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Decrease Text SizeEnrolling New Duals into Part D Plans – GAO Report
A report from the U.S. Government Accountability Office (GAO), Medicare Part D: Challenges in Enrolling New Dual-Eligible Beneficiaries (1.25Mb PDF file), contains useful information about how CMS auto-enrolls new dual-eligible beneficiaries (those enrolled in Medicare and full Medicaid), also called “duals,” into Part D plans and how their transition to Medicare Part D drug coverage actually works.
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As a refresher, people become duals by one of two routes:
- About one-third of new duals first had Medicare and later became eligible for Medicaid.
- About two-thirds had Medicaid first and then aged into Medicare – either by celebrating their 65th birthday or by virtue of having of having received Social Security disability benefits for 25 months.
The GAO report explains many procedures and issues you have probably encountered in your work with new duals. We thought you would find the following aspects of the GAO study relevant to your work:
- Random Assignment of New Duals to Part D Plans
Most of you have worked with duals who were auto-enrolled in plans that did not cover all, or even a majority of their prescribed medications. The GAO report highlights the efforts of some states that have state pharmacy assistance programs (SPAPs). Most notably, Maine and New Jersey reassigned duals to plans based upon comparing their Medicaid-covered prescription usage with Part D plan formulary data. This strategy may be of interest to those of you in other states with SPAPs.
- Processing Time to Auto-Enroll New Duals
The process of auto-enrolling new duals into Part D plans generally takes a minimum of five weeks if all systems work properly. The GAO describes the many information systems that must exchange data to bring about enrollment and to reflect Extra Help/Low-Income Subsidy (LIS) status in the pharmacy system.
The GAO found that some duals paid out-of-pocket to obtain their drugs during that interim period and may be owed reimbursements by their plans. You may know some of these duals, many of whom experienced financial hardship when they paid for the drugs that should have been covered by their plans. The GAO reported that the right to reimbursement is not well-known among duals.
- New Enrollee Transition Prescription Fills
When Medicare beneficiaries join a new plan, they are generally able to obtain at least one refill of prescriptions that are not on the new plan’s formulary or are subject to prior approval by the plan. GAO noted that duals generally do not know what it means to receive a transition fill; they may not be getting, or paying attention to the transition notice (29Kb Word file) that plans must send to their members who receive a transition fill. If new duals do not understand that a transition fill is temporary, they risk losing access to their medication.
- And There's Much More...
There is much more information in the GAO report, including detailed descriptions of auto-assignment processes and automated communications systems that pharmacies can use to access a person’s LIS and Part D plan enrollment status.
- What does this mean for benefits counselors?
The GAO report includes several findings that you can use in your everyday work:
- Random Assignment of New Duals to Part D Plans
Many new duals will continue to need help comparing the formulary of the plan in which they are auto-enrolled with their prescription medications. The data presented in the GAO report suggests that many duals continue to need help evaluating the formularies of other plans with premiums low enough to be fully covered by the LIS.
They also may need counseling on the pros and cons of joining a plan with a higher premium, even though they might need to pay some part of that premium out-of-pocket, in order to get coverage of more of their prescriptions with fewer plan restrictions.
- Processing Time to Auto-Enroll New Duals
You can help duals in your community who may have paid out-of-pocket or borrowed money to pay for prescription fills when their pharmacy lacked access to accurate information about their plan enrollment and/or LIS status.
While CMS has not yet designated a specific procedure for reimbursement requests, you can help duals submit requests that the plan issue a coverage determination for reimbursement of their out-of-pocket payments.
Since no specific procedure has been established by CMS for plans to accept such reimbursement requests, you can ask your clients’ plans if they have a streamlined protocol for processing reimbursement requests. Alternatively, these can be submitted to Part D plans as requests for coverage determinations.
You can find helpful information about Part D coverage determinations here — scroll down to Exceptions and Appeals.
- New Enrollee Transition Prescription Fills
You can educate duals and your community about transition policies and the options open to duals to get their prescribed medications that are not on plan formularies or to which access is limited by prior approval and other utilization management requirements. You can also advocate with plans for consistent and timely mailing of transition notices to duals who obtain transition fills.
