Important Notice for Dual - eligibles (People who receive both Medicare and Medicaid)
All dual eligibles will had their Medicaid drug benefit terminated on December 31, 2005. It was replaced by the new Medicare drug benefit, which began on
January 1, 2006. However, the Medicare drug benefit is not as comprehensive as New Jersey's
Medicaid drug coverage. In addition, there is a complicated set of rules and procedures that govern the new Medicare drug benefit. Click here to see a list of frequently asked questions and their answers on
this critical subject.
"Model Part D Exception and Prior Authorization Request Form"
The American Medical Association (AMA) and America's Health Insurance Plans (AHIP), in conjunction with CMS, have recently released a standardized form designed to assist physicians in applying for
exceptions and prior authorizations on behalf of beneficiaries enrolled in Medicare drug plans. This form
allows for a simplified process for physicians to apply for coverage determinations on behalf of all of their Medicare patients, regardless of which Part D plan the beneficiary is enrolled in.
Please share this form directly to the physicians who prescribe medications for consumers who are enrolled in Medicare Part D, as well as to caregivers to give to the physicians.
A word of caution: When a doctor is responding to a prior authorization request from a Medicare
prescription drug plan (PDP) , please note that the PDP may require different, drug-specific, forms for "biotech or other specialty drugs".
Click here to download the CMS form.
Phase-In Schedule for Medicare Part D Changes for the Dual Eligibles
The Centers for Medicare and Medicaid Services (CMS) has announced that it will not reimburse the
State Medicaid offices for their expenditures on Medicare Part D drugs for the dual eligibles after March 31, 2006.
At the end of the first week in January, the NJ Medicaid office turned off the computer edits. This has
allowed pharmacists to easily bill NJ Medicaid for medications that the Medicare Part D prescription drug plans (PDPs) did not cover. As a result of the announcement from CMS, NJ Medicaid has
developed a phase-in schedule for turning the computer edits back on. When the edits are turned on, pharmacists will no longer be able to routinely charge Medicaid for a dual eligible's
medications that Medicare Part D did not cover. Note: This does not mean that the wrap-around funding is ending; see below for further information on the wrap-around procedures.
We anticipate that some dual eligibles -- who have not had recent problems receiving their prescription
drugs -- will have problems when the Medicaid edits have been turned on. These problems should
immediately be brought to the attention of NJ Medicaid. In an effort to avoid the high level of problems that would likely occur if the Medicaid edits were turned on throughout the state on the same day,
Medicaid has set up the following phase-in schedule.
These are the dates on which the Medicaid edits will be turned on:
Tuesday, March 14: Southern Counties: Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester, Ocean, Salem
Tuesday, March 21: Central and North Central Counties: Hunterdon, Mercer, Middlesex, Monmouth, Morris, Somerset, Union
Tuesday, March 28: Northern Counties: Bergen, Essex, Hudson, Passaic, Sussex, Warren,
There are a few other important things for you to know:
- If the dual eligible is informed by the pharmacist that he/she is not enrolled in any Medicare
prescription drug plan (PDP), the pharmacist can enroll the dual eligible into the Wellpoint PDP
immediately. The pharmacist should know how to do this type of enrollment, but if there are any problems, we recommend calling 1-800-MEDICARE for assistance. The Medicare hotline is
operational 24 hours a day, 7 days a week.
1) Until March 31, 2006: The CMS transitional policy will be in effect, which should require the
Medicare PDPs to cover non-formulary drugs. Therefore, even when the Medicaid edits for your county have been turned on, dual eligibles should be able to receive non-formulary drugs without a
hassle. However, this transitional policy will end on March 31st.
2) After March 31st:
New Jersey is fortunate to have a wrap-around that will pay for the Medicare Part D co-pays and for most non-formulary drugs. This is what you need to know about
NJ's wrap-around process:
- Even if the pharmacist informs a NJ dual eligible that his/her medication is denied by the
Medicare drug plan, the dual eligible should never leave the pharmacy without at least a temporary (6-day) supply of their prescription medication -- paid for by our state's wrap
-around. There is no charge to the dual eligible for this temporary supply of medication.
- If the pharmacist informs a NJ dual eligible (or the caregiver) that their medication is not
on the formulary of their Medicare drug plan, they (or the pharmacist or caregiver) should quickly contact the doctor who should either:
- change the prescription to a drug that is on the formulary, or
- request an exception from the drug plan.
- If the doctor requests an exception and it is denied by the Medicare drug plan, in most
cases, the medically necessary medication will be covered by NJ Medicaid. However, NJ Medicaid will not cover non-formulary drugs until the doctor has filed an exception request
with the PDP. Furthermore, NJ Medicaid will pay for only a 6-day supply of the non-formulary drug. The PDPs are required by CMS to respond to doctors' exception
requests within 72 hours (or 24 hours if the enrollee's situation is very urgent). Therefore, the timeframes leave no room for delay. That is why it is so extremely important to
communicate quickly with the dual eligible's physician or other provider whenever a prescription drug is denied by the PDP.
