Program Overview 2335ALL0216

Transcription

1 Program Overview 1

2 Medicare s Limited Income Newly Eligible Transition Program (LI NET) Program overview LI NET is a demonstration program created by the Centers for Medicare & Medicaid Services (CMS) to eliminate gaps in prescription drug coverage for low-income Medicare beneficiaries It is designed for those who qualify for Low Income Subsidy (LIS), sometimes called Extra Help who have not yet enrolled in a Medicare Part D prescription drug plan LI NET coverage is temporary and lasts for a short time (usually about two months) If a Medicare Part D plan is not chosen during this time, CMS will automatically enroll the beneficiary into a benchmark plan -A 2

3 Eligibility: Who can use LI NET? Eligibility for LI NET: Eligible for Medicare Eligible for Medicaid or low-income subsidy (LIS) assistance Have no other prescription coverage, including: Part D plan coverage Retiree drug subsidy (RDS) plan VA coverage Part C plans (limited number of plans allow concurrent Part D plan enrollment) Have a permanent address in the 50 states or Washington, D.C. Have not opted out of auto-enrollment 3

4 Eligibility: Who can use LI NET? All LIS eligibles can use LI NET, including: Full-benefit dual-eligible beneficiaries Those with Medicare and Medicaid benefits Partial-benefit dual-eligible beneficiaries Those who qualify for Medicare Savings Programs (MSPs) but not Medicaid SSI-only beneficiaries Those with Medicare who receive Supplemental Security Income (SSI) but do not have Medicaid LIS applicants Those who have been awarded Low-Income Subsidy through the Social Security Administration (SSA) or their state 4

5 EligEligibility: Who can use LI NET? Eligibility: More Information More information: ibility: Who can use LI NET? Individuals with questions about income requirements in their states should go to: Listing of state Medicaid and chip eligibility requirements National Council on Aging (NCOA) sponsored site which gives state and community based benefit information 5

6 Enrollment: How are beneficiaries enrolled in LI NET? Enrollment methods: Auto-enrollments by CMS CMS enrolls most beneficiaries based on Medicare eligibility, LIS eligibility and lack of Part D plan coverage Point-of-sale (POS) enrollment Beneficiary is enrolled at the pharmacy counter through claim submission to LI NET by pharmacy personnel Submission of receipt for previous out-of-pocket expenses Beneficiaries who have experienced out-of-pocket expenses while eligible for LI NET may apply for reimbursement This often occurs while appealing an eligibility ruling Eligibility for LI NET is retroactive to date of application 6

7 Benefit Design LI NET Benefit Design Medicare Part D covered drugs LI NET will cover any prescription covered by Medicare Part D No pharmacy network restriction All pharmacies can submit a claim to LI NET Not specific to: Pharmacy chain (e.g., Walgreens or CVS) Health care organization network (e.g., Humana or United) Standard safety/abuse edits There are standard safety edits, such as refill too soon LI NET has payment edits in place that require a Prior Authorization for a covered diagnosis and reasonability of cost 7

8 Beneficiary Experience What the beneficiary should expect: Beneficiaries will receive a welcome letter including the following: Information on LI NET coverage Enrollment dates Medicare Part D enrollment information Next steps How to obtain more information If the beneficiary chooses a plan, LI NET coverage will discontinue when the new coverage begins If the beneficiary does not choose a plan, CMS will enroll the individual into a Medicare Part D Plan Enrollment in LI NET usually lasts about two months 8

9 Beneficiary Reimbursement Reimbursement process: Beneficiaries can submit claims for out-of-pocket expenses in the following manner: Complete reimbursement form included in the beneficiary welcome letter Form is also available online: Include all pharmacy receipts Mail to: Medicare s Limited Income NET Program P.O. Box Lexington, KY

10 For More Information LI NET Advocacy Line: State Health Insurance Assistance Program (SHIPs) Caseworkers Ombudsmen and other advocates LI NET Help Desk: Beneficiaries Pharmacies Online: LI NET program brochure Four Steps for Pharmacy Providers Frequently asked questions Free continuing education for pharmacists and pharmacy techs LI NET mailbox: CMS mailbox: 10

11 Thank You Thank you for your interest in Medicare s Limited Income NET Program LI NET Advocacy line: