Public Health Insurance News

December 1, 2008

In addition to the Medicaid eligibility changes described in Recent Changes to Medicaid Eligibility, advocates should be aware of these important health-related developments:

Continued expansion of mandatory Medicaid managed care

By the end of 2008, mandatory managed care for SSI-related Medicaid recipients had been implemented in these 27 counties outside of New York City:

The NYS Department of Health (DOH) mails a informational booklet (“You Have 90 Days to Choose a Health Plan -- This Guide Tells You How”) to SSI-related beneficiaries effected by the managed care enrollment requirement.  This publication contains lots of information about how the whole process works, including how to request an exemption from the managed care requirement, what types of individuals are excluded from managed care participation, what services are “carved out” from managed care, and how to choose a plan.  You can get the booklet at DOH’s website.

If you encounter clients who are being adversely affected by the managed care requirement, or if you have any questions about Medicaid managed care, please contact Trilby de Jung (tdejung@empirejustice.org), who chairs the Medicaid Matters NY Managed Care Working Group, or Cathy Roberts (croberts@empirejustice.org). 

Expansion of mandatory managed care to persons with HIV/AIDS

Since the inception of managed care in New York’s Medicaid program, persons with HIV/AIDs have been always exempt from the mandatory managed care assignment.  That will very likely change.  The NYS Department of Health is seeking approval from the Center for Medicare and Medicaid Services (CMS) to eliminate the automatic exemption for HIV-infected individuals. If CMS grants the request, mandatory managed care enrollment in New York City could begin as early as spring 2009. 

Prescription medication “carve-out” for Family Health Plus recipients

As of October 1, 2008, Family Health Plus (FHP) recipients began receiving their prescription drugs through the Medicaid program, rather than through their FHP health plan.  NYS DOH mailed notices to all recipients about the new pharmacy “carve-out” benefit, and mailed out Medicaid (CBIC) benefit cards.  (If a FHP enrollee was also receiving food stamps, they did not get a new CBIC card – instead, Medicaid prescription drug benefits were authorized on their existing CBIC.) 

DOH announced the Family Health Plus carve-out change in General Information System (GIS) informational message GIS 08 MA/021, which you can access at: http://www.health.state.ny.us/health_care/medicaid/publications/docs/gis/08ma021.pdf

Passage of federal Medicare legislation

This summer, Congress passed H.R. 6331, the "Medicare Improvement for Patients and Providers Act of 2008," which contained a number of positive changes for Medicare beneficiaries.  Here are just a few of the provisions affecting dual eligibles in NYS:

• Extension of the QI-1 program through December 31, 2009.
• Development of a facilitated Medicare Savings Program (MSP) application process for individuals who apply for the Part D Low Income Subsidy through SSA and are also eligible for MSP.
• Language access requirement – requires CMS to translate the model MSP application form into languages most frequently used by Medicare beneficiaries.
• Changes to definitions of income and resources for LIS (Low Income Subsidy) beneficiaries -- exempts value of life insurance policies and in-kind support and maintenance. 
• Coverage of barbiturates and benzodiazepines: Permits coverage under Part D of barbiturates (for certain conditions) and benzodiazepines, effective January 1, 2012.
• Prohibitions and limitations on marketing of Medicare Advantage (MA) and prescription drug (PDP) plans:  Codifies existing CMS policies prohibiting door-to-door sales, cold calling, and cross selling of non-health-related products.
• “Off-label” drugs:  authorizes CMS to revise the compendia used for identifying medically accepted indication for Part D drugs, and provides that the criteria for anticancer drugs covered under Part D should be the same as the criteria for anti-cancer drugs covered under Part B.
• Special Needs Plans moratorium:  revises definitions, case management requirements and quality reporting standards for SNPS, and maintains a moratorium on new SNPs through December 2010.
• Mental health parity provision: phases in decreases to the co-insurance for Part B mental health services over a 6-year period, from 50% to 20%.

CMS is expected to issue implementing regulations in the near future.

Reminder about Medicare Part D open enrollment period

‘Tis the season of Medicare Part D (prescription drug) annual “open enrollment” … meaning that between November 15-December 31, 2008, all Medicare recipients can change their Part D prescription drug plans for the 2009 calendar year.  Open enrollment can be a pretty stressful time for beneficiaries and those working with them, since there are 51 plans to choose from in New York State, and weighing through all the options can be overwhelming!  CMS does have a helpful “Planfinder” tool to assist in the navigation and enrollment process (at www.medicare.gov), and many local service providers – including HIICAPs (Health Insurance Information, Counseling and Assistance Programs) -- provide hands-on enrollment assistance to seniors and the disabled.

If you are working with LIS beneficiaries, remember that they have a continuous special enrollment period due to their LIS status – they are NOT locked into the annual open enrollment period!  So an LIS beneficiary who winds up in a Part D plan that is not right for him/her can always switch to a better plan.

EPIC and Part D

As of October 1, 2008, EPIC (Elderly Pharmaceutical Insurance Program, New York State’s prescription drug program for seniors) implemented two new requirements, as a result of statutory changes enacted in last year’s state budget:

mandatory generic requirement – EPIC will no longer cover most brand name multi-source drugs where there is a generic equivalent UNLESS the person’s prescriber obtains prior authorization from EPIC or EPIC is the secondary payor.  If an EPIC enrollee has a prescription affected by the mandatory generic rule, their pharmacist should try to contact the person’s prescriber to see if a generic substitution is appropriate or whether a prior authorization request should be made.  Pharmacists may dispense an emergency 72 hour supply when they can’t reach the prescriber.

Part D maximization requirement – EPIC will no longer provide an automatic “wrap” for drugs not covered by a person’s Part D plan.  Instead, pharmacists must consult with the person’s prescriber about a possible substitute on the Part D formulary before billing EPIC for a drug not covered by a Part D plan.  If the prescriber does not authorize an alternative, the pharmacy should document the consultation in their records and bill EPIC for the drug.  In some cases, EPIC will pursue a Part D appeal on behalf of the beneficiary.

Despite the additional complexity that these new rules add to the EPIC program, EPIC has built in a number of client protections so that seniors should not be adversely affected.

Pharmacist vaccine law

New York is now the 49th state to allow pharmacists to administer vaccines, thanks to recent legislation signed into law by Governor Paterson.  Beginning on December 4, 2008, pharmacists in New York State can administer flu and pneumonia vaccines if they complete a vaccination training and certification course.  The new law should help to increase access to these vaccines and keep New Yorkers healthy.

The new law does NOT cover the shingles (Zostavax) vaccine, which must be administered by a physician or certified nurse practitioner.  

If you have questions about this article, or any public health insurance related questions, please contact Cathy Roberts at croberts@empirejustice.org or 518-462-6831 ext. 112.