Medicare Part D FAQs
For Medicaid Recipients, including Dual Eligibles
Q: Have Wisconsin Medicaid's current policies and procedures for drug coverage
for dual eligibles changed as a result of the implementation of Medicare Part D?
A: Yes, drug coverage policies and procedures for dual eligibles have changed as
result of the implementation of Medicare Part D. Wisconsin Medicaid now covers
only those drugs excluded from Medicare Part D coverage (i.e., barbiturates,
benzodiazepine, and 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). Dual eligibles
should present their current Wisconsin Medicaid identification card (e.g., a
Forward card) to a pharmacy provider who will then submit a claim to Wisconsin
Medicaid for Medicare Part D excluded drugs.
Q: For dual eligibles enrolled in a Medicaid HMO, have Wisconsin Medicaid's
current policies and procedures for drug coverage changed as a result of the
implementation of Medicare Part D?
A: Effective for dates of service 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,
benzodiazepine, and 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.
Q: Do institutionalized dual eligibles enrolled in Medicare Part D have
copayment requirements? (Institutionalized dual eligibles are recipients who are
eligible for coverage from Medicare [either Medicare Part A, Part B, or both]
and Wisconsin Medicaid who reside in nursing homes.)
A: Institutionalized dual eligibles are exempt from Medicare Part D copayment
requirements.
Q: Have Wisconsin Medicaid's current policies and procedures changed for drug
coverage for recipients who are not dual eligibles as a result of the
implementation of Medicare Part D?
A: No, drug coverage policies and procedures have not changed for Wisconsin
Medicaid recipients who are not dual eligibles as a result of the implementation
of Medicare Part D. Recipients who are not dual eligibles should continue to
present a Medicaid identification card to a pharmacy provider when having a
prescription filled.
Q: What if a dual eligible has not been assigned a Medicare Part D Prescription
Drug Plan (PDP) (i.e., there is no information available about the recipient
through the Medicare E1 query or by calling the Medicare Pharmacy Hotline at
[866] 835-7595 or Medicare at [800] MEDICARE)?
A: To determine the specific PDP in which a dual eligible is enrolled, providers
should first check with that 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. The E1 query will return one of the
following to the provider:
- Medicare Part D enrollment information (i.e., the plan's Bank Identification
Number [BIN], processor control number [PCN], group identification, and the
participant's cardholder identification). If Medicare Part D enrollment
information is returned, the pharmacist should submit a claim to that PDP.
- A toll-free telephone number for a Medicare Part D PDP. If a toll-free
telephone number is returned, the pharmacist should call the PDP to obtain
billing information.
If the E1 query does not return Medicare Part D plan information or the PDP does
not have a recipient's enrollment information, providers may call the Medicare
Pharmacy Hotline, which is available 24 hours a day, seven days a week.
Point-of-Sale Contractor
If a pharmacy provider verifies that a recipient is a dual eligible who has not
been assigned a Medicare Part D PDP, the provider should submit a claim to the
Point-of-Sale (POS) contractor, Wellpoint (Anthem). To submit the claim, the
provider should enter the available recipient information, such as name,
Medicare identification number, Medicaid identification number, Social Security
number, date of birth, address, and telephone number, and submit the claim to
the unique BIN and PCN account indicated on the POS contractor's payer sheet.
(For Wellpoint [Anthem], the BIN is 610575 and the PCN is CMSDUAL01.)
After receiving a paid claim response from the POS contractor, the pharmacy
provider may dispense up to a 14-day supply of a drug to the recipient and then
collect the appropriate copayment amount ($1 for generic or preferred drugs and
$3 for any other drug). The POS contractor will then begin enrollment of the
recipient into that Medicare Part D PDP.
For More Information
For more information about Medicare Part D claims submission, providers may
visit the NDCHealth Web site at
medifacd.ndchealth.com/. Providers may call Wellpoint's Pharmacy Helpdesk at (800) 662-0210 for additional assistance.
Q: How do providers receive reimbursement for inhalation drugs?
A: For Wisconsin Medicaid fee-for-service recipients, inhalation drugs will
continue to be covered by Wisconsin Medicaid. For dual eligibles, these drugs
will continue to be covered by Medicare Part B. However, for dual eligible
nursing home residents, inhalation drugs will be covered by the Medicare Part D
Prescription Drug Program (PDP).
For SeniorCare Participants
Q: Will SeniorCare participants who were automatically enrolled in a Medicare
Part D PDP incur a Medicare Part D premium during 2006?
A: SeniorCare participants who were automatically enrolled in a Medicare Part D
PDP will not be required to pay a Medicare Part D premium during 2006. The
Centers for Medicare and Medicaid Services, the federal agency responsible for
Medicare, will not attempt to recover any costs from SeniorCare participants who
were automatically enrolled in a Medicare Part D PDP.
Q: How do SeniorCare participants who were automatically enrolled in a Medicare
Part D PDP disenroll from the PDP?
A: To disenroll from a PDP, SeniorCare participants may directly contact the PDP
in which they were automatically enrolled, or participants may call Medicare at
(800) MEDICARE.
Q: How will SeniorCare coordinate benefits with Medicare Part D?
A: For Wisconsin SeniorCare participants enrolled in a Medicare Part D PDP,
providers are encouraged to submit claims to Medicare Part D first for SeniorCare participants who are also enrolled in a Medicare Part D PDP. If the
pharmacy provider cannot reasonably determine the PDP in which a participant is
enrolled (e.g., the participant does not present a Medicare Part D PDP card and
the PDP cannot be identified through Medicare's eligibility system), the
provider may submit the claim to SeniorCare without first obtaining a Medicare
Part D payment determination. This is a temporary measure designed to assist in
the transition to Medicare Part D. Providers should continue to refer to
Wisconsin Medicaid and BadgerCare Updates to learn when the transition period
has ended.
Q: Do institutionalized SeniorCare participants enrolled in Medicare Part D have
copayment requirements?
A: Since they are not enrolled in Wisconsin Medicaid and, therefore, are not
dual eligibles, institutionalized SeniorCare participants who are enrolled in
Medicare Part D are not exempt from Medicare Part D cost-sharing requirements
(e.g., copayments, deductibles).
Pharmacy Information
Q: Will Wisconsin Medicaid cover Medicare Part D PDP non-formulary drugs?
A: Wisconsin Medicaid recently announced temporary measures about coverage of
Medicare Part D PDP non-formulary drugs for dual eligibles when a PDP is not
honoring its transition process. These measures are described in the January 2006
Update (2006-03), titled "Temporary Procedures for Submitting Claims for
Dual Eligibles." The enddate for this temporary measure will be announced in a
future Update.
Q: What happens when Wisconsin Medicaid denies a claim because a drug is covered
by a Medicare Part D PDP?
A: Providers will receive explanation of benefits code "545," which states
"Beneficiary is eligible for Medicare Part D. This is a Medicare Part D drug not
covered by Medicaid for this beneficiary. Submit claim to beneficiary's Part D
Plan for payment."
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