Thursday, March 23, 2006

Medicare to resume paying for dual eligibles on April 1

The Texas Health and Human Services Commission has announced that the state will no longer be reimbursed by Medicare for the cost of prescriptions for dual eligible clients under Medicare Part D effective April 1.

Specifically, for dates of service after March 31, 2006, the Medicaid system will reject outpatient prescription drug claims that are eligible for coverage under Medicare Part D for dual eligible clients. Medicaid will continue to pay for certain drugs that are in the categories of drugs excluded from coverage under Medicare Part D, including benzodiazepines, barbiturates, some non-legend drugs, some vitamins and minerals, some products used in the treatment of a cough or cold and some appetite stimulants. Prescription claims for Medicare covered drugs will be denied with an error code 41 - "Medicare is Primary is Primary Payer. Medicaid is Secondary."

While this suggests that Medicare now thinks that it has the system for dual eligibles under control, April 1 (no irony intended, I'm sure, but there it is) will be another transition date that holds the potential for more snafus.

HHSC has alerted Texas pharmacies, which have been caught in the middle of the need to help their clients and the bureaucratic foul ups of the Part D transition debacle, to several scenarios that may yet present themselves with instructions on what to do:
  • What if a dual eligible beneficiary (Medicare and Medicaid) presents at the pharmacy and does not know what plan into which he or she has been auto enrolled?
  • What if a dual eligible beneficiary who has been auto enrolled presents at a pharmacy with a plan acknowledgement letter indicating that the beneficiary has switched plans?
  • What if a dual eligible beneficiary who has been auto enrolled presents at a pharmacy without a plan acknowledgement letter, but indicates that he or she has switched plans?
  • What if a beneficiary presents at a pharmacy with a Medicaid card and appears to be Medicare eligible, but the pharmacist cannot determine that the beneficiary has been auto-enrolled in any plan?
Let's hope that April Fool's Day is full of good clean fun this year and not the trainwreck that we saw on New Year's Day.

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