Interested individuals should contact their state Medicaid agency for more information and applications. Some people automatically qualify for the LIS and do not have to apply for the program, regardless of their income or asset levels. Calculation of income and assets follow SSI rules. Individuals deemed eligible for the LIS between January 1 and June 30 are deemed eligible for the rest of the year.
Notices of eligibility if the subsidy is reduced or terminated go out in the fall. Dual eligibles and all other LIS-eligibles have a continuous SEP that allows them to enroll in more compatible plans at any time. Enrollment in the new plan is effective the first day of the month following the month of enrollment. Newly granted duals are created when Medicaid recipients become eligible for Medicare. To ensure that newly granted dual eligibles have Part D coverage, states forward twice monthly electronic data files to CMS.
CMS then enrolls these individuals to the temporary NET plan, pending their ultimate prospective random assignment to a benchmark plan in about two months time. The process of enrolling full dual eligibles in a Part D plan is called auto-enrollment.
Newly granted duals are also created if a Medicare beneficiary becomes eligible for Medicaid. Unlike full duals who are enrolled in a temporary plan NET and then are randomly assigned to benchmark plans , other LIS eligibles are enrolled directly into a benchmark plan through the random assignment process. LIS eligible individuals should be auto-enrolled or facilitated enrolled into a Part D plan of they do not select a plan on their own. These processes generally work very well. If the pharmacy has reasonable assurance that the individual qualifies for the LIS, and has no other prescription drug coverage, the pharmacy can immediately fill the prescription s and bill the claim to NET.
The pharmacy can confirm LIS eligibility through an on-line query or may accept other reasonable documentation, such as but not limited to a copy of a current Medicaid award letter with effective dates and a notice from Medicare or SSA awarding Extra Help. NET has an open formulary, with no utilization management restrictions on any drugs, and no pharmacy network restrictions. State Pharmacy Assistance Programs are state-funded prescription drug assistance programs dual-eligibles and other low-income residents.
All Part D plans must have an appeal process through which members can challenge a denial of drug coverage. If the request for coverage is denied, the member may proceed to further levels of appeal, including redetermination by the plan, reconsideration by an Independent Review Entity Maximus , Administrative Law Judge ALJ review, the Medicare Appeals Council MAC , or federal district court. There are two types of exceptions that may be requested:.
Formulary Exceptions — This type of exception is requested because the member:. Members may not request an exception to obtain an excluded drug.
Excluded drugs include but are not limited to erectile dysfunction drugs, drugs for weight loss or gain and drugs for the symptomatic relief of cough. Tiering Exceptions — This type of exception is requested because the member needs a non-preferred drug at the lower cost-sharing terms applicable to drugs in a preferred tier. Further, members may not ask for a tiering exception for high cost and unique genomic and bio-tech products, if the plan maintains a separate tier Tier 4 or 5 for these drugs.
These two caveats essentially mean that member can only ask to receive a Tier 3 non-preferred drug and Tier 2 preferred prices. Without support from the prescriber physician or other provider , the exception will not go forward. The importance of the medical statement of support cannot be overemphasized. The statement need not be lengthy, but it must be specific as to why the prescribed drug is medically necessary at the prescribed dosage. Diagnosis must be provided.
If the drug is being denied because a step therapy requirement, the statement should indicate which formulary alternatives the member has tried and failed, including dates and length of treatment and the reason the drug failed. Providers may include case notes, charts, laboratory reports, etc. A duly appointed conservator or other person named in a health care power of attorney may also apply on behalf of the member.
It is usually best and simplest to use CMS Form to appoint a representative. The appeal may be mailed or faxed the latter is preferable in situations requiring an expedited decision. No specific form is required to complete an exception request or redetermination request. A detailed cover letter, accompanied by relevant medical documentation and a signed appointment of representative form, is sufficient.
If an exception is granted, coverage is granted back to the earliest date of request for the approved drug. If the member has already paid for the drug, the plan is required to reimburse the member in a timely way. The exception continues for the remainder of the plan year although the plan may extend approval beyond this period.
The plan may set a specific Tier at which it will place all drugs approved by exception or appeal. A non-formulary drug approved by exception will be considered a formulary drug for purposes of TrOOP. If the exception is denied, the member may go on to further levels of appeal, which are briefly summarized below.
