Serving children and adults with intellectual and developmental disabilities

Dual-eligibles Managed Care Medicaid

Medicare Part D for the Dual Eligibles in New Jersey

JANUARY 1, 2009: Changes in Medicare Part D for the Dual Eligibles

Effective January 1, 2009, there will only be seven (7) benchmark plans available in New Jersey, while in 2008 there were seventeen (17) benchmark plans available. If a dual eligible is enrolled in one of the 2009 non-benchmark plans, he/she will be required to pay a monthly fee anywhere from $0.20 to $99.20, depending on the plan.

View, download or print the following:

• Benchmark and non-benchmark drug plans in 2009
• Comparison of 2009 and 2008 benchmark drug plans
• Seminar presentation regarding the 2009 Medicare Part D changes

• The federal agency that has authority over all aspects of Medicare – including Medicare Part D – is the Centers for Medicare and Medicaid Services (CMS).
• When the parent of a person with a developmental disability starts to collect Social Security benefits, the adult child starts to receive a Social Security Disability (SSD) check each month.
• 24 months later, the adult child starts to receive Medicare. The person with a disability receives both Medicaid and Medicare, and is a "dual eligible".
• Most dual eligibles receive their prescription drugs from Medicare Part D
• Dual eligibles can switch drug plans at any time during the year (must be done prior to the 15^th of the month in order to take effect the following month).
• The term Disabled Adult Child (DAC) is used by the Social Security system for adults with developmental disabilities.
• A person with a disability who has Medicaid and is eligible to begin receiving Medicare must be coded in the computer as a DAC , as this allows for an override of the usual Social Security rules, which will otherwise disqualify a person with a disability from receiving Medicaid (due to a larger Social Security Disability benefit).
• Low Income Subsidy (LIS): Medicare beneficiaries with limited income and resources may qualify for extra help, in the form of a Low Income Subsidy (LIS), to pay for prescription drug costs. 
• Dual eligibles are automatically eligible for the LIS
• Drug plans that have a $0.00 monthly premium with full LIS are referred to as benchmark plans

For Medicare Part D problems, the CMS regional office in New York can be contacted directly:

Email: PartDComplaints_RO2@cms.hhs.gov
Phone: 1-212-616-2222 (please note this is a toll call)

New Jersey's Medicaid Wrap-around

NJ Medicaid currently provides a wrap-around that covers (wraps around) the following for dual eligibles*:

1. Co-payments for prescriptions covered under Medicare Part D
2. A six-day emergency supply of drugs that are not on a plan's formulary
3. Many drugs that are not on formulary and are denied when a physician requests an exception

 *Please note: The New Jersey Medicaid wrap-around is not guaranteed and is particularly vulnerable to cuts during any fiscal crisis in the state and/or the nation.

This is what you need to know about New Jersey's wrap-around process:

• If a pharmacist informs a NJ dual eligible that his/her medication is not on his/her drug plan's formulary, the dual eligible should receive at least a temporary (6-day) supply of their prescription medication, paid for by the wrap-around. There is no charge to the dual eligible for this temporary supply of medication.
• If a pharmacist informs a NJ dual eligible (or the caregiver) that their medication is not on the formulary of their PDP, the dual eligible (or the pharmacist or caregiver) should quickly contact the physician, who should either (1) change the prescription to a drug that is on the formulary, or (2) request an exception from the drug plan.
• If the physician requests an exception that is denied by the PDP, the medically necessary medication may 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, and NJ Medicaid will only pay for 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 urgent). This is why it is 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, call one of the following:

• Medicaid Hotline: 1-800-356-1561
• Medicare Hotline: 1-800-MEDICARE
• Antonietta Balci, a Medicare Part D specialist who works for NJ Medicaid: 609-588-2732

Model Exception and Prior Authorization Request Form

The American Medical Association (AMA) and America's Health Insurance Plans (AHIP), in conjunction with CMS, developed a standardized Exception Request 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. 

*Please note: the PDP may require different, drug-specific forms for "biotech or other specialty drugs"

Helpful suggestions for contacting the Medicare Hotline

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 automated message or say "agent" to get to connect 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 available 24 hours a day, 7 days a week). 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, which 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 quickly by saying the word "agent").
• 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 the dual eligible, the legal guardian, or the representative payee. 
• The agent will ask some identifying questions to ensure that the caller is legitimate (e.g., dual eligible's date of birth, social security number, home address, 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.
• Please note: this process may be useful for dual eligibles who can speak for themselves or whose rep. payee can make the call. However, it may not work for a dual eligible who has limited verbal ability if the representative payee is not available and a staff person is attempting to obtain the information. 

Additional Information for dual eligibles and their caregivers:

Emergency Numbers for Dual Eligibles

Critical Information Brochure for NJ's Dual Eligibles: English

Critical Information Brochure for NJﾒs Dual Eligibles: Spanish

Communicating with the CMS Regional Office: Handling of Urgent Problems

Enrollment Letter and Q&A: English

Enrollment Letter and Q&A: Spanish

Medicare Prescription Drug Coverage Personal Information Worksheet for Dual Eligibles

Q&A on Medicare Fraud and Abuse

Fact Sheet on obtaining the date of first entitlement for Medicare

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Last updated: January, 2009