1107 Ninth Street, Suite 801
Sacramento, California 95814
Telephone: 916/442-0753; FAX 916/442-7966
[Tags]medicare, medicare part d, prescription drug, medi-medi, dual eligible, emergency measure, california, legislature, law, medi-cal[/Tags]
Continuation of Emergency Coverage
Medicare Part D – Update
May 11, 2006
AB 813 Nunez/Perata
Current state emergency coverage for Medicare Part D failures pursuant to SB 1233 (Perata) will expire on May 16, 2006. Without continuing some state remedy for Medicare Part D problems, some of the most vulnerable persons in the state would be left without prescription drugs when Part D occurred.
AB 813 (Perata/Nunez) as amended May 9, 2006, appropriates $120 million to continue emergency coverage for prescription drugs through the State’s Medi-Cal program from May 17, 2006 through January 31, 2007 for individuals who have both Medicaid and Medicare coverage (dual eligibles).
AB 813 has been fast-tracked through the legislature. It was heard in the Senate Health Committee May 10, 2006. On May 11, 2006, the Senate Appropriations Committee passed the bill to the Senate floor where it received the required two-thirds vote to pas the Senate. AB 813 will be heard on the Assembly floor Monday May 15, 2006 where it is expected to pass and then sent to the Governor for signing before expiration of current emergency coverage on May 16, 2006.
Provisions of AB 813
AB 813 provides more restrictions on state coverage than other emergency coverage proposals enacted this year. AB 813 requires the department to implement prior authorization before providing emergency drug benefits to dual eligible beneficiaries who are unable to obtain drug benefits from his or her Medicare Drug Plan under the following conditions:
1. For each prescription the pharmacy must submit a claim for the provision of drug benefits to the beneficiary’s plan and the claim is denied payment due to error by the Medicare Program Medicare, and the pharmacy has made a good faith effort to resolve the error with the plan and Medicare.
2. The pharmacy is unable to submit a claim for the provision of drug benefits solely due to incomplete or inaccurate Medicare Drug Plan enrollment information from the dual eligible beneficiary’s Medicare Drug Plan, the federal Centers for Medicare and Medicaid Services, or entities under contract with the Centers for Medicare and Medicaid Services to provide enrollment information, and the pharmacy has attempted to resolve these problems with the Medicare facilitated enrollment contractor and the Medicare Drug Plan, where appropriate.
3. The Medicare Drug Plan provides information that the full-benefit dual eligible beneficiary’s deductible or co-payment amount is higher than the co-payment amounts that are established by Medicare for full-benefit dual eligible beneficiaries.
4. Request for prior authorization or exception to the full-benefit dual eligible beneficiary’s Medicare Drug Plan is required and was sought by the pharmacist, but the pharmacy does not receive a response within 24 hours for an emergency drug or within 72 hours for a non-emergency drug. When submitting a request for prior authorization to the department, a pharmacy shall show proof of the submission of the request that was made to either the Medicare Drug Plan or the beneficiary’s prescribing physician. Beginning September 1, 2006, the department shall not cover drug benefits when prior authorization or exception to the full-benefit dual eligible beneficiary’s Medicare Drug Plan is required, unless that authorization was sought by the physician and the Medicare Drug Plan does not provide a response within 24 hours for an emergency drug or within 72 hours for a non-emergency drug.
Leave a Reply