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Provider Notice issued 12/29/05
To: Pharmacies Participating in SeniorCare and Medical Assistance
Date: December 9, 2005
Re: Medicare Part D and Changes to Medicaid, SeniorCare and Circuit Breaker Pharmaceutical Assistance
Medicare Part D changes effective January 1, 2006, will affect Medicare-eligible Medicaid (Dual-eligibles), SeniorCare, Circuit Breaker and Illinois Rx Buying Club clients.
This notice addresses several issues surrounding the Medicare Part D transition.
Eligibility changes:
Medicaid clients enrolled in Medicare Part D (Dual-Eligibles)
Dual Eligibles who were Not Auto-Enrolled
SeniorCare and Circuit Breaker (Now called Illinois Cares Rx)
Illinois Cares Rx Clients also Enrolled in Part D
Illinois Cares Rx Clients not Eligible for Part D
Determining Whether a Cares Rx Client also has Part D Coverage
Illinois Rx Buying Club Clients
Illinois Cares Rx Wrap-Around Benefit
Explanation of Illinois Cares Rx “wrap-around” benefit
Billing Through HFS Point-of-Sale for Dual-Eligibles and Illinois Cares Rx Clients
When to bill HFS Point-of-Sale System
Claims submitted through HFS Point-of-Sale System for Medicare Part D Enrollees
Issues Surrounding Coverage of Particular Drugs
Drugs Not Covered By Medicare Part D
Medicare-Covered Drugs not on a PDP’s Formulary
Information for Clients
Switching PDPs
Where to Direct Clients for Assistance
ELIGIBILITY CHANGES:
Medicaid Clients also Enrolled in Medicare (Dual-Eligibles)
Clients who are eligible for both Medicare and Medicaid (Dual-eligibles) will receive their pharmacy benefits from Part D effective January 1, 2006. Dual-eligibles are eligible for the low-income subsidy (LIS), and will have minimal out-of-pocket expense. Medicare will cover the Part D deductibles and coinsurance for those clients. Dual-eligible clients have been auto assigned to one of fifteen (15) Medicare Prescription Drug Plans (PDPs) in Illinois, unless they were already enrolled in a Medicare Advantage Plan (i.e., Medicare HMO/PPO). Dual-eligible clients already enrolled in a Medicare Advantage Plan have been enrolled in that Plan’s PDP. The CMS website contains a list that identifies the 15 PDPs to which dual-eligibles have been assigned. To obtain a list of Illinois PDPs, go to the link below and click on the link titled “Stand-Alone Prescription Drug Plans.” Dual-eligibles have been assigned to PDPs noted as “ No Premium With Full Low Income Subsidy.”
Dual Eligibles Who Were Not Auto-Enrolled
Most dual-eligibles have been auto-enrolled. However, it is possible that a limited number were missed. CMS has established a mechanism for payment of prescription drug claims for these clients. If a beneficiary presents at a pharmacy with evidence of both Medicaid and Medicare eligibility, but without current enrollment in a Part D plan, pharmacies should follow instructions available on CMS’ website regarding billing to a single national plan for payment of prescription drug claims for the very limited number of dual eligible beneficiaries who have not yet been auto-enrolled into a Part D plan at they time they present a prescription at the pharmacy.
SeniorCare and Circuit Breaker (Combined to Form Illinois Cares Rx)
Effective January 1, 2006, the Circuit Breaker and SeniorCare programs will be combined into one program called Illinois Cares Rx. Circuit Breaker clients will now be in the Illinois Cares Rx Basic Plan. SeniorCare clients will now be in the Illinois Cares Rx Plus Plan. The benefit levels for both programs will remain substantially the same. Clients eligible for the Illinois Cares Rx Basic Plan (formerly Circuit Breaker) will still receive drug coverage limited to ten specific disease states.
Illinois Cares Rx clients will have an Illinois Cares Rx Card. A facsimile of the card will be posted to our website.
Illinois Cares Rx Clients also Enrolled in Part D
Clients currently enrolled in either the Circuit Breaker or SeniorCare program, who are also eligible for Medicare Part D, will be automatically rolled over into Illinois Cares Rx on January 1. At that time, Part D will begin providing the majority of drug benefits for these clients.
