Temporary Emergency Drug Coverage Extended

• The California Department of Health Services urges advocates to distribute this revised and updated MediCal Bulletin (see below or go to the MediCal Web site or the CDCAN Web site) widely and make sure local pharmacy has the latest copy (it should be dated 1/26/06).

• The California Department of Health Services released a new revised MediCal Bulletin this evening (JANUARY 26) that extends the temporary drug coverage for MediCal and Medicare eligible persons with disabilities and seniors until FEBRUARY 11 at 11:59 PM. The revised bulletin contains instructions to pharmacies and other providers on how a person with disabilities or a senior who is eligible for both Medicare and MediCal can obtain drugs from the temporary emergency drug coverage ordered by Gov. Arnold Schwarzenegger last week.

• The Governor signed on January 20, AB 132, emergency legislation passed by the Legislature on January 19 that extended the emergency drug program to 1/27 and gave the Governor the authority to extend the coverage for another 15 days beyond that (to February 11). The bill also provided $150 million in state general fund money to pay for the emergency drug coverage.

• MediCal pharmacies and other providers need to get this bulletin so they are made aware of the temporary drug coverage. There were reports last week that across the State of some pharmacies - including some major chains, even as late as Monday who were still not aware of the Governor's order or were waiting approval to proceed from their corporate offices.

• Participation in the emergency coverage is limited to those dual eligibles who cannot get their medications from the new Medicare drug program. The new special bulletin issued January 26th explains to pharmacies and other providers how they can obtain emergency MediCal coverage to cover their costs of providing the medications under the Governor's emergency coverage and also restrictions.

The bulletin is printed below and also available at the State of California's MediCal (Medicaid) site at www.MediCal.ca.gov or from the California Disability Community Action Network (CDCAN) Web site at www.cdcan.us

California Department of Health Services Telephone Number to Call Regarding Questions:

• Call toll-free number at 1-800-MEDICARE (1-800-633-4227).
• TTY users can call toll-free at 1-877-486-2048
• People can also call a Medicare HICAP counselor for free at 1-800-434-0222 (though lines are often busy)
• Persons who have developmental disabilities and are served by a regional center should contact their service coordinator.
• Persons with other disabilities can also contact their local independent living center for information.

What People with Disabilities and Seniors Should Do
If a person with disabilities or seniors who are eligible for both Medicare and MediCal and are having difficulties in obtaining their medications, the Department of Health Services advises that the following be done:

People should bring their MediCal card Medicare drug card or Medicare acknowledgment letter to the pharmacy to assist them in billing.

People who are concerned about the availability of this emergency drug coverage at their pharmacy can bring a copy of the January 12 provider bulletin with them and show pharmacy. (see below or go print copy from www.MediCal.ca.gov) or from the CDCAN Web site at www.cdcan.us

People can also tell the pharmacy to go to the State of California MediCal Web site themselves to read the bulletin that describes the emergency drug coverage and billing.

People should note that this emergency drug coverage process is being put in place to provide prescription drugs in those cases where the pharmacy is not able to obtain payment, eligibility, or the correct co-payment amount from the Medicare program.

Persons who are dually eligible for MediCal and Medicare and were charged too much for their medications after January 1, according to the Department of Health Services, can be reimbursed.

Medical Bulletin (Revised/Updated 1/26/06)
(Previous versions dated 1/12/06 and 1/17/06 and 1/20/06. Reprinted from Dept of Health Services MediCal site at www.medi-cal.ca.gov)

Updated Information

MediCal Bulletin
January 26, 2006
Pharmacy

Emergency MMA Drug Supply Program Period Extended

Note: This program has been extended until 11:59 p.m. on February 11, 2006.

In order to ensure that people who are dually eligible for Medicare and MediCal continue to get needed medications during the transition of drug coverage from MediCal to Medicare, the California Legislature has enacted and Governor Arnold Schwarzenegger has signed Assembly Bill (AB) 132 which allows the California Department of Health Services (CDHS) to continue covering the cost of medications for those who are unable to obtain them from Medicare. This program began the evening of January 12, 2006, will continue through Saturday, February 11, 2006 and provides emergency payment for prescription drugs dispensed to beneficiaries who are dually eligible for MediCal and Medicare if the pharmacy has tried and been unable to obtain reimbursement from Medicare.

