Provider Notice issued 12/29/05

To: Participating Pharmacies

Date: December 29, 2005

Re: Illinois Cares Rx/Medicare Part D Contingency Plan – IMPORTANT Information

The Department of Healthcare and Family Services has developed a number of safeguards to ensure that seniors covered by both Illinois Cares Rx and Medicare Part D do not fall through the cracks during Part D implementation on January 1, 2006.

The Illinois Cares Rx Program (formerly SeniorCare and Circuit Breaker) fills in the gaps left by Medicare Part D, e.g., the deductible period, premiums, and cost sharing.

The assignment of Illinois Cares Rx beneficiaries to Medicare Prescription Drug Plans (PDPs) has involved various data exchanges between the federal government (CMS), HFS, and the PDPs. We have worked extensively to ensure that Illinois Cares Rx beneficiaries are properly assigned. Most of the 242,500 Illinois Cares Rx beneficiaries have been assigned to a coordinating stand-alone PDP (United AARP and PacifiCare) or are enrolled in a coordinating Medicare Advantage plan’s PDP (Wellcare, OSF, and Health Alliance) and will have access to their Illinois Cares Rx benefit through their Medicare Part D PDP. Pharmacies will be able to bill for these beneficiaries in accordance with the informational notice released on December 9, 2005.

However, HFS is concerned that certain groups of Medicare-eligible Illinois Cares Rx beneficiaries will not be enrolled in a coordinating Medicare PDP for January 1, 2006, coverage. Therefore, HFS has extended direct coverage for these groups through January 2006.

Important: If an Illinois Cares Rx beneficiary presents at the pharmacy and one of the following things happens, the pharmacy should then submit the claim to the Department:

 

1. The Beneficiary’s Illinois Cares Rx card indicates that they have Medicare Part D coverage (this is indicated by PCN ISC47865), but the TROOP facilitator does not return Part D eligibility information for them; or

 

2. The claim processes through a Part D PDP, but the PDP returns the standard Medicare Part D cost-sharing to the pharmacy, rather than the Illinois Cares Rx wrap-around co-pays ($2/generic; $5/brand; $15/non-preferred brand and specialty).

 

In either of the above cases, the pharmacy should attempt to bill HFS directly via NCPDP 5.1 point-of-sale. If the beneficiary falls into the second category, the claim should contain the Medicare payment in the Other Payer Amount Paid field, and the code 910 in the Other Payer ID field. A claim will not reject only because the Illinois Cares Rx PCN for Medicare eligible beneficiaries (ISC47865) is entered for a non-Medicare beneficiary.

Pharmacies who experience one of the above scenarios and are unable to bill a prescription through HFS point-of-sale should contact HFS at 800-226-0768 and ask for assistance with the client’s eligibility status.

Steps to Take to Determine Eligibility Status for Illinois Cares Rx ( SeniorCare and Circuit Breaker) Beneficiaries

If a beneficiary does not have their ID cards, eligibility information may be found as follows:

Medicare Part D: If the beneficiary does not have their PDP ID card but should be enrolled in Medicare Part D, submit a NCPDP 5.1 E1 Transaction (eligibility inquiry) to the TROOP facilitator. This transaction will return PDP enrollment/eligibility information.

Illinois Cares Rx: If the beneficiary does not have their Illinois Cares Rx Card, use their old SeniorCare ID number; or their old Circuit Breaker Pharmaceutical Assistance ID number but drop the first digit. If neither is available, then submit a NCPDP 5.1 E1 transaction to HFS using the beneficiary’s name, date of birth and SSN. This will return eligibility information, including an ID number, on both SeniorCare and Circuit Breaker Beneficiaries.