Improved Help for Low-Income Beneficiaries at the Pharmacy Counter

from My Medicare Community, NCOA The Best Available Evidence Rule and the Point of Sale enrollment processes have been improved to enable your low-income Medicare clients to more easily and quickly get their prescriptions filled, even when their Extra Help or plan enrollment status is not yet within the CMS or plan electronic systems. The settlement of a lawsuit brought on behalf of people with Extra Help led to these improvements. Read more about the Situ case settlement here and view a summary of the settlement here. Here’s what this means to your clients. Best Available Evidence The Best Available Evidence Rule is used to establish Extra Help status so that your clients do not pay more than the applicable Extra Help co-payment to fill their prescriptions. For more on the Best Available Evidence Rule, click here. CMS has reminded plans that adherence to the Best Available Evidence Rule is mandatory. Plans must accept documentary proof of Extra Help status when submitted by your client, a family member, your client’s pharmacist, advocate or representative. Once plans have the Best Available Evidence, they must immediately make your clients’ on-formulary prescriptions available and see to it that the pharmacy charges no more than the applicable Extra Help co-payment. View the CMS Memorandum here. If your client gets Extra Help because of having both Medicare and Medicaid, but cannot document her Extra Help status, your client’s plan must provide CM S with detailed information, and the CMS Regional Offices will work through state Medicaid offices to verify her Extra Help status. Plans must have in place methods for your client, you, or the pharmacist to submit Best Available Evidence, or to request help from CMS in getting that proof through your state Medicaid agency. Part D plans are required to ascertain whether or not your client will run out of their medication within less than three days. If your client is about to run out, CMS will expedite its efforts to verify Extra Help status. When CM S notifies the plan of your client’s Extra Help status, the plan must tell your client within one business day and must make sure your client can fill her prescriptions paying no more than the applicable Extra Help co-payments. Auto-Enrollment of New Extra Help Beneficiaries and Point of Sale Enrollment Auto-enrollment of people who become dually entitled to Medicare and Medicaid has been speeded up. For the basics on Point of Sale enrollment, click here. States are now able to submit their data files to CMS more frequently than once monthly and once received by CMS, these new cases are now processed within one business day of receipt. CMS and WellPoint, the Point of Sale enrollment contractor, are working to educate pharmacies and encourage them to make better use of the Point of Sale enrollment option when it is needed. The Point of Sale enrollment procedure remains optional for pharmacists, however, pharmacists have not been held at financial risk if it turns out that somebody who was enrolled using POS was in a plan, or was not actually eligible for Extra Help for the past year. WellPoint ascertains whoever should have paid for any prescriptions filled using POS, whether that is another Part D plan, or an individual who turns out not to have been eligible for Extra Help. Since the first step in the Point of Sale procedure is often using the Best Available Evidence Rule to verify Extra Help status, the improvements to both processes should make it easier for you to assist your Extra Help clients to promptly fill their prescriptions.