This process is only available in cases where the pharmacy has attempted to obtain Medicare billing information and has attempted to bill Medicare for this drug. To receive reimbursement, a pharmacy must certify that certain conditions have been met.

This program will provide payment for emergency supplies of drugs for these dual eligibles that are unable to obtain their drugs under the Medicare program. This emergency program is available to full-benefit, dual eligible beneficiaries previously covered either by fee-for-service MediCal or by a MediCal managed care plan. For beneficiaries enrolled in a MediCal managed care plan, providers are to bill the emergency claims to MediCal fee-for-service and not the MediCal managed care plan.

Billing Criteria
These emergency drug benefits are available only when one of the following has occurred:

• The pharmacy has submitted a claim for the provision of drug benefits to the full-benefit dual eligible beneficiary’s Medicare Drug Plan and the claim has been denied payment for reasons other than processing errors or omissions made by the pharmacy, lack of medical necessity or health or safety reasons. Note: Pharmacy billing of inappropriate quantities (for example, billing greater than a 30-day supply when only a 30-day supply is allowed under the Medicare Drug Plan) is considered a pharmacy processing error.

• The pharmacy is unable to submit a claim solely due to the unavailability of complete or accurate Medicare Drug Plan enrollment information from the full-benefit dual eligible beneficiary’s Medicare Drug Plan, the Centers for Medicare and Medicaid Services (CMS) or entities under contract with the CMS to provide enrollment information, including having attempted to obtain eligibility information from the Medicare E1 eligibility system.

• The Medicare Drug Plan provides information that the full-benefit dual eligible beneficiary’s deductible or co-payment amount is higher than the $1 to $5 co-payment amounts that are established by Medicare for full-benefit dual eligible beneficiaries.

Process
The Department has developed a process that allows pharmacy providers to submit this emergency claim electronically. The pharmacy provider need only indicate that the Code I requirements of the claim have been met. By doing so, the pharmacy provider is certifying that all of the following conditions are met:

(A) One of the three situations noted above has occurred.
(B) The pharmacist provides or dispenses the drug as a critical service.
(C) The pharmacist has not previously provided or dispensed, nor has knowledge that another pharmacist has provided or dispensed, a quantity of the same drug that is sufficient to cover the period of time for which the prescription is being dispensed.
(D) The date of service (date the prescription is dispensed) is from January 12 through February 11 inclusive.

For claims where Medicare has set the co-payment amount to be greater than that for dual eligibles ($1 to $5), the pharmacy should submit an “other coverage” claim. The amount billed field should contain the pharmacy’s usual and customary charge for the prescription and the other coverage paid field should contain the amount that the Medicare program is reimbursing the pharmacy plus the normal co-payment due for the patient. This is the same method used for all MediCal claims for beneficiaries who have other coverage.

Code I (Restrictions)
Code I drugs typically require prior authorization in accordance with Section 51003, unless used under the conditions specified in the Contract Drugs List. In this instance, the Code I is being used outside the Contract Drugs List. The emergency claims discussed in this notice are subject to the prescription documentation requirements in CCR, Title 22, Section 51476(c).

To submit a Code I:

• Paper: Place a “Y” in the “CODE I MET” box on the 30-1 claim form. (Indicates the Code I restriction for the drug was met.) The provider should also note in the “Specific Details/Remarks” section of the form that the claim is for “Medicare Part D drugs.”

• Electronic: Place a “7=Medically Necessary” in the Submission Clarification Code (42Ø-DK). (Code indicating that the pharmacist is clarifying the submission.)

This use of the Code I indicator shall only be used for Medicare Part D emergency drug benefit claiming. Other emergency claims for MediCal beneficiaries shall continue using the paper claim process.

If the claim meets the three conditions above and is denied by the MediCal claims processing system due to the beneficiary not meeting their monthly share of cost, the pharmacy must submit the claim on paper via a 30-1 claim form as indicated above. The “Remarks” section must be filled in as noted.

Please note that MediCal is the payer of last resort available only when information to be paid by Medicare cannot be obtained and this prescription is a one-time emergency supply. It is critical that providers work with beneficiaries, the Medicare drug plan and Medicare to resolve these problems to allow for the proper administration of the Medicare drug program on an ongoing basis. Providers who misuse this program are subject to state audit and recovery.