Getting Poor/Old People Drug Coverage: Part II

Yesterday, I mentioned that low-income individuals on Medicare can also qualify for Medicaid and, as full-beneift dual eligible beneficiaries, they have significantly lower cost sharing than the typical Part D beneficiary.  How does CMS identify these individuals?

For currently beneficiaries on Medicaid who ‘age’ into Medicare, this process is fairly easy.  CMS can auto-enroll these individuals prospectively into Medicare drug plans.  The “Medicaid–>Medicare” population makes up 25% of all new full benefit dual eligible (FBDE) individuals each month.

For individuals who are currently Medicare eligible who become poor, this process is more complex.  Oftentimes, these beneficiaries only receive the more generous coverage months after they are initially eligible.  Thus, CMS must retroactively reimburse these beneficiares for the additional incurred expense.

To eliminate the lag in identifciation of these new FBDE individuals, CMS has taken a number of steps such as: increasing the rate at which state data are reviewed and eligibility and provided additional guidance to states on how to backdate FBDE coverage already in Medicare Prescription Drug Plans (PDP).

In addition, a new demonstration aims to make the transition between regular beneficiary and dual-eligible state more transparent.  The Limited Income Newly Eligible Transition (LI NET) “will cover all claims during retroactive auto-enrollment periods for full-benefit dual eligible (FBDE) beneficiaries and Supplemental Security Income (SSI)-only beneficiaries plus immediate need claims for all Low- Income Subsidy (LIS)-eligible beneficiaries.”  Humana won this contract for 2 years.  In particular, the LI NET will do the following:

• Cover approximately 450,000 FBDE and SSI-only beneficiaries each year who, under the current process, would have been randomly enrolled into a Low-Income Subsidy (LIS) PDP with retroactive coverage.
• Cover another approximately 60,000 LIS-eligible beneficiaries each year who need immediate coverage at the Point of Sale (POS) because they present with no Part D plan enrollment.
• Provide a centralized point of contact for all retroactive coverage issues including confirming the dual/LIS eligibility of all individuals, informing beneficiaries through outreach efforts of their right to retroactive claims reimbursement, and paying for appropriate claims.
• For POS beneficiaries, provide up to two Eligibility Reviews for those who had rejected claims or for those who had claims paid but were later determined to be ineligible. If either happened in error, the Eligibility Review performed by Humana allows the beneficiary to show proof of eligibility for LI NET.
• Provide reimbursement to beneficiaries for Part D covered drugs if paid out-of-pocket during LI NET eligible periods.

As an individual’s life circumstances change, it is important to make sure these beneficaries receive the benefits for which they are eligible.