at (703) 837-4126, the American Pharmacists Association at Medicare@aphanet.org or your state pharmacy association by e-mailing your name and address to MedicareDVD@naspa.us.Look to this space in the coming weeks for pharmacy training materials, a Part D reference document for pharmacists and other important materials that can help pharmacists prepare for 2007.
“My Health. My Medicare.” training sessions are available…
The next presentation in the My Health. My Medicare. series of audio-conference training sessions sponsored by the Centers for Medicare & Medicaid Services (CMS) will be held this Thursday, October 26, 2006 from 1:00 – 2:00 p.m. EDT. The topic will be "Countdown to November 15: Part D Current Topics.”
This audio-conference will feature presentations by CMS subject matter experts in Part D policy, the Drug Plan Finder and the National Medicare Training Program. The experts will provide the latest information on the re-determination and re-assignment processes for people who currently qualify for the extra help with drug plan costs, letters being sent to a small group of beneficiaries regarding their plan premiums and resources for partners to help people understand and use the Medicare Prescription Drug Plan Finder and the MyMedicare.gov web portal. To call in, dial 1-888-605-5716 and enter pass code 5440297. Please call in 15 minutes before the session begins. You can also visit http://www.cms.hhs.gov/ on the morning of the call to download the PowerPoint presentation for this session.
S. Lawrence Kocot
Senior Advisor to the Administrator
Centers for Medicare and Medicaid Services (CMS)
Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201
Reminder: Special Pharmacy Training is Monday…
CMS will be hosting Coordination of Benefits training at a Special Pharmacy Open Door Forum (ODF) on Monday, December 4, 2006 at 2 PM EST. The covered topics will include the new E1 functionality, Medicare Part B versus Part D, Plan-Pharmacy Standardized Claims Messaging, Beneficiary Cash Purchases (Lower Cash Price Policy), Correcting Beneficiary Co-payments Using Best Available Data, Special Transition Period for Retroactive Medicaid Enrollments, Clarification of TRICARE Coverage, Patient Assistance Programs, and Part D References. Training slides are available now at www.cms.hhs.gov/pharmacy.
To participate by phone dial 1-800-837-1935 and reference conference ID 2228370. Note: TTY Communications Relay Services are available for the Hearing Impaired. For TTY services dial 7-1-1 or 1-800-855-2880 and for Internet Relay services click here http://www.consumer.att.com/relay/which/index.html. You may listen to an encore recording of this call that can be accessed by dialing 1-800-642-1687 and entering the Conference ID beginning 2 hours after the call has ended. The recording will expire after 3 business days.
… And One E1 Change Becomes Effective TodayWhile most of the E1 changes will not take effect until software vendors are able to upgrade their systems to support the Enhanced E1 functionality, one change to the existing E1 service is effective today. Pharmacists searching the Cardholder ID field (Medicare Part A/B ID, Social Security Number (SSN) or Railroad Retirement Board (RRB) number) must also input a minimum of the first four letters of the Last Name for a match to occur. If the first four letters of the Last Name are not provided in the request the existing E1 response will be “NON MATCH MEMBER ID” even if the submitted Cardholder ID information is correct.
This new functionality will reduce the number of false positive E1 responses. However, in the short run, pharmacists may receive “NON MATCH MEMBER ID” messages if they omit the required last name characters.
S. Lawrence Kocot
Senior Advisor to the Administrator
Centers for Medicare and Medicaid Services (CMS)
Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201
Many Low-Income Patients Still Need Assistance…
As we have outlined in previous Medicare Rx Updates, beneficiaries who are no longer automatically eligible to receive the LIS in 2007 must re-apply through the Social Security Administration. Those who do not re-apply for 2007 could experience sticker shock at the pharmacy counter in January when they have to pay higher co-payments, premiums and deductibles. In order to avoid any interruptions to drug therapy in January, we strongly recommend that pharmacists continue to remind people who currently receive the LIS that if they have received notification from CMS about a status change, they must apply or they will have higher co-payment and premium liabilities in 2007. We encourage Pharmacists to continue helping beneficiaries submit LIS applications or to refer them to the Social Security Administration by calling 1-800-772-1213 or visiting http://www.ssa.gov/medicareoutreach2/index.htm.
