CMS is aware that there are instances in which a beneficiary may need to access drugs at an out-of-network pharmacy. Plans are required to assure that their enrollees have adequate access to drugs dispensed at out-of-network pharmacies when they cannot reasonably be expected to obtain covered Part D drugs at a network pharmacy. Provided that such access to out-of-network pharmacies is not routine, we expect that plans would guarantee out-of-network access to beneficiaries when, for example they are: (1) traveling outside their plan’s service area and run out of or lose their covered Part D drugs or become ill and need a covered Part D drug, and cannot access a network pharmacy; (2) not able to obtain a covered Part D drug in a timely manner within their service area because, for example, there is no network pharmacy within a reasonable driving distance that provides 24/7 service; (3) filling a prescription for a covered Part D drug and that particular drug (for example, an orphan drug or other specialty pharmaceutical) is not regularly stocked at accessible network retail or mail-order pharmacies); (4) administered a vaccine covered by Part D in a physician’s office; and (5) provided covered Part D drugs dispensed by an out-of-network institution-based pharmacy while in an emergency department, provider-based clinic, outpatient surgery, or other outpatient setting. We will closely monitor out-of-network access to ensure that plans are adequately meeting enrollees’ out-of-network access needs.

Plans will have some flexibility to establish reasonable rules to assure that enrollees use out-of-network pharmacies appropriately. When an enrollee purchases a drug at an out-of-network pharmacy under these circumstances, he or she will pay the same cost-sharing as would have applied at a network pharmacy, plus the difference between the out-of-network pharmacy’s price and the network pharmacy price for that drug.

Yes. Duals can switch plans even though they receive letters indicating a plan into which they are being auto enrolled. And, those individuals can change up to once per month throughout the plan year. All other eligible beneficiaries may enroll in a plan and change that enrollment one time before May 15, 2006. After that time, those individuals will only be able to switch plans during the open enrollment period (November 15-December 31 each year) or in special circumstances, such as moving to another region, the plan stops offering benefits etc.

SNPs are able to limit their marketing and enrollment in Part D to one of three categories of beneficiaries: dual eligibles, institutionalized individuals, and those with long-term disability or chronic health conditions. SNPs with Medicaid managed care contracts are permitted by CMS to conduct passive enrollment of duals for coverage that begins January 1. 43 plans in 13 states (AZ, CA, CO, FL, KY, MN, NJ, OR, PA, TN, TX, UT, and WA) have been approved to do this. CMS criteria for the SNPs to conduct passive enrollment includes: existing contract as a Medicaid managed care provider, very similar provider network, identical pharmacy benefits manager, notice to beneficiaries of the ability to opt-out of the SNP, and no premium charged for Medicare Part A, B or D. Affected individuals should already have received a letter from their Medicaid managed care plan notifying them of this passive enrollment and allowing them to opt-out by the end of October. Those who opted out will also have a confirmation letter. Duals CAN switch out of these plans but will need to select and enroll into a different plan before January 1.
NMHA is aware that there is strong concern about the global benefit package for these SNPs; please call if you have further questions or specific detail in your state that would add to the body of knowledge about this issue.

All people with Medicare can choose to join a plan to get Medicare prescription drug coverage. The steps to enroll may differ if you have both Medicare and Medicaid (known as "dual eligibles").

You can sign up for the new Medicare prescription drug benefit by submitting an application to the plan you choose. You will receive information from Medicare in October 2005 about the different plans available in your area. Since plans may cover different drugs, it is important that you compare available plans before choosing a plan. A Plan Comparison Web Tool and Medicare Personal Plan Finder will be available at www.medicare.gov in late October 2005. These tools may help you in choosing a prescription drug plan that is right for your needs.

If you currently have Medicare and Medicaid benefits, you are called dual eligible and will be automatically enrolled in a Medicare prescription drug plan. There are two different types of dual eligibles. Your Medicaid ID card may have this information.

• You are a full-benefit dual eligible if you receive your prescription drugs from Medicaid right now.
• You are a partial-benefit dual eligible if Medicaid pays for your Medicare premiums and maybe some other Medicare costs, but not your prescription drugs.

