This Wisconsin Medicaid and BadgerCare Update describes the standard procedures for providers who submit claims to Wisconsin Medicaid for dual eligibles (i.e., recipients who are eligible for coverage from Medicare [either Medicare Part A, Part B, or both] and Wisconsin Medicaid). Information in this Update applies to situations in which the Medicare Part D Prescription Drug Program (PDP) in which a dual eligible is enrolled can be clearly identified and the provider can successfully submit a claim to the PDP. For situations in which a PDP cannot be identified or a claim cannot be successfully submitted for a dual eligible, refer to the January 2006 Update (2006-03), titled "Temporary Procedures for Submitting Claims for Dual Eligibles."

Eligibility Verification

On January 1, 2006, the Centers for Medicare and Medicaid Services (CMS) implemented the Medicare Part D outpatient drug benefit for Medicare beneficiaries.

Providers may verify Medicare Part D enrollment for a dual eligible through the Medicaid Eligibility Verification System (EVS) or the Automated Voice Response (AVR) system. The EVS or AVR will state only that a dual eligible is in a Medicare Part D PDP. It will not indicate the name of the specific PDP.

To determine the specific PDP in which a dual eligible is enrolled, providers should first check with the individual. If the individual does not know the PDP in which he or she is enrolled, providers may send an online eligibility transaction through Medicare's E1 query. If the E1 transaction does not return Medicare Part D plan information, providers may call the Medicare Pharmacy Hotline, available 24 hours a day, seven days a week, at (866) 835-7595. Providers may also call Wisconsin Medicaid's Provider Services at (800) 947-9627 or (608) 221-9883 to determine the PDP in which a dual eligible is enrolled.

Submitting Claims to Wisconsin Medicaid

For dates of service (DOS) on and after January 1, 2006, Wisconsin Medicaid will deny claims for Medicare Part D-covered drugs for dual eligibles. Claims for Medicare Part D-covered drugs for dual eligibles must be submitted to the appropriate Medicare Part D PDP.

Providers may continue to submit claims to Wisconsin Medicaid for drugs covered by Wisconsin Medicaid but excluded from coverage by Medicare Part D. Medicare Part D-excluded drugs include barbiturates, benzodiazepines, over-the-counter [OTC] drugs, agents that are used for the symptomatic relief of cough and cold, prescription vitamins and mineral products (except prenatal vitamins and fluoride), and weight loss agents.

Prior authorization requests for drugs covered by Medicare Part D will be denied because these drugs will be covered by a Medicare Part D PDP.

State-Contracted Managed Care Organizations or HMOs

Effective for DOS on and after January 1, 2006, reimbursement for drugs will no longer be included in the capitation payment for dual eligibles enrolled in any state-contracted managed care organizations (MCOs) or HMOs.

Drug claims for dual eligibles enrolled in state-contracted MCOs or HMOs should be handled in the same way as claims for dual eligibles who receive drug coverage from Wisconsin Medicaid fee-for-service. Claims for barbiturates, benzodiazepines, OTC drugs, agents that are used for the symptomatic relief of cough and cold, prescription vitamins and mineral products (except prenatal vitamins and fluoride), and weight loss agents may be submitted to Wisconsin Medicaid fee-for-service for dual-eligible MCO or HMO enrollees.

Drug claims for recipients who are not dual eligibles should continue to be submitted to the state-contracted MCO or HMO.

Special Handling Requests

On January 27, 2006, system changes will be completed to allow providers to submit claims through the pharmacy Point-of-Sale (POS) system for all drugs excluded from coverage by Medicare Part D. Claims for many of these drugs, including claims for barbiturates, benzodiazepines, and OTC drugs, may be submitted through the POS system. Providers that are unable to submit claims through the POS system for excluded drugs may submit claims on paper by completing the Noncompound Drug Claim form, HCF 13072 (fillable PDF, 75 KB) (Rev. 06/03), and the Pharmacy Special Handling Request form, HCF 13074 (fillable PDF, 26 KB) (Rev. 06/03). Providers should mail the completed Noncompound Drug Claim form and the Pharmacy Special Handling Request form to the address indicated on the Pharmacy Special Handling Request form.

Wisconsin Medicaid Recipients Who Are Not Dual Eligible

Wisconsin Medicaid recipients who are not dual eligibles (i.e., recipients who are not eligible for coverage from Medicare) will continue to receive drug coverage from Wisconsin Medicaid. Pharmacy providers should continue to use recipients' Medicaid identification cards to submit drug claims to Wisconsin Medicaid. Possession of a Medicaid identification card does not guarantee eligibility.

For More Information

For more information about Medicare Part D, refer to the CMS Web site at www.cms.hhs.gov/. Providers may also contact Provider Services at (800) 947-9627 or (608) 221-9883 with questions about submitting claims for dual eligibles.

Providers may refer dual eligibles to the following resources:

• The Medicare program at (800) MEDICARE ([800] 633-4227) or www.medicare.gov/.
• The Wisconsin Prescription Drug Helpline at (866) 456-8211 for Medicare beneficiaries age 60 and older with questions about Medicare Part D. This helpline is sponsored by the Coalition of Wisconsin Aging Groups' Elder Law Center.
• The Disability Drug Benefit Helpline at (800) 926-4862 for persons under age 60 who receive Medicare coverage as a result of a disability. This helpline is sponsored by the Wisconsin Coalition for Advocacy.
• A county/tribal social or human services agency if the dual eligible is age 60 or older and would like to speak to a benefit specialist for the elderly.