Many dual eligibles reside in LTC facilities and receive their prescription drugs through an LTC pharmacy. As of January 1, 2006, all patients with both Medicare and Medicaid in LTC facilities will transition to the new Medicare prescription drug benefit and will no longer receive their prescription drug through Medicaid. LTC pharmacies will contract directly with Medicare prescription drug plans (PDPs) and will not bill Medicaid.

Eligible people with Medicare who are residing in nursing homes will be expected to enroll in a Medicare prescription drug plan (PDP) (or be automatically enrolled if they are dual eligible). The new plans are expected to contract with long-term care pharmacies.

Eligible people with Medicare who are temporarily residing in a psychiatric facility will follow the same procedures for enrollment as discussed in the Enrollment section.  These enrollment procedures are dependent upon what group a consumer falls into (for example, a person eligible for both Medicare and Medicaid). Providers will need to assist individuals in this process.

If a consumer is hospitalized during the Fall 2005 enrollment period, then providers need to coordinate with the institutional staff to ensure that the consumer is enrolled in the most appropriate PDP for their needs. Assisted living facilities may fall under different criteria and are not considered an institutional setting. Income and resource limits will determine a consumers’ enrollment or auto-enrollment status and if they automatically qualify for the extra help.

No, individuals who are incarcerated are not eligible for Medicare prescription drug coverage because they are not considered to "reside" in a prescription drug service area. Providers should be prepared to help these individuals upon re-entry into the community and, if eligible, to enroll in a PDP and apply for Extra Help.

All facilities that comply with Medicare and Medicaid conditions are covered under the new benefit. These are primarily nursing home facilities.

Other living arrangements such as assisted living facilities, other facilities recognized by state law, group homes for the developmentally disabled, and other forms of congregate living arrangements regulated by the states, but not by the Federal government, are not covered under Part D.

Under the new Medicare Prescription Drug Coverage, enrollee drug plans will be administered by either a Medicare Advantage organization or a Prescription Drug Plan (PDP). LTC pharmacies will contract with these PDPs and negotiate payments.

CMS expects that each LTC facility will select one or possibly more than one eligible Network LTC Pharmacy (NLTCP) to provide Medicare drug benefits to its residents.

PDPs will be required to offer a contract to any pharmacy willing to participate in its LTC pharmacy network, so long as the pharmacy is capable of meeting certain minimum performance and service criteria (and relevant state laws governing the practice of pharmacy in the LTC setting) and any other standard terms and conditions established by the plan for its network pharmacies.

Consumers should be able to check www.medicare.gov in November 2005 to compare the available prescription drug plans and the pharmacies in their area.

A large proportion of LTC residents who are dual eligible will be auto-enrolled into the plan without making an affirmative selection based on the individual existing treatment needs. Other people with Medicare will have to enroll into a PDP (see section on Enrollment).

Dual eligibles residing in LTC facilities will receive continuous prescription drug coverage, with no premiums, no deductibles, and no co-payments. Other people with Medicare might be subject to the costs of the Medicare prescription drug program (See section on Costs).

Plans must accommodate the needs of LTC residents within a single formulary structure by providing coverage for all medically necessary medications at all levels of care.

Access to necessary medications for LTC residents may be provided through formulary inclusion, and utilization management tools may restrict access to specific drugs. There are the exceptions processes to override restrictions.

Each PDP should have procedures in place for addressing the needs of enrollees who reside in LTC facilities, with particular attention to situations where there is a disparity between the Part D requirements and the Medicare Conditions of Participation (COP) for LTC facilities.

Plan sponsors must cover a temporary or emergency supply of non-formulary Part D drugs for LTC residents as part of their transition process. LTC residents must receive their medications as ordered without delay.