Mental Health Part D News Alert

December 15, 2005

Dual Eligible Transition from Medicaid to Medicare: Point of Sale Protection Plan

The Centers for Medicare and Medicaid Services (CMS) recently announced a new point of sale (POS) fallback plan for dual eligible patients (individuals eligible for both Medicaid and Medicaid) who, for whatever reason, failed to be enrolled in a pharmacy benefit plan, as part of the autoenrollment process for duals. When dual eligible patients appear at the pharmacy because they need a refill of their medication, if the pharmacist is unable to verify that the customer has been enrolled in a drug plan using the new centralized query system established by CMS, the point of sale (POS) protection plan will go into effect.

Query and Coordination of Benefits (COB) System

CMS has created an electronic Part D eligibility query and coordination of benefits system that can be accessed by all U.S. pharmacies. This centralized system will allow pharmacists to look up a Medicare beneficiary’s billing information (including relevant Part D eligibility and enrollment information), and determine which, if any, Part D pharmacy plan the beneficiary is enrolled in. The pharmacist should be able to access the information even if the beneficiary presents with no more than a photo ID card. The system will be open and accessible to all pharmacies regardless of their network affiliation or current pharmacy management system. This system will be used to facilitate the new Point of Sale Protection Plan CMS has initiated.

Point of Sale (POS) Protection Plan

Even with all of CMS’s efforts to have all dual eligibles auto-enrolled in pharmacy benefit plans (PDPs) before January 1, 2006, there will still be some dual eligibles who will show up at the pharmacy without having been assigned to a prescription drug plan (PDP). To ensure that, despite this, all dual eligibles will continue to have access to their medications, CMS has established a POS protection plan in all pharmacies throughout the country. Through the POS plan, dual eligibles will be able to leave the pharmacy with their medications for the appropriate subsidized copayment amount even when the system shows that have not been enrolled in a PDP. The POS plan will also work to rapidly enroll these no-PDP dual eligibles into an appropriate PDP with no premium cost to them.

The POS plan applies only to full-benefit dual eligibles, and not to those who receive partial benefits (such as QMB, SLMB, or QI-1). The plan will begin January 1, 2006, with claims being initiated directly from pharmacies.

CMS has announced that two national vendors, Wellpoint and Z-Tech, will be responsible for processing all the claims for these nonplan dual eligible individuals. Wellpoint will provide the POS drug access in every region in the U.S. and Z-Tech will validate dual eligibility and facilitate the retroactive enrollment for dual eligibles in one of the low premium plans offered in their region.

How it will work:

1. A full-benefit dual eligible walks into a pharmacy with either a Medicaid card or a previous history of Medicaid billing in the pharmacy system.
2. The pharmacist, who does not yet know the customer is also eligible for Medicare, attempts to bill Medicaid, and the claim is denied.
3. The pharmacist checks for Part D enrollment through the eligibility and COB system by using a photo ID care and:
1. A Medicare card; or
2. Calling 1-800-Medicare; or
3. Requesting to see the customer’s Medicare Summary Notice
4. If the COB system identifies the beneficiary’s enrollment in a PDP, the medication is dispensed, and the appropriate plan is billed, or, if the pharmacy is out-of-network for that PDP, the beneficiary is referred to any appropriate pharmacy.  If the patient is not found in the system, the pharmacist continues with the POS protection plan procedures.
5. The pharmacist enters the claim into the automated pharmacy system, including benficiary’s name, ID number (Medicare, Medicaid, or SSN), date of birth, address, and phone number (most of this is information that pharmacies will already have).
6. The claim is submitted to the POS Contractors (Wellpoint and Z-Tech), and the beneficiary receives her medication at the $1 or $3 copayment amount.
7. Z-Tech will validate the beneficiary’s eligibility for Part D and enroll him into a PDP.  As with all enrollment for dual eligibles, a new PDP may be selected by the enrollee at any time.