Transcript Equitable Adjustment: Responding to Scope Creep, Special

Legal issues for Medicaid Plans
Under Part D in Serving Dual
Eligibles
MEDICAID HEALTH PLANS OF AMERICA
Medicare Part D: The First 100 Days, Washington, DC
April 19, 2006
Adam J. Falk, Esq.
FELDESMAN TUCKER LEIFER FIDELL LLP
Dual Eligibles
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7.5 million low-income seniors and people with
disabilities who are enrolled in both Medicare and
Medicaid
Dual eligibles rely on Medicaid to pay Medicare
premiums and cost-sharing and to cover benefits
not covered by Medicare
As of January 1, 2006, prescription drug coverage
for dual eligibles has shifted from Medicaid to
Medicare Part D.
Feldesman Tucker Leifer Fidell LLP
Transitioning to Medicare Drug
Coverage
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Over 6 million dual eligibles were randomly
assigned to Part D plans offering coverage
below the benchmark premium.
Medicare fully subsidizes the Part D premium
Medicare subsidizes Part D co-payments so that
co-payment amounts do not exceed $1 or $3 for
generics and $2 or $5 for brand name drugs
Feldesman Tucker Leifer Fidell LLP
Transition Issues
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Beneficiaries charged incorrect cost-sharing
amounts
Pharmacies lacked billing information to bill
Part D plans
Beneficiaries not aware they were assigned
to a Part D plan
Beneficiary having difficulty contacting plans
for help
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Delivery Combinations for Dual
Eligibles after January 1, 2006
Medicaid
Medicare
Fee-for Service + PDP
Managed Care Plan (MA-PD)
Fee-for-Service + PDP
Managed Care Plan X (MA-PD)
Managed Care Plan Y (MA-PD)
Fee-for-Service
Fee-for-Service
Managed Care
Managed Care Plan X
Managed Care Plan Z
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Coordination between Part D and
Medicaid
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Claims data on Part D drugs may no longer
be available to Medicaid plan
No ability to assure appropriate drug
utilization
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PDPs are not at risk for hospitalization and has no
incentive to cover / manage medications
PDP must provide Medication Therapy
Management (MTM) for targeted beneficiaries.
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What if dual- eligible is not enrolled in
a Part D plan?
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State prohibited from drawing federal
Medicaid funds (FFP) for Medicare drugs for
dual-eligibles even if not enrolled in a
Medicare plan.
State Medicaid capitation payment will not
include costs for Part D drugs for dualeligibles.
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Part D Stop Gap Coverage
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In light of transition issues, a number of states agreed to reimburse
pharmacy providers for the cost of prescriptions for who were not
able to receive drugs.
 Typically limited benefit, e.g., one claim for 30-day supply
 Some limited to All Medicare beneficiaries vs. LIS-eligible
beneficiaries
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CMS announced that it will reimburse states for Part D drug costs
provided through March 8, 2006 within four weeks of receipt of clean
claims.
 Demonstration authority under section 402 of the Social Security
Amendments of 1967, as amended.
 Includes dual-eligibles and low-income subsidy (LIS) entitled
individuals
 Includes reimbursement for Part D drugs as well as certain
administrative costs
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Myth: Medicare Pays for All Drugs for
Dual Eligibles
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Fact: Medicaid continues to pay cost-sharing for Medicare Part B
covered drugs.
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Fact: Medicaid will continue to pay for a few categories of drugs
not covered by Medicare (to the extent drugs are covered under
state Medicaid program):
 Nonprescription drugs (OTC meds)
 Barbiturates
 Benzodiazepines
 Drugs for anorexia, weight loss, and weight gain.
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Fact: Medicaid cannot pay for a drug whose class is covered by
Medicare but not included a particular Part D plan’s formulary.
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Processing Drug Claims for Dual
Eligibles
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Claims for Part D drugs should be rejected
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(Rejected to bill Part D plan)
Claims for non-Part D drugs covered by
Medicaid should be either
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Paid (if costs included in capitation payment) or
Submitted to State FFS
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Options for payment of Part D CoPays for dual eligibles
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State wrap-around (no FFP)
State Pharmaceutical Assistance Program
(SPAP)
Medicaid HMO wrap-around (self-funded)
Pharmacy waivers
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Waiver of Part D Co-Payments
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Under new anti-kickback safe harbor established by
the MMA, pharmacies may waive applicable copayment
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For dual-eligibles, pharmacy may routinely waive or reduce
cost-sharing as long as done in an unadvertised manner
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For non-dual eligibles, pharmacy may waive or reduce
cost-sharing on a non-routine basis after determining
that a beneficiary is in financial need or after failing to
collect the cost-sharing portion, provided it is also
done in an unadvertised manner
Feldesman Tucker Leifer Fidell LLP
TrOOP
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Medicare excluded drugs do not count
towards TrOOP
Non-formulary drugs do not count towards
TrOOP
Payments made on behalf of recipients by
another federal program (e.g., Medicaid) do
not count towards TrOOP.
Feldesman Tucker Leifer Fidell LLP
Adam J. Falk, Esq.
Feldesman Tucker Leifer Fidell LLP
(202) 466-8960
[email protected]
Feldesman Tucker Leifer Fidell LLP