Many individuals who require long-term care in a nursing home or similar care at home impoverish themselves so they can qualify for Medicaid to cover these costs. For these "dually eligible" people who qualify for both Medicaid and Medicare, Medicaid generally becomes the primary benefit source. Most services not covered by Medicaid, such as hospice care and skilled home healthcare, are paid for by Medicare. These individuals may now find coverage for prescription medications is limited.
A Long List of Challenges
Dually eligible individuals may face problems arising from: physical and cognitive limitations; differences in drug formularies and cost-sharing tier structures in the prescription drug plan; inconsistencies among eligibility criteria for Social Security Disability Income, Supplemental Security Income, Medicaid long-term care; home- and community-based services, and bureaucratic complexities.
The state Medicaid agency may provide the Centers for Medicare and Medicaid Services with inaccurate information such as a misspelled name, incorrect Social Security numbers, and incomplete identifying information. These individuals may find themselves without prescription drug benefits until the mess can be untangled.
Medicare is the primary payer for those who enroll or could enroll in Medicare Part D. Medicaid will not pay for prescription drugs covered under Part D for dually eligible individuals. Thus, those who are eligible to enroll in Medicare Part D will lose Medicaid benefits for prescription drugs when their Part D eligibility is established, whether or not they actually enroll in Part D.
The drug formularies may not include the medication an individual requires. On the other hand, the drug formulary may list similar drugs. Thus, there may be a problem with access to necessary drugs.
Adverse Determination
Beneficiaries need to know what to do if they receive written notice of an adverse coverage determination. A reconsideration request needs to be filed as soon as possible and the healthcare provider needs to be notified to obtain statements necessary for an appeal in addition to assuring care is not interrupted. At times, an expedited appeal may be necessary.
Medicare Part D has a five-level process to appeal an adverse coverage determination such as denial of a request for a formulary exception or the refusal to approve or pay for a medication on the basis of medical necessity. The first step in the appeal process is a redetermination by the prescription drug plan. The second step is the reconsideration by the Independent Review Entity. The third step is a hearing before an administrative law judge. The fourth step is a review by the Medicare Appeals Counsel. The final step is judicial review in federal district court. An appeal above the Independent Review Entity requires the amount in controversy to be at least $100 and for judicial review in federal court if it is higher.
The initial determination must be completed and an answer provided within 72 hours. Redetermination and reconsideration must be completed and an answer provided in 7 days. An expedited appeal process is available for those for whom a delay would seriously jeopardize the life or health of the beneficiary or affect the beneficiary's ability to regain maximum function. Under the expedited process, the initial determination and answer must be provided within 24 hours. Failure of the prescription drug plan to issue a timely answer at step one or two constitutes an adverse determination and the matter must be forwarded directly to the Independent Review Entity for review within 24 hours.