• June 2005: You should have received a letter in the mail from the Centers for Medicare and Medicaid Services (CMS) and the Social Security Administration (SSA). This letter explained that Medicare will start paying for your prescription drugs on January 1, 2006. The letter says you are signed up for the Extra Help program, which will lower the costs of your medications.
• Fall 2005: You should receive a letter from your state Medicaid agency saying that your Medicaid prescription drug coverage will end on January 1, 2006 and that the Medicare program will automatically enroll you in a Medicare plan.
• If you do not receive these letters, call 1-800-MEDICARE (1-800-633-4227) to get this information.
• October-November 2005: You should receive a letter from CMS with the name of the Medicare prescription drug plan that you will be enrolled in unless you choose another plan that better meets your needs. You should read through the plan materials, compare the coverage with other plans, and decide if you´ll keep the plan or switch to another one.
• If you find a Medicare prescription drug plan that better meets your needs, you can switch to that plan before January 1, 2006. Tell the plan you want to join that you are switching, and also tell CMS after you join the plan you choose.
• January 1, 2006: Your new Medicare prescription drug coverage begins and your Medicaid drug coverage ends. If you find a plan that better meets your needs, you can change to a new plan once a month.

• June 2005: You should have received a letter from the Social Security Administration (SSA) about the Extra Help program. The letter says you are signed up for the Extra Help program, which lowers the costs of your medications.
• If you did not receive this letter, call 1-800-MEDICARE (1-800-633-4227) to get this information.
• October 2005: Review CMS materials (Medicare & You handbook and online plan comparison tool at www.medicare.gov) about available plans in your area and choose the best one for your medication needs.
• November 15, 2005: This is the first day you can join a plan, and you will need to complete and submit that plan's application. You will receive a confirmation letter and, later, a membership card that you can use at the pharmacy to show your enrollment in a plan. Remember that if you find a plan that better meets your needs, you may switch plans once a month after January 1, 2006.
• January 1, 2006: The program starts if you signed up by December 31, 2005. If you sign up after December 31, the plan will start the month after you sign up.
• May 15, 2006: This is the deadline to choose and sign up for a plan. If you do not join a plan before this date, Medicare will automatically select a plan for you.

• August 2005: If you have a limited income, you should have received a letter and application from the Social Security Administration about the Extra Help program. People with limited incomes and resources will have most or all of their prescription drug costs paid for by the government.
• Call 1-800-MEDICARE (1-800-633-4227) or your local Social Security Administration office to find out if you automatically get the Extra Help or to fill out an application.
• October 2005: Review CMS materials (Medicare & You handbook and online plan comparison tool) about available plans in your area and choose the best one for your medication needs.
• November 15, 2005: This is the first day you can join a plan, and you will need to complete and submit that plan´s application. You will receive a confirmation letter and, later, a membership card that you can use at the pharmacy to show your enrollment in a plan. Remember that if you find a plan that better meets your needs, you may switch plans only during the open enrollment period (November 15 - December 31) each year.
• January 1, 2006: The program starts if you signed up by December 31, 2005. If you sign up after December 31, the plan will start the month after you sign up.
• May 15, 2006: This is the deadline to choose and join a prescription drug plan. If you do not join before this date, and you have no other source of creditable coverage, you will have to pay a higher monthly premium for your drug plan when you do enroll.

The first day to enroll in a Medicare prescription drug plan is November 15, 2005. The initial deadline for signing up is May 15, 2006. If you do not have comparable drug coverage (coverage that is as good as the Medicare prescription drug plan) through either an employer or past employer, TRICARE, the Veterans Administration, or some other provider of prescription drug coverage (such as a MediGap policy) you must sign up by this deadline or you will have to pay a higher monthly premium for your drug plan when you do enroll. Your employer or other organization through which you have your drug coverage will provide you with written information that tells you if your drug coverage is as good or better than the Medicare drug coverage.

Consumers with Medicare and Medicaid ("dual eligible") can change plans every 30 days. Other people with Medicare only are allowed to change plans during open enrollment period (November 15 — December 31 each year).

You need to know what subsidies or programs you are eligible for (see "Extra Help" section). You should examine three key issues when selecting a plan:

• Drug coverage (including tiered coverage and co-pays)
• Accessibility of pharmacies
• Cost of plan (including premiums, deductibles, and co-payments)

Social security number, zip code, and date of birth may be required to obtain some specific information. General plan information should also be available online without any identification requirements.

Yes, if they are your appointed representative.

You are the only person, besides the prescription drug plan, who will have complete records of enrollment information. Your network pharmacy may have access to plan information, and so, if you lose your Part D card, you may be able to still get prescriptions from the pharmacy. Your physician, with your permission, may be able to call the pharmacy and verify enrollment. They will need your name and social security number in order to do so.

Individuals can access their plan information by logging onto www.medicare.gov, calling 1-800-MEDICARE, or speaking with their pharmacist. Medicaid case managers, in some states, may also be able to assist you.