Illinois Cares Rx Clients Not Eligible for Part D
There are approximately 10,000 SeniorCare and Circuit Breaker clients not eligible for Medicare Part D. Illinois Cares Rx Plus (formerly SeniorCare) and Illinois Cares Rx Basic (formerly Circuit Breaker) clients who are not eligible for Medicare Part D will continue to get their drug coverage through Illinois Cares Rx. Claims processing for those clients will be administered by HFS through the Department’s point-of-sale system. Express Scripts, Inc. will no longer administer the Illinois Cares Rx Basic (formerly Circuit Breaker) benefit effective January 1, 2006.
All Illinois Cares Rx Basic (formerly Circuit Breaker) enrollees who are not eligible for Medicare Part D will continue to be enrolled in the Illinois Rx Buying Club for all drugs not covered in Illinois Cares Rx Basic (formerly Circuit Breaker). Claims for drugs not covered by Illinois Cares Rx Basic (formerly Circuit Breaker), should be processed to SavRx RxBIN # 610150. HFS is developing programming that will return a message to the pharmacy indicating that the claim should be processed to SavRx when a pharmacy bills HFS for a non-Illinois Cares Rx Basic covered drug for a non-Medicare client.
Determining Whether an Illinois Cares Rx Client also has Part D Coverage
Illinois Cares Rx clients will have an Illinois Cares Rx Card. A facsimile of the card is included at the end of this notice. Pharmacists will be able to distinguish between Illinois Cares Rx clients who are eligible for Part D and those who are not by the Processor Control Number on the front of the Illinois Cares Rx card. Clients eligible for Illinois Cares Rx Basic (formerly Circuit Breaker) will have language on the back of their Illinois Cares Rx Card stating that coverage is limited to specific disease states. Medicare-eligible Illinois Cares Rx clients will have two cards, one from their PDP and one from Illinois Cares Rx.
The Processor Control Numbers for Illinois Cares Rx are as follows:
Processor Control Number for clients eligible for Medicare Part D: ISC47865
Processor Control Number for clients NOT eligible for Medicare Part D: ISC47875
To determine which PDP the client is enrolled in, pharmacies may submit an NCPDP 5.1 E1 transaction to the TROOP facilitator.
Illinois Rx Buying Club Clients
The eligibility requirements for the Illinois Rx Buying Club have been expanded to include anyone with income under 300% of FPL, regardless of age or disability. However, if Medicare-enrolled clients use the Illinois Rx Buying Club when they are in the Medicare deductible or coverage gap periods, the costs they incur will not count toward their out-of-pocket expenses. Therefore, only patients NOT enrolled inMedicare Part D should use the Illinois Rx Buying Club benefit.
ILLINOIS CARES RX WRAP-AROUND BENEFIT
The Illinois Cares Rx Wrap-Around Benefit Explained
In order to help fill the coverage gaps (deductibles, coinsurance) of the Part D program, the Illinois Cares Rx program will "wrap around" the Part D benefit so clients will experience approximately the same out of pocket costs as they do under the current Circuit Breaker and SeniorCare programs. Illinois Cares Rx will pay the plan's monthly premium for the basic Medicare benefit and cover most of the deductibles and coinsurance. Clients will have a $2 co-pay for generics, a $5 co-pay for preferred brands and a $15 co-pay for non-preferred medicines up to a benefit threshold of $1,750 per year. After the benefit threshold, clients still have coverage but are required to pay 20% of the cost of each prescription plus the applicable co-pay. (Note: If a client is eligible for extra help under Medicare, their copays may be lower.)
Illinois Cares Rx Basic (formerly Circuit Breaker) clients will receive wrap benefits only for the drugs covered under the Illinois Cares Rx Basic (formerly Circuit Breaker) . Drugs not used to treat the ten specific disease states covered by this benefit will not be “wrapped around,” so clients will be responsible for the full Medicare cost sharing for those drugs.
NOTE: Pharmacies will only have to submit one claim to the Medicare PDP for Illinois Cares Rx clients for drugs covered under Medicare Part D. The transaction will be processed through the PDP. The PDP will coordinate the wrap coverage, but that will be transparent to the pharmacy.
IMPORTANT: In order to receive the wrap around benefit offered by Illinois Cares Rx, clients must be enrolled with one of the Medicare prescription drug plans (PDPs) that have agreed to coordinate these benefits with the state. The two stand-alone Medicare PDPs that are coordinating benefits with Illinois Cares Rx are United Healthcare's AARP MedicareRx Plan (Plan Number S5820/016) and the PacifiCare Saver Plan (Plan Number S5921/082). Stand-alone prescription drug plans are for Medicare enrollees that are not in a Medicare Advantage Plan (i.e., Medicare HMO/PPO). Illinois Cares Rx has automatically assigned Medicare-eligible SeniorCare and Circuit Breaker clients who are not in a Medicare Advantage Plan to one of the two coordinating plans.
