Report 007-2006 STATE RELEASE SPECIAL MEDICARE DRUG BULLETIN

CDCAN
CALIFORNIA DISABILITY COMMUNITY ACTION NETWORK
DISABILITY RIGHTS NEWS REPORT
#007-2006 January 12, 2006 Thursday late evening
Connecting people with disabilities & seniors to rights and unified action
1225 8th Street Suite 480 - Sacramento, CA 95814 916/446-0013 Fax: 916/446-0026
Marty Omoto - director email: martyomoto@rcip.com website: www.cdcan.us

MEDICARE PART D DRUG PLAN CRISIS
* STATE RELEASES BULLETIN FOR PHARMACIES REGARDING EMERGENCY DRUG PLAN
* DEPT OF HEALTH SERVICES SAYS EMERGENCY PROCESS "SHOULD WORK"
* EMERGENCY COVERAGE ORDERED BY GOV. SCHWARZENEGGER
* LEGISLATURE WILL MOVE ON EXTENDING EMERGENCY DRUG COVERAGE
* SPECIAL CDCAN TOWNHALL TELEMEETING ON ISSUE SET FOR 1/19 THU AT 1 PM

SACRAMENTO - The California Department of Health Services released a special bulletin late Thursday evening (Jan 12) containing instructions to pharmacies and other providers on how a person with disabilities or a senior who is eligible for both Medicare and Medi-Cal can obtain drugs from the temporary emergency drug coverage ordered by Gov. Arnold Schwarzenegger earlier today. Participation in the emergency coverage is limited to those dual eligibles who cannot get their medications from the new Medicare drug program. The special bulletin explains to pharmacies and and other providers how they can obtain emergency Medi-Cal coverage to cover their costs of providing the medications under the Governor's emergency coverage and also restrictions. The bulletin is printed below and also available at the State of California's Medi-Cal (Medicaid) site at www.medi-cal.ca.gov or from the California Disability Community Action Network (CDCAN) website at www.cdcan.us See CDCAN Disability RIghts Report #006-2006 for additional details on this issue.

The swift action by the Department of Health Services follows an executive order issued by Gov. Arnold Schwarzenegger late Thursday afternoon (Jan 12) that immediately authorized a 5 day temporary emergency drug coverage to nearly 1 million Californians who are are eligible for both Medi-Cal and Medicare but are unable to obtain needed medications. The Governor's emergency order was in response to a growing crisis caused by increasing turmoil, confusion and delays over the implementation of the new federal Medicare prescription drug plan across the state. Dual eligibles include persons with developmental and other disabilities and seniors. Nearly every part of the State has reported major confusion and even panic over the problems in people with disabilities and seniors unable to get needed medications under the new drug plan. Democratic legislative leaders from both houses pledged to move quickly on emergency legislation to appropriate state funds to extend the emergency coverage another 10 days or longer. [NOTE: There will be a special CDCAN Disability Rights Townhall Telemeeting on this issue scheduled next week on Thursday, January 19 at 1:00 PM to 2:45 PM for persons who have questions or concerns about the Medicare Part D program or about the Governor's order for a temporary emergency drug program. ]

The temporary emergency drug coverage applies to those persons with disabilities and seniors who are dually eligible for both Medicare and Medi-Cal and also met one of the following criteria:
A pharmacy must certify that it was either unable to obtain necessary information from Medicare to submit a claim; OR it's claim was incorrectly denied; OR that the Medi-Cal/Medicare eligible recipient's deductible or co-payment was higher than the $1 to $5 amount set by Medicare (see below for details and process)

Stan Rosenstein who heads the Medical Care Services for the Department of Health Services which oversees the state's Medi-Cal (or Medicaid) program, said that the existing Medi-Cal pharmacies "should know how to use this process as it uses processes that have been used in the Medi-Cal program for years. Reports from pharmacies that have tested the process indicate it works."

