A number of Medicare beneficiaries have received a notice from their Medicare Advantage Plan that their current Plan is leaving the Medicare program on January 1, or that it will no longer serve the area the beneficiary lives in, effective with that date. (These are called, respectively, a “nonrenewal” and a “service area reduction.”)
As I point out on page 126 (“Nonrenewals”) of Managing Your Medicare, a special election period (these are also called “special enrollment periods” and are often abbreviated SEP) exists for members of Medicare Advantage (MA) plans that are affected by a nonrenewal or service area reduction effective January 1.
For beneficiaries currently affected by this, your special election period began October 1, 2010, and ends next year, on January 31, 2011.
As noted in the book, your current Medicare Advantage Plan must send you a detailed notice about what your options are, and the deadlines imposed on you. The Centers for Medicare & Medicaid Services (CMS) supervises these notices quite closely, and they are fairly comprehensible, but it’s important to clearly understand them and to know what your several options are.
These are your options:
You may choose to go into another Medicare Advantage Plan with Part D drug coverage. Or you may join one without drug coverage AND also join a stand-alone Part D drug plan. Or you may join one without drug coverage and NOT join a stand-alone Part D drug plan.
You may take any of the three options above whether or not you currently have any Part D drug coverage.
OR
You can go into Original (fee-for-service) Medicare, and, if you wish, join a stand-alone Part D drug plan. And you can do this whether or not you were ever in Original Medicare, or whether you do or don’t currently have Part D drug coverage.
The effective date will depend on what choice you make. If you enroll in another Medicare Advantage Plan, your enrollment will be effective January 1 if the Plan you choose receives your request before that date. If it receives your request in January, it will be effective February 1, 2011.
The same is true if you enroll in a stand-alone Part D drug plan. If you enroll in one of these, your enrollment will be effective January 1 if they receive the request before that date. If they receive your request in January, it will be effective February 1, 2011.
If you do not sign up for another Medicare Advantage Plan, you will automatically be put in Original Medicare effective January 1. If you had drug coverage with your Medicare Advantage Plan, you will no longer have drug coverage unless you sign up for a stand-alone Part D plan. The exception to this is that if you have extra help (the low income subsidy, sometimes abbreviated LIS), and you don’t sign up with a drug plan, Medicare will automatically enroll you in one.
For those beneficiaries who are 65 years of age or older, and decide to go back to Original Medicare, you will get a special federal right to buy a Medigap policy. These special rights are sometimes called “Medigap protections” or “guarantee issue rights.” (And for those of you who are not 65 years of age or older, your state may require Medigap insurers to sell you a policy; check with your state insurance commissioner.)
Beneficiaries who are 65 years of age or older and go back to Original Medicare have only until March 4, 2011, to purchase a Medigap policy using their guarantee issue rights. (This is the standard 63 days from when you loose your coverage from your Medicare Advantage Plan) Specifically, any company that offers a Medigap policy of type A, B, C, F-High, F-Low, K or L in your area has to sell you one. That is, the company (1) must sell you a policy, (2) it must cover your pre-existing conditions, and (3) it cannot charge you more because any past or current health problems you may have had or have.
And remember that if you go into Original Medicare effective January 1, your SEP continues until the end of that month. You still have the option of signing up with a Medicare Advantage Plan with or without drug coverage. And if you decide to stay in Original Medicare, or if you sign you with a Medicare Advantage Plan that does NOT have drug coverage, you may still use your SEP to join a stand-alone Part D drug plan. The effective dates for these actions will be February 1, 2011. And remember that, if you decide to stay in Original Medicare, your deadline to get a Medigap policy continues to be March 4.
You notice from your Plan will also tell you that there are some other special Medigap protections which apply to you (1) if you are age 65 or older and got Part B within the last six months, or (2) if in the last 12 months (sometimes up to 24 months) you dropped a Medigap policy to join a Medicare Advantage Plan for the very first time; or, (3) if in the last 12 months (sometimes up to 24 months) you joined a Plan when you were first eligible for Part A at age 65. (These are covered in detail in items 8.1, 8.2.4 and 8.2.5 of the book.) These may permit you to buy a policy other than type A, B, C, F-High, F-Low, K or L, that is, type D, M or N.
There is also one other special right that comes if you are affected by your Medicare Advantage Plan’s nonrenewal or service area reduction. If you are one of the few beneficiaries who have End Stage Renal Disease and are in one of these Medicare Advantage Plans, you get a one-time right to join a Medicare Advantage Plan. You may exercise this right at this point in time, or you may hold it and use it in the future. But you have only a ONE-time right, and remember that otherwise, in general, beneficiaries of any age with this disease cannot join a Medicare Advantage Plan, so use this special right carefully.
By the way, there is some confusion as to the proper effective date. This is simply because in the past CMS has allowed the effective date, at the beneficiary’s choice, to be the first of the month immediately following the month the beneficiary files their enrollment request. (So, for example, if you filed it in November, you could choose December 1.) This, however, has changed for this year; the effective date can only be January 1 or February 1, depending only on when the request is received by the Medicare Advantage Plan and/or stand-alone drug plan you are joining. This probably makes more sense as if you went into Original Medicare or a new Plan on December 1, you would again have to meet all the applicable deductibles for calendar year 2010, and then have to do this all over again beginning in 2011.
