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.

People with Medicare will have two choices to get their health care and prescription benefits:

1. Through participation in the Original Medicare Fee-for-Service Plan or a Medicare Private Fee-for-Service Plan (PPFS); or
2. Through a Medicare Advantage Plan, like an HMO (health maintenance organization) or PPO (preferred provider organization).

Consumers who are in the Original Medicare Fee-for-Service Plan or a private fee-for service plan can enroll in an independent Medicare Prescription Drug Plan or PDP. There will be a choice of at least two PDPs in each region, with a total of 34 PDP regions in the U.S. Consumers who are in a Medicare Advantage Plan will receive their Medicare prescription drug coverage through a Medicare Advantage Prescription Drug Plan, or MA-PD. Some Medicare Advantage Drug Plans may not offer prescription drug coverage; the consumers in those plans can enroll in an independent PDP.

Dual eligibles will be automatically enrolled in a Medicare PDP by CMS before December 31, 2005, and their Medicaid drug prescription coverage will be stopped as of January 1, 2006. It is critical for these individuals to be enrolled in an appropriate PDP plan before the Medicare prescription drug benefit takes effect on January 1, 2006. However, there may be challenges with auto-enrollment, such as: if CMS enrolls the consumer in a PDP that does not support his/her mental health medication; or the consumer may not know what pharmacies participate in his/her PDP.

Consumers with partial dual eligibility, such as Qualified Medicare Beneficiaries (QMB), Specified Low-Income Medicare Beneficiaries (SLMB), and Qualifying Individuals (QI) are automatically eligible for extra help and will be automatically enrolled in a PDP by May 15, 2006, if they have not already enrolled themselves before then. Supplemental Security Income (SSI) recipients and individuals with Medicare Savings Plans will also be auto-enrolled in a plan by May 15, 2006 (if they have not already enrolled before that time) and automatically qualify for the extra help. Providers should help these individuals make a plan selection before December 31, 2005 to avoid a gap in coverage.

Those in a Medicaid spend-down scenario must spend down one time between August and November 2005 to be auto-enrolled in a prescription drug plan by December 31, 2005 and qualify for the extra help. If a consumer does not spend down to qualify for Medicaid during this period, then a consumer must spend down one time in 2006 to be automatically enrolled in a plan and to qualify for extra help within two months of meeting the spend down. Check with your state Medicaid office for specific details about how these individuals will be enrolled in your state.

Consumers who have Medicare only can voluntarily enroll in Medicare prescription drug plans any time from November 15, 2005 to May 15, 2006. These individuals will not be automatically enrolled. If they do not join a plan by May 15, 2006, they will pay a penalty if they want to enroll later.

Consumers with Medicare and Medicaid (known as "dual eligibles") and partial dual eligibles can change plans every 30 days. Other consumers with Medicare only are allowed to change plans during open enrollment periods decided by the plans (most likely November – December each year).

Providers must help consumers examine three key issues when selecting a plan:

• Drug availability (including tiered coverage and other utilization management techniques)
• Accessibility of pharmacies
• Cost (co-pays, premiums and deductibles)

A chosen plan should have a drug formulary that includes all (or most) of the prescriptions currently being taken at the lowest available price.

The CMS search tools, available on-line in October 2005, will provide a wide range of information about plan pharmacy networks, formularies and costs. With basic identifying information such as Medicare number, Medicare enrollment date, zip code, and date of birth, a person with Medicare can obtain some specific information. People with Medicare and Medicaid (known as "dual eligibles") will also be able to look up into what plans they are auto-enrolled. General plan information will be publicly accessible online without any identification requirements.

Yes, if they are an appointed representative of the enrollee, or if a person, like a provider, has the Medicare beneficairies' basic identifying information to plug into the web search tools. The consumer is the only person, besides the prescription drug plan, who will have complete records of enrollment information. The consumer's new network pharmacy may also have access to plan information, and so, if the consumer loses his/her Part D card, he/she may still be able to get prescriptions from the pharmacy.

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 consumers.