Rosenstein urged community groups and providers to pass the word about the process for the emergency drug coverage saying that "given the very short time that is available in this emergency action, we need to get the word out quickly [to people who are dual eligible for Medicare and Medi-Cal]"

Advocates Praise Emergency Action - Harshly Criticize Federal Government Implementation
Advocates for persons with disabilities and seniors generally praised the action by the Governor and legislative leaders and harshly criticized the federal government implementation of the new drug plan proposed by the Bush Administration and passed last year by Congress. .
On January 1, 2006, the Medicare Modernization Act took effect, with the federal government taking over responsibility for prescription drug coverage for the nearly one million Californians dually eligible for Medi-Cal and Medicare. The transition of these individuals to federal Medicare plans in just one day resulted in an error rate of 20% according to information from the Department of Health Services, resulting in nearly 200,000 persons with disabilities and seniors who are not receiving the medications they need. In addition, dual eligibles and pharmacies facing problems and attempting to clarify eligibility and Medicare drug plan enrollment have experienced long waits while trying to obtain information from Medicare's overloaded phone lines.

WHAT THE GOVERNOR ORDERED
The Governor's ordered the following action:
* The Department of Health Services, which oversee the Medi-Cal program, will "immediately" implement a 5 day emergency program to pay for prescription drugs for the dually eligible Medi-Cal and Medicare recipients who have been unable to obtain those medications through their Medicare Part D coverage.
* The Legislature is scheduled to move quickly next week in passing emergency legislation - which the Governor promised he would sign - that would extend the coverage for an additional 10 days.
* The Governor's order indicated that, starting today (Jan 12), the State "will be the payer of last resort" regarding people who are dually eligible for Medi-Cal and Medicare and were unable to obtain their needed prescription drugs.
* The Governor will request reimbursement from the federal government to the State for the cost of this emergency program.

WHAT PEOPLE WITH DISABILITIES AND SENIORS SHOULD DO
If a person with disabilities or seniors who are eligible for both Medicare and Medi-Cal and are having difficulties in obtaining their medications, the Department of Health Services advises that the following be done:
* People should bring their Medi-Cal card Medicare drug card or Medicare acknowledgement letter to the pharmacy to assist them in billing.
* People who are concerned about the availability of this emergency drug coverage at their pharmacy can bring a copy of the January 12 provider bulletin with them and show pharmacy. (see below or go print copy from www.medi-cal.ca.gov or from the CDCAN website at www.cdcan.us
* People can also tell the pharmacy to go to the State of California Medi-Cal website themselves to read the bulletin that describes the emergency drug coverage and billing.
* People should note that this emergency drug coverage process is being put in place to provide prescription drugs in those cases where the pharmacy is not able to obtain payment, eligibility, or the correct co-payment amount from the Medicare program.

DEPARTMENT OF HEALTH SERVICES PROVIDER BULLETIN FOR PHARMACIES
TO IMPLEMENT GOVERNOR'S EMERGENCY DRUG COVERAGE FOR DUAL ELIGIBLES
This provider bulletin was released by the Department of Health Services late Thursday evening, January 12, 2006 for distribution to all Medi-Cal providers, pharmacies, advocacy organizations and others:

In order to ensure that people who are dually eligible for Medicare and Medi-Cal continue to get needed medications during the transition of drug coverage from Medi-Cal to Medicare, Governor Arnold Schwarzenegger directed the California Department of Health Services (CDHS) to immediately begin temporarily covering the cost of medications for those who are unable to obtain them from Medicare. This program began the evening of January 12, 2006, and will continue on an emergency basis for five days and provide emergency payment for prescription drugs to beneficiaries who are dually eligible for Medi-Cal and Medicare if the pharmacy has tried and been unable to obtain reimbursement from Medicare.

This process is only available in cases where the pharmacy has attempted to obtain Medicare billing information and has attempted to bill Medicare for this drug. To receive reimbursement, a pharmacy must certify that certain conditions have been met.

This program will provide payment for emergency supplies of drugs for these dual eligibles that are unable to obtain their drugs under the Medicare program. This emergency program is available to full-benefit, dual eligible beneficiaries previously covered either by fee-for-service Medi-Cal or by a Medi-Cal managed care plan.

