Transition Readiness
As AEP comes to a close on December 7, we are well into the time that organizations need to make sure that new members receive all of their required materials, including their identification cards. Having the annual election stretch to December 31 in the past was certainly to an organization’s advantage from a sales perspective, but it was an operational challenge when it came to ensuring those late applicants had access to services on day one.
In regards to access to services, there is no time like the present to make sure your Part D transition policies and procedures are in place, functional, and operational. (In fact, there’s no time like the past to have done this already.) CMS identified in their September 10 memo that transitioning new and existing members is a best practice, insomuch that it eases administration and all beneficiaries are treated as new in order to meet the transition requirements. However, plan sponsors tell me that this is not always feasible, and thus they implement the minimum requirements necessary.
So what is the requirement you ask? Plan sponsors must provide a temporary fill when the member requests a refill of a non-formulary drug (including Part D drugs that are on a plan‟s formulary but require prior authorization or step therapy under a plan‟s utilization management rules) within the first 90 days of coverage under a new plan. This 90 day time frame applies to retail, home infusion, long-term care and mail-order pharmacies. Failure to do so was a common finding in the 2012 program audits. CMS found that incorrect transition logic or edits had been applied, leaving some transition-eligible drugs to be rejected.
Think about what the obligations are as outlined in the Prescription Drug Benefit Manual Chapter 6 (as well as all subsequent guidance), and ask the right questions of your PBM to ensure this process is in place. Not only that, but to share the wise words of a former manager of mine, “Trust but verify.” Review your rejected claims on a daily basis and analyze if any rejections are inappropriate, and if so, do what’s needed to ensure members get their drugs. Failure to do so, in my opinion, is one of the most serious reasons that CMS may find a plan in breach of their Federal contract. Your Medicare Compliance Officer will soon be attesting to seven questions specific to Part D transition via the 2013 Readiness Checklist. Give him or her the confidence to attest favorably by means of robust documentation, including test results that demonstrate functioning logic and appropriate edits, and a plan for focused daily rejected claims review.