MEDICARE RX BYTES

Official Update From CMS

NCPA has been working closely with the Centers for Medicare & Medicaid Services (CMS) to address the concerns we are hearing from community pharmacists around the country. We wanted to update you on recent steps that CMS says it has taken to identify and address the most pertinent implementation problems:

• E1 response times.  Response time delays were addressed early last week and are now consistently running at a response time of less than a second with no time outs.  With much more data in the system, "hit rates" are also improving as data augmentation continues.  NDCHealth will be sending additional guidance to pharmacies to assist in improving efficiencies in pharmacy match rates. 
  
  
• CMS pharmacist help line.  CMS expanded the dedicated pharmacist help line for eligibility and enrollment information (866-835-7595) so it is open 24 hours a day, 7 days a week.  Also, CMS increased staffing of the pharmacist help line from 150 to 4,500 customer service representatives to handle the additional volume and reduce wait time.  Using this line, pharmacists can determine plan enrollment status as well as whether the beneficiary is eligible for a limited income subsidy (LIS) copay.  Remember, when calling this number, you must provide the beneficiary's name, Medicare ID, date of birth, and address.  Unlike the E1, the HICN alone will not be sufficient on this line.
  
  
• Overloaded plan help desks.  CMS and prescription drug plans worked to improve processes for addressing beneficiary issues at the pharmacy.  In addition to improving pharmacy phone support, CMS addressed plan submission of enrollment data, processing of acknowledgement letters and more.
  
  
• Transition policies.  Late last week, CMS contacted plans regarding miscommunications about plan transition policies.  CMS stressed that delaying or denying the filling of initial prescriptions for new enrollees at the point-of-sale is not consistent with the intent of CMS’ transition policy.  For easy reference, the attached charts (PDP and MA) contain basic information to outline plan transition policies.
  
  
• Establishing a process for emergency situations.  If for some reason a person at a pharmacy cannot obtain their life-saving prescriptions and the current alternative methods do not allow the person to obtain their drugs, the person and/or their pharmacist can call 800-Medicare.  The customer service representative will refer the case to a special regional office inbox.  The regional office staff will have special access to the plans in order to obtain the necessary information, such as an override to the billing system that will enable the person to obtain their prescriptions.
  
  
• Pharmacy open door forum.  Last week pharmacists were loud and clear that they have specific questions to ask and precious little time to spend on a phone call with CMS.  Therefore, CMS has scheduled an open door forum for pharmacists with live Q&A on Tuesday, Jan. 10, at 2 p.m. EST.  To participate, please call 800-837-1935 and reference conference ID 3100979.  A recording of this call will be available beginning 2 hours after the call has ended.  To access the recording, call 800-642-1687 and use the same conference ID (3100979).

NCPA continues to communicate daily with CMS about issues impacting community pharmacists. If you are experiencing trouble in your pharmacies, here are important contacts to remember

Dual Eligibles

1. Use the eligibility (E1) check – as mentioned above, this time-saving eligibility check is now running smoothly and should provide all the information needed to process Medicare Part D prescriptions

2. If nothing is available in the E1 system, call the CMS Pharmacist Help Line (866-835-7595) 24 hours a day, 7 days a week

3. If you can document that the patient is eligible for Medicaid and Medicare and is not in a Part D plan, you can adjudicate claims through one national contractor, WellPoint.  More information is provided here.

Experiencing trouble with a Part D plan or Medicare in general?
1. Contact your local CMS representative – they may be able to provide quick, regional solutions to recurring Part D problems

2. Contact your local, state and federal legislators – let them know all of your efforts to provide excellent customer service to your Medicare patients through this difficult start-up time.