Illinois Cares Rx

What Happens “Behind the

Scenes”

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

“Behind the Scenes”

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

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

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

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

• 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 20th

• Response received around 10th

Medicare Eligibility/Enrollment

KEY to providing benefits

• 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 PlansKey to timely wrap benefits

• 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 PaymentKey to Keeping Plans Happy ;-) and Providing

Services!!!

Claims Processing

• Part D Plans process pharmacy claims, and then send detail to CMS’s 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

Reconciliation to CostICRx is a full “reconciliation to cost”

SPAP• Plans aren’t at risk and don’t profit—ICRx 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

ICRx Current Issues

• 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. 1-1-2010)

• 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

• Aging must transmit member to HFS before 23rd for eligibility first of next month

• In December, in order to re-establish coverage for 2010, apps must be processed by 12-18-09

ICRx Eligibility Timing

Processing/Effective Dates

• > 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

• 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 CoverageWhat should they do

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)

• 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

• 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

• 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

• 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

• 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?

• 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

• 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

• 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

Non-ICRx Issues

• 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

• 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

• 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

• 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 isn’t 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