A grievance is a complaint about some aspect of service from the plan, other than actual denial of a drug. Some complaints can have aspects of both an appeal and a grievance. For example, A person may file an appeal because a drug was denied, and then file a grievance because the plan did not issue a timely coverage determination.
It is up to the plan to determine whether a complaint is an appeal or a grievance. A grievance must be filed within 60 days of the event that is the source of complaint. The plan must issue a written decision if one is requested. Generally, the plan should respond to the grievance within 30 days. For older articles, please see our article archive. Medicare Rights Center, June 11, Kirchhoff, Suzanne M.
Congressional Research Service, August 16, Congressional Research Service, December 18, Medicare Communications and Marketing Guideilnes Mcmg. Medicare Marketing Guidelines. Medicare Part D Reporting Requirements. Between and , net Medicare spending is also projected to grow as a share of the federal budget—from Over the longer term that is, beyond the next 10 years , both CBO and OACT expect Medicare spending to rise more rapidly than GDP due to a number of factors, including the aging of the population and faster growth in health care costs than growth in the economy on a per capita basis.
Medicare is funded primarily from general revenues 43 percent , payroll taxes 36 percent , and beneficiary premiums 15 percent Figure 7. Figure 7: Sources of Medicare Revenue, The solvency of Medicare in this context is measured by the level of assets in the Part A trust fund.
In years when annual income to the trust fund exceeds benefits spending, the asset level increases, and when annual spending exceeds income, the asset level decreases. When spending exceeds income and the assets are fully depleted, Medicare will not have sufficient funds to pay all Part A benefits.
In the Medicare Trustees report, the actuaries projected that the Part A trust fund will be depleted in , the same year as their projection and three years earlier than their projection Figure 8. The actuaries estimate that Medicare will be able to cover 89 percent of Part A costs from payroll tax revenue in In the and Medicare Trustees reports, the actuaries attributed the earlier depletion date to several factors, including legislative changes enacted since the report that will reduce revenues to the Part A trust fund and increase Part A spending:.
The 2. Under Part A, beneficiaries are covered for hospital services, including:. Under Part B, beneficiaries receive coverage for medical services , including:. Both trust funds also help cover Medicare administration costs, such as collecting Medicare taxes, paying out for benefits, and dealing with cases of Medicare fraud and abuse. For Medicare Advantage plans in particular, any costs not covered by Medicare funding must be paid for with other funds.
There are different costs associated with enrolling in Medicare. Here are some that you will notice in your Medicare plan:.
Each Medicare part has a different set of costs, as listed above. Along with the two trust funds that have been set up for each Medicare part, some of these monthly costs also help pay for Medicare services. It can even go all the way up to percent of the costs, depending on the length of your stay. Unlike the Part A deductible, this amount is per year rather than per benefits period. The Part B coinsurance is 20 percent of the cost of your Medicare-approved amount.
This is the amount that Medicare has agreed to pay your provider for your medical services. In some cases, you may also owe a Part B excess charge. In addition to the costs of original Medicare parts A and B , some Medicare Advantage plans also charge a monthly premium to stay enrolled. Part A Trust Fund solvency is affected by growth in the economy, which affects revenue from payroll tax contributions, health care spending trends, and demographic trends: an increasing number of beneficiaries, especially between and when the baby boom generation reaches Medicare eligibility age, and a declining ratio of workers per beneficiary making payroll tax contributions.
Part B and Part D do not have financing challenges similar to Part A, because both are funded by beneficiary premiums and general revenues that are set annually to match expected outlays. However, future increases in spending under Part B and Part D will require increases in general revenue funding and higher premiums paid by beneficiaries.
For example, the Independent Payment Advisory Board IPAB , a member board which was authorized by the ACA, is required to recommend Medicare spending reductions to Congress if projected spending growth exceeds specified target levels.
IPAB is required to propose spending reductions if the 5-year average growth rate in Medicare per capita spending is projected to exceed the per capita target growth rate, based on inflation or growth in the economy and beyond.
The ACA required the IPAB process to begin in , but CBO has estimated that spending reductions will not be triggered for several years because Medicare spending growth is expected to be below the target growth rate during the next decade. As yet, no members of the board have been nominated or appointed. While Medicare spending is on a slower upward trajectory now than in the past, Medicare is likely to be a focus of future policy discussions about reducing the federal budget debt, given the health care financing challenges posed by the aging of the population.
0コメント