Billing Criteria
These emergency drug benefits are available only when one of the following has occurred:
• The pharmacy has submitted a claim for the provision of drug benefits to the full-benefit dual eligible beneficiary’s Medicare Drug Plan and the claim has been denied payment for reasons other than processing errors or omissions made by the pharmacy, lack of medical necessity or health or safety reasons. Note: Pharmacy billing of inappropriate quantities (for example, billing greater than a 30-day supply when only a 30-day supply is allowed under the Medicare Drug Plan) is considered a pharmacy
processing error.
• The pharmacy is unable to submit a claim solely due to the unavailability of complete or accurate Medicare Drug Plan enrollment information from the full-benefit dual eligible beneficiary’s Medicare Drug Plan, the Centers for Medicare and Medicaid Services (CMS) or entities under contract with the CMS to provide enrollment information, including having attempted to obtain eligibility information from the Medicare E1 eligibility system.
• The Medicare Drug Plan provides information that the full-benefit dual eligible beneficiary’s deductible or co-payment amount is higher than the $1 to $5 co-payment amounts that are established by Medicare for fullbenefit dual eligible beneficiaries.

Process
The Department has developed a process that allows pharmacy providers to submit this emergency claim electronically. The pharmacy provider need only indicate that the Code I requirements of the claim have been met. By doing so, the pharmacy provider is certifying that all of the following conditions are met:
(A) One of the three situations noted above has occurred.
(B) The pharmacist provides or dispenses the drug as a critical service.
(C) The pharmacist has not previously provided or dispensed, nor has knowledge that another pharmacist has provided or dispensed, a quantity of the same drug that is sufficient to cover the period of time for which the prescription is being dispensed.
(D) The date of service (date the prescription is dispensed) is from January 12 through 17 inclusive. For claims where Medicare has set the co-payment amount to be greater than that for dual eligibles ($1 to $5), the pharmacy should submit an “other coverage” claim. The amount billed field should contain the pharmacy’s usual and customary charge for the prescription and the other coverage paid field should contain the amount that the Medicare program is reimbursing the pharmacy plus the normal co-payment due for the patient. This is the same method used for all Medi-Cal claims for beneficiaries who have other coverage.

CODE I (RESTRICTIONS):
Code I drugs typically require prior authorization in accordance with Section 51003, unless used under the conditions specified in the Contract Drugs List. In this instance, the Code I is being used outside the Contract Drugs List. The emergency claims discussed in this notice are subject to the prescription documentation requirements in CCR, Title 22, Section 51476(c).
To submit a Code 1:
• Paper: Place a “Y” in the “CODE I MET” box on the 30-1 claim form (Indicates the Code I restriction for the drug was met.) The provider should also note in the “Specific Details/Remarks” section of the form that the claim is for “Medicare Part D drugs”. Electronic: Place a “7=Medically Necessary” in the Submission Clarification Code (42Ø-DK). (Code indicating that the pharmacist is clarifying the submission.)

This use of the Code I indicator shall only be used for Medicare Part D emergency drug benefit claiming. Other emergency claims for Medi-Cal beneficiaries shall continue using the paper claim process.

If the claim meets the three conditions above and is denied by the Medi-Cal claims processing system due to the beneficiary not meeting their monthly share of cost, the pharmacy must submit the claim on paper via a 30-1 claim form as indicated above. The “Remarks” section must be filled in as noted.

Please note that Med-Cal is the payor of last resort available only when information to be paid by Medicare cannot be obtained and this prescription is a one-time emergency supply. It is critical that providers work with beneficiaries, the Medicare drug plan and Medicare to resolve these problems to allow for the proper administration of the Medicare drug program on an ongoing basis.

Providers who misuse this program are subject to state audit and recovery.
This program is temporary and will continue until 11:59 p.m. on January 17, 2006. Governor Arnold Schwarzenegger is seeking to obtain emergency legislation to extend this program.

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The California Disability Community Action Network is a non-partisan link to thousands of Californians with developmental and other disabilities, people with traumatic brain and other injures, seniors and their families, community organizations and providers, direct care and other workers, and other advocates. These action alerts and news reports is for all of them. If you would like to get on this distribution (and conversely, get off of it) please send an email with that request to: martyomoto@rcip.com OR sign up via the NEW CDCAN website at www.cdcan.us Sharing information is part of our organizing effort. Please feel free to forward or copy this (attribution is nice). We're all in this together!