In spite of all best efforts to identify and auto-enroll dual eligible individuals prior to the effective date of their Medicare Part D eligibility, some individuals may show up at pharmacies before they have auto-enrolled. For this reason CMS developed a process for a point-of-sale solution to ensure full dual-eligible individuals experience no coverage gap. CMS established a process whereby beneficiaries who present a pharmacy with evidence of both Medicaid and Medicare eligibility but do not have evidence of current enrollment in a Part D plan, can have the claim for their medication submitted to a single account for payment. The recipient can leave the pharmacy with a prescription, and a CMS contractor will follow up immediately to validate eligibility and facilitate enrollment into a Part D plan.

In order for this process to operate effectively, there must be a uniform and straightforward set of instructions that pharmacists follow no matter which plan networks they are in or where they are located. This requires a single account administered by one payer. In addition, a national plan that offers a basic plan for a premium at or below the regional low-income premium subsidy amount in every Prescription Drug Plan (PDP) region will be able to both process the initial prescription (generally at in-network rates) and enroll the beneficiary in a matter of days, thus eliminating any gap in coverage. Therefore, CMS has contracted with Wellpoint, an approved national PDP, to manage a single national account for payment of prescription drug claims for the very limited number of dual eligible beneficiaries who have not yet been auto-enrolled into a Part D plan at the time they present a prescription to a pharmacy. Further details on our Point-of-Sale (POS) Facilitated Enrollment process are provided in the following questions and answers.

This is a special type of facilitated enrollment that permits a full-benefit, dual-eligible individual who presents a prescription at the pharmacy, and who the pharmacist discovers has not yet been auto-enrolled a plan, to obtain a prescription at the subsidized copayment amount before leaving the pharmacy and to be rapidly enrolled into a PDP with a fully subsidized premium.

This special facilitated enrollment applies only to full-benefit, dual-eligible individuals, and not to the deemed (SLMB, QMB, QI-1) population or Medicare-only beneficiaries.

In spite of all efforts to identify and auto-enroll dual-eligible individuals prior to the effective date of their Medicare Part D eligibility, a limited number of individuals may present prescriptions at pharmacies before they are auto-enrolled. For instance, this could occur when an individual becomes newly qualified for Medicaid between the dates on which the state creates the monthly files for CMS.

This process will be operational by January 1, 2006 to catch any potential dual-eligible individuals missed in auto-enrollment.

The process of facilitated enrollment will start at the pharmacy with the pharmacist billing a special Wellpoint account. That begins a series of steps described below.

CMS contracted with two vendors to coordinate and expedite the facilitated enrollment process. The first vendor is Wellpoint, a national PDP (“POS Contractor”) that can provide point-of-sale access and offer plans below the low-income premium subsidy amount in every region. The second vendor is Z-Tech, a CMS contractor (“Enrollment Contractor”) that can expedite validation of dual-eligibility and return independently verified information on the individual’s eligibility for enrollment to the national PDP.

It is important to understand that since there is no fee-for-service component of Part D, the only way to process a claim at point-of-sale is through a Part D plan that has an account set up in advance to match the beneficiary and accept the claim. This POS contractor will maintain a pre-established service account to handle the initial processing of the claims and will clear transactions from this account as soon as the enrollment contractor returns validated information. Claim transactions for verified dual-eligible recipients will clear by retroactively enrolling the dual-eligible individual into the plan and reprocessing the initial claim with the correct member record. Claim transactions for individuals who are determined ineligible (no Medicaid and/or Medicare status) will be reversed to the pharmacy for collection. Note that this provides an incentive for the pharmacy to bill the special account as accurately as possible, a control that our pharmacy industry contacts endorse.

Selected pharmacy industry contacts from both chain and independent pharmacies have commented on this process and agree it is a reasonable approach to addressing the potential gap in coverage. They are most concerned with continuing to serve their customers returning to the store after January 1, and believe this process allows them to do so in the most seamless way possible for the recipient. They have suggested that allowing a pharmacy (particularly an out-of-network pharmacy) to limit the initial dispensing at its discretion would also limit pharmacy liability for false positives.

