The Limited Income Newly Eligible Transition Program

Starting January 1, 2010, a special program began to make sure that those newly eligible for Part D because they become eligible for extra help would get their prescription medicines. These persons are automatically enrolled in the Limited Income Newly Eligible Transition Program, also called the Limited Income NET Program, and sometimes known as LI NET or LI-NET. They are immediately permitted to use this special Part D drug plan to get their prescriptions at their pharmacy. After they are in the program for two months, they are automatically enrolled in a regular Part D drug plan; in this way, beneficiaries will typically get advance notice of what their regular Part D plan will be. And beneficiaries in this new program can also use it to get retroactive reimbursement for drugs they already paid for if they were entitled to Part D in certain past periods.

The program is a little difficult to explain, but if you keep in mind that it has these diverse aims, you can see how it really eases a beneficiary’s transition into extra help status and Part D.

Smooth Bumps in the Enrollment Process - If there is delay or confusion in the extra help enrollment process, or if the beneficiary has not received timely notice of their enrollment, these beneficiaries can still get their prescriptions filled as pharmacists (and others, such as SHIP counselors) can deal directly with the program to have this happen.

Facilitate Transition into Part D and Extra Help - These beneficiaries are initially and temporarily put in drug plan which will, almost without exception, cover whatever prescription medicines they are taking. This will give these beneficiaries a little time, as they transition to a regular drug plan, to have their prescriptions adjusted or use the exceptions process to help ensure their prescriptions will continue to be covered to the maximum extent possible.

Ease Retroactive Reimbursement - Beneficiaries who qualify for extra help because of Medicaid or SSI are sometimes retroactively entitled to extra help, and thus eligible for reimbursement for prescriptions they already paid for. This program is designed to facilitate compensating them for drugs they paid for out-of-pocket during the period of their retroactive entitlement.

Notify Beneficiaries of Ineligibility - Some beneficiaries who believe they may be entitled to Part D or extra help may be told by their pharmacy that they are not. This program will notify beneficiaries in writing of this result and indicate what they may do to overcome it.

Some special features should be noted about this program. One rationale for the program is to overcome the problem of making sure that beneficiaries can get their prescriptions while the various eligibility systems at both state and federal levels process the many data streams to show that these beneficiaries are indeed eligible for Part D and extra help. In effect, they become eligible for Part D before they get notification or proper proof of this. For this reason a beneficiary can bring documentation of their dual eligible or extra help (low income subsidy) status to a drug store, have the pharmacist enter certain information into their systems, and get an immediate OK to dispense medicine. These are sometimes called “point-of-service” or “POS” beneficiaries. The Centers for Medicare & Medicaid Services believes that about 60,000 beneficiaries fall into this category each year.

And if it later turns out that the individual was not in fact eligible, the Medicare program holds that person, and not the pharmacy, liable for the cost of prescriptions. Also, if it later turns out that the beneficiary’s co-payment level changes up or down, any refund, or any bill for additional charges, will go directly to the beneficiary, and not to the pharmacy. This feature helps to insure that pharmacies will cooperate with the program.

While in this transition program, beneficiaries will not have to pay any monthly premium, nor meet any deductible, but they will be responsible for any applicable co-payment. There is no specific formulary, so any drug which can properly be dispensed under Medicare Part D will qualify. Presumably, the eligible beneficiary, when actually enrolling in a regular Part D plan, will get into one which is best suited for their particular prescriptions. But in the interim while the beneficiary is in the Limited Income NET program, this “no formulary” approach allows them to get whatever specific drug has been prescribed for them. In addition, other than some safely limits, there are no prior authorization requirements or other similar utilization controls. Nor are there any restrictions on what pharmacy they can use.

The program also has generous dispensing rules. When a beneficiary goes to fill a prescription, and they are shown as eligible by the Limited Income NET system, the pharmacist may dispense up to a 90-day supply. If they are not in the system but it appears they are eligible for the program, the pharmacist may dispense up to a 34-day supply.

It should be clearly understood that, under Medicare’s general policy of beneficiary choice, if a beneficiary proactively enrolls in a regular Part D drug plan (or a Medicare Advantage Plan with Part D drug benefit) before or in their very first month of their coverage in the Limited Income NET program, then their enrollment choice will trump the Limited Income NET program’s POS option. That is, on the first day of the month following their enrollment, they will be switched to the regular Part D plan they chose. Because of the liberality of the Limited Income NET program’s rules, they should avoid this.