Pharmacy Coordination of Benefits training available on-line…
As promised during last week’s training, we have posted a link entitled “Handling Medicare Part D Prescription Drug Plan Complaints” on the www.cms.hhs.gov/pharmacy website. Additionally, CMS has posted an outreach tool-kit to assist partners and family members in educating people with Medicare with their Part D decisions during open-enrollment. You can view the Open Enrollment Toolkit and print materials especially for partners.
Legislation Changes Part D Vaccine Administration policy…
The Centers for Medicare & Medicaid Services (CMS) recently released a Special Edition MLN Matters article (SE0678), which addressed CMS’s approach for providers to obtain payment for Part D vaccines under the Medicare Drug Benefit. Subsequent to that release, legislation was passed that may impact the information provided in the article. Therefore, we have retracted SE0678 and we will keep you apprised when further guidance becomes available.
S. Lawrence Kocot
Senior Advisor to the Administrator
Centers for Medicare and Medicaid Services (CMS)
Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201
Proposed rule on Medicaid AMP released.
CMS today announced proposed changes in the payment for certain prescription drugs in the Medicaid program. These changes implement provisions of the Deficit Reduction Act of 2005 (DRA). The DRA changes how the federal government limits payments to state Medicaid agencies for the aggregate costs of prescription drugs when a generic substitute is available. The DRA establishes a new FUL calculation that is based on 250% of the lowest AMP in a drug class. States will retain the authority to set their own reimbursement levels and dispensing fees paid to pharmacists, and may pay above or below the FUL as long as overall payments for drugs subject to a FUL are under the annual aggregate cap. As required by DRA, the proposed rule includes a proposed definition of AMP on which CMS requests public comment.
AMP disclosure required. but not until late spring
The proposed rule published by CMS today is the first step in the regulatory process. CMS expects broad public comment on the proposals contained in the rule. The comment period on this proposed rule will remain open for 60 days from publication in the Federal Register. CMS
will revise and publish a final regulation after consideration of these comments. The DRA requires that the final regulation be promulgated by July 1, 2007.The DRA also requires the Centers for Medicare & Medicaid Services (CMS) to disclose the AMP of drugs. CMS expects that these will be available to the states and public in late spring. Until CMS issues new FULs, states may continue to rely upon the FULs published prior to January 1, 2007.
S. Lawrence Kocot
Senior Advisor to the Administrator
Centers for Medicare and Medicaid Services (CMS)
Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201
'Tis the season. to prepare for the start of the January 2007 plan year
As the end of the enrollment period for the 2007 Medicare Drug Benefit year fast approaches, we have been busy trying to make sure we have a smooth transition from 2006 to 2007 at the pharmacy in January. Assuring that all pharmacy systems are locked and loaded with up to date Plan and beneficiary information for the 2007 Plan year is high on our
priority list.By now, Part D plan sponsors should have updated their payer sheets for any billing changes associated with their 2007 Part D benefits. CMS' Part D contracts with Plans require plans to ensure that all information necessary for online, real-time billing is available at the point-of-sale. Any Part D sponsors who have not already communicated 2007 changes in plan names, BIN/PCNs, or other relevant billing information to all contracted pharmacies have been notified by CMS that they must do so immediately.
Additionally, CMS has been tracking the submission of beneficiary "4Rx" data by Plans to make sure that we have as much information in the E1 database as possible so that pharmacists will have updated beneficiary plan information at their finger-tips in January. While the E1 database may not have complete data on some last minute enrollees or plan switchers on January 1, we are doing everything possible to load this information as soon as it is transmitted to minimize the burden on the pharmacist at the beginning of the 2007 plan year.
