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Illinois Cares Rx What Happens Behind the Scenes.

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Presentation on theme: "Illinois Cares Rx What Happens Behind the Scenes."— Presentation transcript:

1 Illinois Cares Rx What Happens Behind the Scenes

2 1) Overview of ICRx Behind the Scenes Processes 2) Detail specific to current issues 3) Non-ICRx Issues - Duals in MA plans - LIS/MSP application process

3 Behind the Scenes

4 Coordination of Benefits Invisible to Pharmacy and Member ICRx pays coordinating plans a per member/per month payment for each ICRx member to administer the ICRx benefit Pharmacy only has to submit claim to one payer and both the Part D benefit and ICRx wrap-around benefit are applied in one transaction No secondary transaction needed by pharmacy

5 Coordination is Key Requires coordination between: Two state government agencies--Department on Aging (DoA) and Department of Healthcare and Family Services (HFS) HFS and Federal CMS (oversees Medicare) HFS and multiple Medicare Part D plans

6 Key Components Maintaining and sharing Eligibility Files – DOA/HFS; HFS/Medicare; HFS/Part D Plans Part D Plan Payment Claims Processing Reconciliation to Cost for Drugs

7 ICRx Eligibility Determination The basics Eligibility determined by Department on Aging DoA sends HFS weekly file - contains adds/changes Average approx 600 new members each week HFS loads file to database that houses eligibility information for ICRx and all HFS Medical Programs Information included: Drug Coverage or Rebate, Medicare status, Basic or Plus, HIV/AIDS status

8 Monthly file sent to Medicare to obtain Medicare eligibility, plan enrollment, and LIS information Response file used to update Medicare status, Part D plan, and LIS information Timing issues can result in lag in updates Send file on 20 th Response received around 10 th Medicare Eligibility/Enrollment KEY to providing benefits

9 Monthly file to each coordinating plan including all common members Two monthly files to each plan informing them of eligibility CHANGES for common members Plans return response files with discrepancies Response files manually worked and responses sent to plans Timing issues cause discrepancies Eligibility Sharing with Plans Key to timely wrap benefits

10 Monthly payment files created using eligibility database Payment includes Premium and Drug PM/PM Payment amount determined by: Basic/Plus, HIV/AIDS, LIS, plan enrollment Payment created and processed; payment member- level detail provided to plans Timing creates discrepancies Plan Payment Key to Keeping Plans Happy ;-) and Providing Services!!!

11 Claims Processing Part D Plans process pharmacy claims, and then send detail to CMSs contractor – PDE file Part D plans send ICRx PDE record for each ICRx member A single event may be submitted to CMS multiple times HFS processes claims - determines payable or non-payable; adjusts prior duplicate claims Claims are loaded to and stored in our Data Warehouse

12 Reconciliation to Cost ICRx is a full reconciliation to cost SPAP Plans arent at risk and dont profitICRx reconciles to actual cost of drug claims PDE claims used to reconcile with Part D plans HFS works with plans to come to agreement on total reconciliation amount due for plan year HFS adjusts future payments to account for reconciliation amount

13 ICRx Current Issues

14 Different income limits/household sizes for ICRx Plus vs. Basic One income limit to get into ICRx program (3 household sizes) If Medicare eligible, then member is Plus (eff ) If non-Medicare, and member meets additional ICRx Plus requirements, then eligible for ICRx Plus; if not, they are Basic ICRx Plus eligibility determined using two household sizes ICRx Income Eligibility How it works

15 Aging must transmit member to HFS before 23 rd for eligibility first of next month In December, in order to re-establish coverage for 2010, apps must be processed by ICRx Eligibility Timing Processing/Effective Dates

16 > 73,000 ICRx members have not reapplied (up about 15,000 from previous years) > 60,000 Medicare eligible >20,000 full LIS Disproportionate number of re-applicants did not request pharmaceutical assistance – 26,000 Failure to Reapply for ICRx

17 Apply for LIS!!!!!!! LIS eligibility retroactive to beginning of month of application ICRx internet application available January 13 Must apply very quickly in order to be re- established for February ICRx Lapse in Coverage What should they do

18 Eligibility Overlap Issues Individuals may be eligible for multiple programs: ICRx and LIS ICRx and Medicaid/Medicare (Dual Eligibles) ICRx and Medicare Savings Plans (MSPs)

19 Duals and MSPs have full LIS Most Duals do not need ICRx--they are fully subsidized by the federal Medicare program Drugs for full LIS members, including duals/MSPs always fully subsidized by Medicare Premium not fully subsidized if: Basic plan over benchmark Enhanced plan when portion of premium is Enhanced ICRx and Duals/MSPs

20 ICRx pays portion of premium not subsidized by Medicare for Duals/MSPs/Other full LIS Regardless of Part D plan: Medicaid (not ICRx) covers Part D excluded drugs for Duals ICRx covers excluded drugs for ICRx members, including MSPs and other full LIS Encourage enrollment into $0 premium plan How Duals/MSPs Benefit from ICRx

21 United members mapped to AARP Medicare Rx Saver effective 1/1/2010 Mapping took place with an 11/01/09 application date ANOC showed the Saver plan Any members identified as ICRx between now and the end of the year will be mapped to Saver ICRx Mapping Processes United/AARP

22 Humana members mapped to Humana Value plan effective 1/1/2010 ANOC showed the Enhanced plan Mapping did not take place on 11/15 as planned Mapping expected to happen 12/9/09 Any other members Humana identifies as ICRx between now and end of the year will be mapped ICRx Mapping Processes Humana

23 Members must be in a coordinating plan in order to receive benefits If a member learns that they have not been placed in a coordinating plan, they should contact the coordinating plan immediately to enroll Plans have until 1/11/10 to enroll with a 1/1/10 effective date ICRx Mapping Processes What happens if a member is missed?

24 Processes are plan-specific Plans determine process in accordance with CMS guidelines Some plans will automatically map members to a like plan Some plans will have notified members that they must choose a new plan for 2010 MA Plans No Longer Operating in 2010

25 Effective 1/1/2010, all Medicare-eligible members receive Plus benefits Members do not need to take any action to receive this benefit If eligible for ICRx, and for Medicare, member will be provided Plus benefits ICRx Basic Switch to Plus Medicare-eligibles only

26 Non-Medicare members still divided between Basic and Plus Increase in income limit, but otherwise, no real change in the program for non-Medicare members Non-Medicare Members

27 Non-ICRx Issues

28 Medicaid is required to cover Part A and Part B cost-sharing for Duals enrolled in MA plans A dual or QMB is NEVER required to pay cost- sharing or deductible Under federal law, a provider cannot bill a dual/QMB for cost-sharing Duals Enrolled in Medicare Advantage Plans

29 Medicaid is requesting CMS approval to change this method PFFS plans will bill HFS for copays/cost-sharing for dual eligibles/QMBs Providers will still seek payment of copays/cost- sharing from MA plans for non-PFFS plans, i.e., HMOs and PPOs Duals Enrolled in Medicare Advantage Plans

30 Any LIS App submitted after 1/1/2010 will be sent to the state to determine MSP eligibility SSA sends file to state Extra Help denials for Assets, no Medicare, not in US are automatically denied Extra Help approvals and denials for Income/failure to comply still considered LIS Applications and MSP Programs

31 Potential approvals sent 267MSP next day after receipt of file from SSA Explains how the state got their application Explains what client needs to do to complete application process Most information from SSA LIS application isnt usable LIS income/asset rules are different from Illinois MSP income/asset rules, e.g., under MSP, certain income is disregarded LIS Applications and MSP Programs

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