Clients enrolled in a coordinating Medicare Advantage Plan have been automatically assigned to their plan’s PDP. In order for clients currently enrolled in a non-coordinating Medicare Advantage Plan to receive the wrap-around benefit offered by Illinois Cares Rx, they must switch to one of the three Medicare Advantage Plan PDPs that have agreed to coordinate these benefits with the state, or switch to regular Medicare and enroll with a coordinating stand-alone PDP. The three (3) Medicare Advantage Plans coordinating benefits with the state are Health Alliance, OSF Health, and WellCare.
Clients who become eligible for Illinois Cares Rx in the future will be assigned to one of the coordinating PDPs unless they are already enrolled in one.
BILLING THROUGH HFS POINT-OF-SALE SYSTEM
When to Bill Through HFS Point-of-Sale System
Illinois Cares Rx claims will be processed through the HFS point-of-sale system when:
patients are eligible for Illinois Cares Rx but are NOT eligible for Part D; or
patients are eligible for Illinois Cares Rx and Medicare Part D, and the drug is a drug that is excluded from coverage under Medicare Part D (benzodiazepines, barbiturates, and certain OTCs). Illinois Cares Rx Plus is required to cover Part D excluded drugs to the same extent these drugs are covered for the regular Medicaid population.
Prior approval should only be requested through the HFS prior approval system when the client’s claim is being processed through the HFS point-of-sale system.
Claims submitted through HFS Point-of-Sale System for Medicare Part D Enrollees
If a claim is submitted to HFS for a Medicare Part D covered drug for an Illinois Cares Rx client enrolled in Medicare Part D, the claim will reject with the following message: Part D Service - Bill Medicare. To determine which PDP the client is enrolled in, pharmacies may submit an NCPDP 5.1 E1 transaction to the TROOP facilitator.
ISSUES SURROUNDING COVERAGE OF PARTICULAR DRUGS
Drugs Not Covered By Medicare Part D
Some drugs not covered by Medicare Part D, but formerly covered by SeniorCare, Circuit Breaker or Medicaid will continue to be covered by Illinois Cares Rx and Medicaid. Claims for those drugs should be billed through the HFS point-of-sale system. Based on program eligibility, those drugs include benzodiazepines, barbiturates and some over-the-counter (OTC) drugs currently covered by HFS.
Drugs covered for beneficiaries under Medicare Part A and Part B are not covered under Medicare Part D.
Medicare Part D Drugs not included on PDP Formularies
Each of the PDPs has a formulary which can be found on the individual PDP’s website. The formularies were subject to review and approval by the Centers for Medicare and Medicaid Services (CMS). Illinois Cares Rx clients enrolled in a PDP must follow their PDP’s formulary. Illinois Cares Rx will not cover Part D covered drugs just because they are not on the client’s PDP’s formulary.
INFORMATION FOR CLIENTS
Changing PDPs
All Cares Rx clients have been assigned to a PDP. Clients have the option to pick a different plan if they choose to do so. However, if a client chooses a Medicare PDP that is not coordinating benefits with the state, Illinois Cares Rx will still pay the monthly premium for the basic Medicare benefit but will not pay any deductibles or coinsurance. It is very important that clients understand the effects of changing PDPs, especially if that change may result in a reduction in coverage. Illinois Cares Rx clients considering a change in PDPs should call one of the hotlines listed below so that they can make a fully-informed decision.
When advising their clients, pharmacies should always remind the client to base their decision on which PDP’s formulary suits their needs best and the PDP’s network. Pharmacies should NOT direct clients to change PDPs in order for the client to be enrolled in a PDP for which that pharmacy is included in the network.
IMPORTANT: Illinois Cares Rx clients wishing to switch PDPs should call one of the State’s Hotlines listed below. It is important that the State facilitate the switch for Illinois Cares Rx clients.
Medicaid dual-eligibles do not have to call one of the State’s hotlines to switch PDPs. They should contact the PDP they want to enroll with.
Where to Direct Clients for Assistance
Clients with Medicare Part D questions should be directed to the Senior Health Insurance Program (SHIP) at 800-548-9034 or Senior Helpline at 1-800-252-8966 or Medicare at 1-800-MEDICARE (633-4227).