IF A DUAL ELIGIBLE HAS A PROBLEM RECEIVING HIS/HER PRESCRIPTION DRUGS, THESE ARE THE PHONE NUMBERS TO CALL:
Medicaid hotline: 1-800-356-1561
Antonietta Balci, a Medicare Part D Specialist who works for NJ Medicaid: 609-588-2732
Medicare hotline: 1-800-MEDICARE
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Important
EMERGENCY NUMBERS
For problems that arise when dual eligibles try to get their prescription drugs,
due to the January 1st start of Medicare Part D
1-800-356-1561
TOLL-FREE
NJ MEDICAID HOTLINE
Callers to this Medicaid
hotline who have problems getting prescription drugs will probably be transferred to the number below. You may want to call this number directly:
DIRECT LINE at 1-609-588-2732.
(Note that this is a toll call. To save on the toll call, you can call the toll-free number
and be transferred to this line.)
If you prefer to get in contact with someone from the Centers for Medicare & Medicaid Services (CMS), e-mail is
the preferred method to communicate with the CMS regional office in New York. Be sure to include your name and telephone number in any e-mail communications
in case there is a need to follow up with you. All issues pertaining to Medicare prescription drug coverage for New Jersey can be e-mailed to:
PartDComplaints_RO2@cms.hhs.gov
If you need or prefer to call, the CMS regional office hotline is 212-616-2222.
E-mails and voicemails will be checked by CMS staff regularly during
business and non-business hours during the initial days and weeks of the program – including January 1st and 2nd.
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GOOD NEWS!
For Dual Eligible consumers who have Employer Sponsored Drug Benefits
- Now, Medicaid pays the co-pay, and Medicaid will continue to cover these co-pays after January 1, 2006.
- (If you have attended one of our seminars regarding the "The Impact of the Medicare Drug Benefit on the Dual Eligibles," the information
provided may have been different. New Jersey Medicaid recently announced that they will continue to cover the co-pays for dual eligibles after Jan. 1st.)
- In most cases, dual eligibles should not be in both an employer-sponsored plan and Medicare Part D, but there are exceptions. Talk to
the employer to check on your own situation.
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Helpful suggestions for contacting the Medicare hotline
Most dual eligibles have already received the yellow auto-assignment letter from CMS, but some have not
. If you are a dual eligible (or a caregiver), and you have not received the yellow letter, it is suggested that you contact the Medicare hotline to request this information.
The Medicare hotline (1-800-Medicare) is able to provide the name of the plan to which the dual eligible
was auto-assigned, but the Medicare staff will need the date of first entitlement to Medicare before they
provide that information. The date of first entitlement to Medicare is printed on the Medicare card.
Some people have had difficulty navigating the Medicare hotline, but we have had good success in getting accurate information by following these guidelines:
- Call 1-800-Medicare (800-633-4227).
- As soon as the automated voice says, "Here are your choices," you can say "More Options."
- Hold on for the rest of that automated message, or say "agent" to get to speak to a customer service operator.
- If you want to speak with a person who is knowledgeable about the dual eligible issues (rather than
a regular operator), when you reach the customer service person, ask to be transferred to a
Medicare Benefits Specialist. These specialists are working 24 hours a day, 7 days a week, just as
the other telephone operators are. If your question is very basic, then the regular operator may be
able to help, but for anything complicated, we recommend speaking to a specialist.
Helpful information for obtaining the date of first entitlement for Medicare
In order to switch from the prescription drug plan (PDP) to which a dual eligible was randomly auto
-assigned, it is necessary to have the date of first entitlement for Medicare. This date is printed on the
Medicare card; however, some dual eligibles have misplaced the Medicare card. I have just learned about a relatively easy way to obtain the date of first entitlement for Medicare:
- Call the toll-free number for the Social Security Administration: 1-800-772-1213.
- There is a lengthy automated message, but you can be switched to an operator more quickly by saying the word "agent."
- You may be put on hold for several minutes, but the recorded message will let you know approximately how long your wait will be.
- When the caller is connected to a Social Security agent, the caller should request confirmation of
the dual eligible's date of first entitlement for Medicare (and the caller may want to add that this information is necessary to switch drug plans in the Medicare Part D system).
- The person who speaks with the Social Security agent should be either the dual eligible, the legal
guardian, or the rep. payee. The agent will ask some identifying questions to ensure that the caller
is legitimate (e.g., the dual eligible's birth date and Social Security number; home address;
mother's maiden name, etc.) When these questions have been answered satisfactorily, the Social Security agent will provide the date of first entitlement for Medicare.
- After receiving the requested information, the caller may also want to request that the agent send another Medicare card.
NOTE: This process may be useful for dual eligibles who can speak for themselves or whose rep. payee
is able to make the call to Social Security. However, it may not work for a person with a developmental
disability who has limited verbal ability, if the rep. payee is not available and a staff person is attempting to obtain the information.
December 14, 2005
Click here to view an important consumer alert for individuals who are enrolled in Medicare Part D.
Additional Information for dual-eligibles and their caregivers:
Please bookmark this page as information changes daily
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