The Centers for Medicare & Medicaid Services signed contracts with national providers to prevent drug coverage gaps for people eligible for both Medicaid and Medicare who were not enrolled automatically in a Medicare drug plan by Jan. 1, 2006, CMS Administrator Mark B. McClellan announced Dec. 1. Dual eligibles are those 6 million low-income Medicaid beneficiaries who also qualify for the new Medicare prescription drug coverage. As of Jan. 1, 2006, these individuals will no longer receive their medications under states' Medicaid programs, but qualify for special Medicare drug plans with low or no premiums and small copayments. CMS is automatically enrolling the dual eligibles in prescription drug plans. The contracts to handle pharmacy claims are just one part of CMS's comprehensive effort to ensure a smooth transition for the dual-eligible population, McClellan said in a press conference. Drug plans are taking many additional steps to smooth transition for those automatically enrolled, including sending out special enrollment packages with their new ID cards before the new year, he said. CMS has awarded Z-Tech Corp., based in Rockville, Md., a $1.6 million contract to serve as the enrollment contractor for unenrolled individuals, CMS spokesman Gary Karr told BNA. This contract will expedite validation of dual eligibility and return independently verified information on eligibility for enrollment to the prescription drug plans. Karr also said that WellPoint, a national prescription drug plan, will provide point-of-sale coverage of prescriptions for dual eligibles who will be retroactively enrolled in a WellPoint plan after the eligibility has been confirmed by Z-Tech. The contract with WellPoint does not have a specific dollar amount attached to it, Karr said. WellPoint is based in Indianapolis. The transition of this population from one government program to another has caused concern among policymakers and advocates. Sen. Max Baucus (D-Mont.), ranking Democrat on the Senate Finance Committee, has criticized CMS's plan to move the dual eligibles, saying it comes up short. Citing preliminary findings from a study he ordered from the Government Accountability Office, Baucus said in mid-November that the transition relies too heavily on the voluntary efforts of states, drug plan sponsors, and pharmacists. In addition, the Medicare Rights Center and other groups filed a lawsuit recently in a federal court seeking to protect this population's coverage. Under the new contracts, for any dual eligible who has not been automatically enrolled in a prescription drug plan by CMS, this single national provider will ensure coverage at the point of sale--the pharmacy, CMS said. From the first day of the plan, if a beneficiary comes to a pharmacy with evidence of both Medicaid and Medicare eligibility, but no enrollment in a Part D plan, the beneficiary will still be able to leave with his or her prescriptions filled. "We do not expect many dually-eligible beneficiaries to fall into this category because we have done such extensive work in advance on the transition," McClellan said. CMS has required each Medicare prescription drug plan to establish a "transition process" for all new enrollees. For instance, plans are required to provide a means of educating patients and medical providers about the plans' formularies and the procedures for filing requests for "exceptions" for off-formulary drugs. Plans must provide a response to expedited exception requests within 24 hours and the rest within 72 hours, he said. To ease transition for dual eligibles, many of whom live in nursing homes, all Part D plans are required to provide in-network coverage to all enrollees who live in long-term care facilities, he said. McClellan said the Part D plan formularies (lists of covered drugs) are "very broad" and "robust," reflecting the best practices and most current treatment standards, and covering about 80 percent of medications taken by senior citizens. The plans must cover at least two drugs in each approved category and class. Furthermore, he pointed out that the plans must cover "all or substantially all" medications in some key categories, including antidepressants, antipsychotics, anticonvulsants, anticancer drugs, immunosuppressants, and antiretrovirals to treat HIV/AIDS. However, prescription medication taken by some dual eligibles may not be covered by their new plan. McClellan said this is most likely to happen for drugs to treat less-serious conditions, such as hay fever. To ease the transition, McClellan said plans are required to honor current prescriptions, even those off the formulary, for at least 30 days to give the beneficiaries an opportunity to explore their options with their doctors. Futhermore, dual eligibles have the option of switching to a new plan at any time. Also to help smooth transition for the dual eligibles, CMS has helped develop an automated Part D eligibility query and process to coordinate benefits. It will work with pharmacies' existing computer systems, McClellan said, and identify beneficiaries' plan billing information, even for those who do not present a plan ID card or are even aware that they have been auto-enrolled in a Part D plan. The query system also will ease coordination of benefits with other coverage beneficiaries may have. More information about the drug coverage of dual eligibles is at the CMS website.
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