East Central Illinois Area Agency on Aging

Mission Statement

"We are dedicated to enhancing the quality of life for Older Americans and their families by providing information about and access to a variety of services in their community in the 16 counties of East Central Illinois"


East Central Illinois
Area Agency on Aging, Inc.


1003 Maple Hill Road
Bloomington, IL 61705-9327
Telephone Numbers:

309-829-2065
Seniors may call toll free:
1-800-888-4456
Fax: 309-829-6021

Email: JLIB_HTML_CLOAKING

 

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Make Medicare Work Coalition Alert

MMAI & Medicare Part D Plan Letters

3/24/2014

The Medicare Medicaid Financial Alignment Initiative (MMAI) is a managed care program that will change the way that individuals with full Medicare (Medicare Parts A & B) and full Medicaid (Medicaid without a spenddown) will receive their healthcare benefits.  For information about what MMAI is and how it will affect people with Medicare and Medicaid, please view our MMAI recorded webinar, fact sheet, and timeline on this page: http://www.ageoptions.org/services-and-programs_MMW-MedicaidandManagedCare.html

Voluntary enrollment into MMAI has begun for individuals in the Chicago area and central Illinois who are not receiving Long Term Care Services and Supports (LTSS).  These individuals are currently receiving letters from the Client Enrollment Broker explaining the MMAI program and their health plan options.  Individuals can respond to the letter by contacting the Client Enrollment Broker to choose a Primary Care Provider and health plan of their choice or by opting out of the program.  The letters state that if they do not respond by May 31st 2014, they will be automatically enrolled into an MMAI health plan during the Passive Enrollment period beginning in June 2014.    

To prepare for the Passive Enrollment period, the Department of Healthcare and Family Services (HFS) and the Centers for Medicare and Medicaid Services (CMS)have already been working with the MMAI Client Enrollment Broker to assign individuals to plans. However, because the passive enrollments will not occur until later in the year, affected individuals will not receive their MMAI passive enrollment letters until 60 days before their passive enrollment is scheduled to occur.  

However, because these plan assignments already exist in the HFS and CMS data systems, and Medicare Part D (prescription drug) plans have to follow federal guidelines about how and when to notify consumers about changes in coverage,Medicare Part D Plans have already been sending out letters to individuals who are eligible for the MMAI program. These letters confirm the individuals’ disenrollment from their Medicare Part D plans. The letters state an effective disenrollment date from the individual’s Medicare Part D plan. This disenrollment date is the date that the individual will be passively enrolled into an MMAI plan, unless s/he opts out of MMAI for medical services. Unfortunately, many consumers are receiving these letters now, before they receive their passive enrollment letter about MMAI.

Please be aware that even though these letters state an effective disenrollment date from their Part D plan, beneficiaries will still have the option to contact the Client Enrollment Broker to choose an MMAI health plan or opt out of the program for their medical services.  If an individual opts out of the MMAI program before their passive enrollment date (which in most cases will be May 31, 2014, for individuals currently receiving these letters), they will keep their current Medicare coverage and will not be disenrolled from their Medicare Part D plan. If for some reason an individual is mistakenly disenrolled from their Medicare Part D plan during the Passive Enrollment process, individuals can use theLimited Income NET program for temporary Medicare Part D coverage until they are re-enrolled in their Medicare Part D plan.

 

Please note:  Individuals receiving long term services and supports (LTSS), including individuals who live in long term care facilities and individuals who receive home and community-based waiver services, have separate MMAI enrollment periods beginning in July 2014. Please see the Make Medicare Work Coalition MMAI Implementation Timeline for information about these enrollment periods. For more information about the MMAI program, please visit the MMW Coalition website for fact sheets and a recorded webinar: http://www.ageoptions.org/services-and-programs_MMW-MedicaidandManagedCare.html

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3-24-2014

Dear Marci,
I went to the pharmacy to pick up a new medication, but my pharmacist told me that there is a coverage restriction on the drug I need. What is a coverage restriction? 
- Chuck (Staten Island, NY)

 

Dear Chuck,

A coverage restriction is a restriction that Medicare prescription drug plans, also known as Medicare Part D plans, place on certain covered drugs to limit use of that drug. In other words, while a drug may be covered by your Part D plan, your plan may not pay for a drug you need if it has a coverage restriction.There are three types of coverage restrictions:

  • Prior authorization is a type of coverage restriction that requires you to get prior approval from your Part D plan, before your plan will pay for a prescription drug you need. 
  • Quantity limit is a type of coverage restriction that limits you to a specific amount of a medication over a certain period of time. For example, let’s say your Part D plan only covers 30 pills of Drug X in one month. If you need 40 pills of Drug X in one month, your prescription may be denied. As such, you will most likely need to request that your Part D plan make an exception to its quantity limit.
     
  • Step therapy is a type of coverage restriction that requires you to try other, usually cheaper drugs that treat your medical condition, before your Part D plan will cover the drug that your doctor originally prescribed.

If you aren’t able to get your drug at the pharmacy because of a coverage restriction, your pharmacist should give you a notice called, Medicare Prescription Drug Coverage and Your Rights. This is a notice that explains the process of contacting your Part D plan to request coverage of the drug you need. Keep in mind that this is simply an educational notice that provides you with very general information on the first steps of the appeal process. This is important to know, since you generally need to receive a written, formal denial notice from your Part D plan in order to begin the appeal process. The Medicare Prescription Drug Coverage and Your Rights notice is not a formal denial from your Part D plan. However, you should still read it for your own understanding.
 
If your pharmacist told you that your Medicare Part D plan will not cover the drug you need, you should contact your Part D plan directly. It’s helpful to do this to find out why your Part D plan is not covering the drug you need. If the denial is due to an administrative error, it should be resolved when you call your plan. Remember to write down the date and time in which you call, the name of the Part D plan agent you speak to, and the outcome of your call.
 
If your Part D plan is denying your drug because of a coverage restriction, contact your doctor to see if another unrestricted drug covered by your Part D plan will work for you. If your doctor cannot prescribe a different drug, ask your doctor to help you file a formal request to your Part D plan so that you can try to override the coverage restriction. This is called filing an exception request. It may also be referred to as filing a coverage determination. Filing an exception request with your Part D plan is the step you take before you can file an appeal. While plans generally provide decisions on exception requests within 72 hours, you and your doctor can request that your plan make a quicker (expedited) decision to your exception request in 24 hours if your health would be harmed by waiting the standard 72 hours for a plan decision.
 
Keep in mind that you can file an exception request with your Medicare Part D plan, whether you get Medicare Part D through a stand-alone Part D plan that works with Original Medicare or through a Medicare Advantage Prescription Drug Plan, also known as a Medicare private health plan that provides you with Medicare prescription drug coverage. Click here to use a Medicare Interactive Roadmap that can help walk you through the necessary steps of appealing a Part D drug denial. Click here for information on the Medicare Part D appeal process.
-Marci

 

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Making Sense of Medicare Resources

Click on the links to find helpful information:

 

Making Sense of Medicare 

Medicare Care Finder 

Reading Your Medicare Summary Notice