• A full dual-eligible recipient presents a prescription at the pharmacy with either a Medicaid card or a previous history of Medicaid billing in the pharmacy system patient profile.
• Pharmacist bills Medicaid and the claim is denied.
• Pharmacist requests photo identification and checks for Part D enrollment by submitting an E1 query to the TROOP facilitator. If the E1 query returns Part D plan enrollment information, the pharmacist bills the appropriate plan. There is no need to proceed with the Point-Of-Sale Facilitated Enrollment.
• Pharmacist also checks for A/B Medicare eligibility by:
  - Requesting to see a Medicare card; or
  - Calling 1-800-MEDICARE; or
  - Requesting to see the Medicare Summary Notice (MSN).
• If the pharmacist cannot identify the appropriate plan to bill but is able to verify both Medicaid eligibility (Step 1) and Medicare eligibility (Step 4), proceed with the Point-Of-Sale Facilitated Enrollment.
• Pharmacist enters the claim into the automated pharmacy system, including available data on the beneficiary as to name and ID number (HICN, Medicaid ID number or SSN), as well as date of birth, address, and phone number. Pharmacies routinely collect this information at point-of-sale anyway in accordance with state pharmacy laws.
• Pharmacist submits the claim to the single pre-established service account indicated on the POS contractors payer sheet, and in response to the paid claim response, provides the prescription drug to the beneficiary at the $1/$3 cost sharing level.
• The POS contractor processes the claim as paid (network pharmacies) or as a captured response (out-of-network pharmacy).
• If the pharmacy is out-of-network then special instructions are sent to the pharmacy to establish the mechanism for payment.
• The POS contractor sends a daily file to the enrollment contractor on the recipient data submitted with these paid claims.
• The enrollment contractor uses this information to validate dual-eligibility via access to CMS and state systems and returns validation of eligibility or ineligibility to the POS contractor.
• If the individual is verified to have dual-eligibility and has not been enrolled in a Part D plan, the POS contractor immediately submits an enrollment transaction on behalf of the dual-eligible recipient to enroll him/her to a POS contractor plan retroactively. Normal rules for dual-eligibles opting out of the plan would apply.
• If the beneficiary is a full dual-eligible and already enrolled in a Part D plan, the claim is reversed and the pharmacy is the appropriate Part D plan.
• If the beneficiary is Medicaid only, the claim is reversed and the pharmacy bills the appropriate state agency.
• If the person claiming dual status is found to be Medicare eligible only, the enrollment contractor notifies the recipient by letter that s/he is ineligible for the facilitated enrollment service but may enroll in a Part D plan under normal enrollment rules, and the claim is reversed to the pharmacy for collection.

• Wellpoint will provide the details of this process on its industry “payer sheet” – the mechanism utilized in the pharmacy industry to communicate billing processes among pharmacies, switches and processors (payers). Pharmacy IT staff and software vendors pick up payer sheets, and systems are coded to automate as much as possible. The Wellpoint payer sheet is available through the TrOOP facilitator, NDC Health, Web site.
• CMS is producing a CD-ROM for distribution to bench pharmacists that will address these instructions, plus the use of the E1 (eligibility) query, coordination of benefits, and other issues of concern to pharmacists. It will be distributed to our pharmacy contacts and be available upon request from CMS. Part D plans are encouraged to advertise the CD-ROM or make copies available to their network contacts. Additional information/training can be obtained at the Centers for Medicare & Medicaid Services (CMS) Web site.
• This process will be spotlighted on a number of regularly scheduled conference calls with NCPDP members, Part D plans and Regional Office Pharmacy Outreach staff as soon as all procurement-sensitive arrangements have been resolved.

• Emergency Drug Benefit Claim Submission To End June 29, 2007
• California Emergency Drug Benefit – January 2007 Updates (PDF format - 51 KB)
• California Emergency Drug Benefit – November 2006 Changes (updated November 3, 2006)
• California Emergency Drug Benefit – Instructions to Providers (updated January 5, 2007)
• Medi-Cal and MMA – Medicare Part D (Prescription Drug) Program (PDF format - 402 KB) –
       Presentation from the September 2005 Medi-Cal Now seminar
• Medi-Cal Notice of Action and Reduction of Benefits
• Medicare Part D Dual-Eligible Facilitated Enrollment FAQs (links to CMS instructions and payer sheet)
• Medicare Part D Prior Authorization and Exceptions Request Form
• Medicare Part D FAQs
• Medicare Part D Impact on Ancillary Costs
• Medicare Part D Included/Excluded Drugs – CMS Clarifications (PDF format - 46 KB)
• MMA Part D Carrier Cross-Reference Table Updated (PDF format - 14 KB)

• Center for Medicare & Medicaid Services Web site
• CMS Point-Of-Service (POS) Facilitated Enrollment Process in Four Steps for Pharmacists
• Medicare Part D POS Facilitated Enrollment Payer Sheet
• Medicare Prescription Drug Benefit Information – CDHS Web site
• Or call 1-800-MEDICARE.