Tuesday, October 26, 2010
Saturday, October 16, 2010
Clinical Trials and Medicare Advantage Beneficiaries – New Rules in 2011
Not too long ago, Medicare began covering certain of the costs of those clinical trials which meet very specific approval requirements. Prior to that time, clinical trials were considered to be “experimental,” and nothing was covered under Medicare. The information on this is in section 2.13 of Managing Your Medicare, on page 57.
This section of the book also mentions that even beneficiaries in Medicare Advantage must have these costs covered, and that this is true even if they use out-of-network services, which is normally the case with clinical trials. For 2011, the Center for Medicare & Medicaid Services has given Medicare Advantage Plans additional direction on this issue, specifically:
1. Plans will be required to reimburse enrollees for the difference between fee-for-service cost sharing incurred for covered clinical trial items and services and the Medicare Advantage Plan’s in-network cost sharing for the same category of service. What this means is that if you get a clinical trial service that is Medicare covered, let’s say a specialist’s consultation, and that Original Medicare would approve $100 for the consult, and pay $80, and you are billed for the 20 percent coinsurance, or $20, but for this same type of consult your Plan’s in-network rule is that you are responsible for a co-payment of $15, then you are responsible for only this $15, and your Plan is responsible for the remaining $5.
What is basically going on here is that the clinical trial people are charging you as if you were in fee-for-service Medicare, but you are responsible only for what you would pay under the terms of your Plan’s benefit structure. One of the issues here is that because the clinical trial people have no contractual relationship with your Plan, they may bill you the standard Medicare coinsurance. If this happens, you may submit the bill to your Plan, and it must pay the provider any difference between what you owe under their rules and the Medicare fee-for-service amount.
(And it’s quite possible that the clinical trial people may send you a bill for the whole service because they don’t understand that you are in a Plan. If this happens, send the whole bill to your Plan, and make sure, when they process it, that they pay everything except what you would owe for an in-network service.)
So you get the nice benefit of getting a covered clinical trial service out-of-network, but you pay only what you pay if you had gone in-network. Not bad. But it gets better!
2. Starting in 2011, your Medicare Advantage Plan, in adding up all the medical costs which count toward your annual out-of-pocket maximum amount, must include in these medical costs not only what you pay out-of-pocket, but also what it must pay under the new rule just discussed. So in the example given, your Plan has to count toward your yearly maximum not only the $15 you were responsible for, but also the $5 it had to pay. That is, $20 will go to count for your annual out-of-pocket maximum, not just $15.
And be aware that you do not have to get any pre-authorization or permission from your Plan to join a clinical trial, or even advise them that you are in such a trial. However, best advice seems to be that, if you are in a coordinated care Plan of any type, letting your Plan’s health care providers know what is going on with all of your health care is very important. And, as it has no other way of knowing, your Plan may ask you for information it needs to properly process claims relating to the clinical trial.
This section of the book also mentions that even beneficiaries in Medicare Advantage must have these costs covered, and that this is true even if they use out-of-network services, which is normally the case with clinical trials. For 2011, the Center for Medicare & Medicaid Services has given Medicare Advantage Plans additional direction on this issue, specifically:
1. Plans will be required to reimburse enrollees for the difference between fee-for-service cost sharing incurred for covered clinical trial items and services and the Medicare Advantage Plan’s in-network cost sharing for the same category of service. What this means is that if you get a clinical trial service that is Medicare covered, let’s say a specialist’s consultation, and that Original Medicare would approve $100 for the consult, and pay $80, and you are billed for the 20 percent coinsurance, or $20, but for this same type of consult your Plan’s in-network rule is that you are responsible for a co-payment of $15, then you are responsible for only this $15, and your Plan is responsible for the remaining $5.
What is basically going on here is that the clinical trial people are charging you as if you were in fee-for-service Medicare, but you are responsible only for what you would pay under the terms of your Plan’s benefit structure. One of the issues here is that because the clinical trial people have no contractual relationship with your Plan, they may bill you the standard Medicare coinsurance. If this happens, you may submit the bill to your Plan, and it must pay the provider any difference between what you owe under their rules and the Medicare fee-for-service amount.
(And it’s quite possible that the clinical trial people may send you a bill for the whole service because they don’t understand that you are in a Plan. If this happens, send the whole bill to your Plan, and make sure, when they process it, that they pay everything except what you would owe for an in-network service.)
So you get the nice benefit of getting a covered clinical trial service out-of-network, but you pay only what you pay if you had gone in-network. Not bad. But it gets better!
2. Starting in 2011, your Medicare Advantage Plan, in adding up all the medical costs which count toward your annual out-of-pocket maximum amount, must include in these medical costs not only what you pay out-of-pocket, but also what it must pay under the new rule just discussed. So in the example given, your Plan has to count toward your yearly maximum not only the $15 you were responsible for, but also the $5 it had to pay. That is, $20 will go to count for your annual out-of-pocket maximum, not just $15.
And be aware that you do not have to get any pre-authorization or permission from your Plan to join a clinical trial, or even advise them that you are in such a trial. However, best advice seems to be that, if you are in a coordinated care Plan of any type, letting your Plan’s health care providers know what is going on with all of your health care is very important. And, as it has no other way of knowing, your Plan may ask you for information it needs to properly process claims relating to the clinical trial.
Friday, October 15, 2010
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.
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.
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