When a beneficiary is enrolled in this Limited Income NET program, they are automatically and prospectively enrolled in a regular Part D plan. The effective date of this will be the second month after being enrolled in the Limited Income NET program. For example, if a beneficiary is enrolled in the Limited Income NET program on April 20, he or she will be enrolled in a regular Part D plan effective on June 1. These automatic enrollments will always be into a plan with a monthly premium at or below the “benchmark.” But, as indicated above, a beneficiary has the right to choose any regular Part D plan.

One of the special features of this program is to simplify retroactive reimbursement to beneficiaries who have already paid for prescription drugs. When a decision is made that an individual is a full dually-entitled Medicare and Medicaid beneficiary, or entitled to both Medicare and SSI, it is also often determined that a period of retroactive entitlement exists. The Limited Income NET program will enroll these beneficiaries retroactively, with certain limits. This retroactivity will go back to either the start of their dual Medicare and Medicaid eligibility or, if later, their last enrollment in a Part D plan. If they have SSI and then get Medicare, it will go back to the start of their Medicare eligibility. Other beneficiaries will be limited to 30 days or even shorter periods of retroactivity.

This is particularly important to beneficiaries because it enables them to more easily get reimbursement for prescription drugs they purchased with their own, often very limited, funds during this retroactive period.

Beneficiaries who are enrolled in this program will get the YELLOW letter from the Centers for Medicare & Medicaid Services. There are two versions. Version one, “CMS Product No. 11429,” will indicate that the beneficiary has retroactive enrollment, and will state how far back it goes. Version two, “CMS Product No. 11154,” will be sent to those without any retroactive enrollment. Both will also show which regular Part D drug plan the beneficiary has been automatically enrolled into, and the effective date of that enrollment.

Those who receive version one will also get a letter from the Limited Income NET program, run by Humana, explaining how to get reimbursement for retroactive prescriptions. Beneficiaries should be certain to make these requests timely, as they cannot do so after they have been disenrolled from this program for over 180 days. But they should also clearly understand that even if they are currently enrolled in a regular Part D plan, this reimbursement feature is available to them for those 180 days. And this is true even if they never actually got a prescription dispensed by the Limited Income NET program before they went into their regular Part D plan.

Beneficiaries who believe they have become eligible for extra help but don’t get either of these YELLOW letters can take any of the following documents to their pharmacy and ask the pharmacist to verify their eligibility:

Any of these letters issued by the Social Security Administration:
“Notice of Award”
“Notice of Change” indicating an award increase
“Notice of Planned Action” indicating an award reduction
“Notice of Important Information” indicating no change to an award
a letter showing the beneficiary receives SSI

Any of the following state issued documentation that shows any Medicaid eligibility or enrollment after June of the previous calendar year:
a Medicaid card
any state document confirming active Medicaid status
a printout from the state Medicaid enrollment or eligibility file
any other appropriate documentation from the state Medicaid office

Beneficiaries who try to use this program but cannot be confirmed as eligible (this typically happens when a pharmacist tries to get the program to OK the dispensing of a prescription) will be sent a special letter the “Beneficiary Evidence of Eligibility Letter” – indicating what proof the can submit if they believe they are eligible. Humana has a help line, 1-800-783-1307, which is open 8 AM to 8 PM in each time zone. While this is a general help line for the program, beneficiaries, Medicaid staff, SHIP counselors and so forth may call it for help with eligibility issues.

Humana also has a web site www.humana.com/pharmacists/pharmacy_resources/information.aspx which is of particular help to pharmacists.

The web site also has a “Prescription Drug Claim Form” which can be used to make a claim for retroactive reimbursement for a prescription drug from the Limited Income NET program. However, the program has noted that many such requests are invalid because (1) the claim is for a drug dispensed when the beneficiary was not both Medicare AND Medicaid or SSI eligible; (2) the beneficiary was actually enrolled in another Part D plan when the drug was dispensed; or (3) the drug is not covered by the Part D program (such as an over-the-counter (OTC) drug or vitamin.