...and one more reminder about communicating beneficiary rights
Plan network pharmacies are REQUIRED to post or distribute notices for use in instructing enrollees to contact their plans to obtain a coverage determination or request an exception for an off-formulary drug. Despite this requirement, some beneficiaries are reporting that they have not been notified of their rights at the pharmacy counter.
Standard forms are available to ensure that beneficiaries are aware of their rights. CMS has provided a model pharmacy notice about the formulary exceptions and appeals process that should be posted or given to beneficiaries interested in contacting a Plan about a coverage determination or formulary exception. Click here for instructions for using the notice.
S. Lawrence Kocot
Senior Advisor to the Administrator
Centers for Medicare and Medicaid Services (CMS)
Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201
January preparation. The best medicine for beneficiaries.
January is the busiest month in the pharmacy due to changes that millions of Americans make to their insurance coverage that take effect in January. For this reason, we have been encouraging Medicare beneficiaries to help pharmacists by taking 3 easy steps:
1. If you have a prescription or refill that can be filled at or near the end of 2006, don't wait. get it filled before January 1. Taking care of refills in December will reduce the burden on pharmacists and may reduce the time a beneficiary has to wait to get the prescription filled in January.
2. If you have a prescription to be filled in early January and you have changed plans or have not used your new plan coverage, make sure you bring your new insurance card (and proof of Medicaid or LIS eligibility if applicable) to the pharmacy with your prescription. Providing correct and complete information to the pharmacist will make it easier for the pharmacist to serve beneficiaries which will reduce prescription fill times and delays at the pharmacy. Beneficiaries should be sure to have their Plan ID card, Medicare and/or Medicaid card, and a Photo ID (See Quick Tips for the first trip to the pharmacy). People who been approved for the low-income subsidy (LIS) should also bring a copy of the yellow automatic enrollment letter from Medicare, an approval letter from the Social Security Administration, or other proof that they qualify for extra help.
3. If you have not received your new insurance card from your new plan, make sure that you bring a confirmation letter or some other proof of coverage from your new plan with you to the pharmacy in January. Because people may enroll in Part D through the end of December, some late enrollees may not receive their plan ID card by the first day of the New Year (see Tip Sheet ). In this case, beneficiaries should bring an acknowledgement or confirmation letter from the plan, or an enrollment confirmation number received from the Plan. If the person has not received any enrollment materials, the pharmacist may be able to submit an E1 query, or call the dedicated pharmacy enrollment/eligibility helpline (1-866-835-7595) or 1-800-MEDICARE to identify the plan in which the person is enrolled. As a last resort, the beneficiary may have to pay out-of-pocket for the prescription and send receipts to the plan.
Point of Sale Option improved for 2007.
CMS will continue to contract with WellPoint to provide Point-of-Sale Facilitated Enrollment (POS FE) for those qualified low-income beneficiaries who are not enrolled in a Part D plan. To avoid submission of ineligible claims, CMS and Wellpoint will include tighter front-end edits to check for eligibility at the POS. These edits will allow the pharmacist to know how to properly adjudicate claims at the POS rather than submitting the claim through WellPoint POS FE only to have it reversed weeks or months later due to ineligibility.
CMS anticipates that far fewer beneficiaries will need to use the POS in 2007 because the vast majority of dual eligibles are already enrolled in a Part D plan. In addition, CMS and States have worked to prospectively identify beneficiaries so they can be enrolled in a Part D plan as of the effective date of their dual eligibility. Pharmacists should review the POS Tip Sheet for further information on the 2007 POS program
And finally, thanks for all you do...
For one last time in 2006, we want to take this opportunity to thank the entire pharmacy community for all that has been done to help Medicare beneficiaries take advantage of the new Medicare drug benefit. The accomplishments of Medicare Part D have been reflected in numerous customer satisfaction polls and millions of prescriptions filled and that is a tremendous tribute to pharmacists and all who have been involved with us in this historic endeavor.
Please accept our best wishes for a safe holiday season and a Happy New
Year.S. Lawrence Kocot
Senior Advisor to the Administrator
Centers for Medicare and Medicaid Services (CMS)
Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C. 20201