State of California-Health and Human Services Agency Department of Health Services California Department of Health Services SANDRA SHEWRY Director ARNOLDSCHWARZENEGGER Governor DATE June21,2006 MMCD All Plan Letter 06003 TO: 1WO PLAN MODEL CONTRACTORS, GEOGRAPHIC MANAGED CARE CONTRACTORS, KAISER PRE-PAID HEALTH PLAN, SCAN HEALTH PLAN, PACE PLANS, AIDS HEAL THCARE FOUNDATION SUBJECT: MEDICARE PART D UPDATE On December 29, 2005, the California Department of Health Services (CDHS) sent out Medi-Cal Managed Care Division (MMCD) All Plan letter 05015 to inform you of recent changes to the Fiscal Intermediary Access to Medi-Cal Eligibility (FAME) File layout due to the implementation of the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA). The primary ch.ange to the monthly FAME files and the daily FAME updates was the addition of the Medicare Part D Status Code, which identifies a beneficiary's Part D eligibility status. On January 12, 2006, Governor Schwarzenegger signed emergency legislation, AB132, to ensure that all Medicare/Medi-Cal dual eligible beneficiaries receive their drug benefits. The purpose of this letter is to provide information regarding The Medicare Part D Status Code values; . The location of the Medicare Part D Status Code on the Non-COHS FAME Files; . The State's Emergency Part D Prescription Drug fill process and beneficiary claims; . The State's notification process for Medicare Part 0 eligible beneficiaries; and Improvements to the Non-COHS FAME File.. . Medi-Cal Managed Care Division 1501 Capitol Avenue, P.O. Box 997413, MS 4400 Sacramento, CA 95899-7413 Phone: (916) 449-5000 Fax: (916) 449-5005 Internet Address: www.dhs.ca.QOV ARNOLD SCHWARZENEGGER Governor DATE June 21, 2006 TWO PLAN MODEL CONTRACTORS, GEOGRAPHIC MANAGED CARE CONTRACTORS, KAISER PRE-PAID HEALTH PLAN, SCAN HEALTH PLAN, PACE PLANS, AIDS HEALTHCARE FOUNDATION
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State of California-Health and Human Services Agency
Department of Health Services
CaliforniaDepartment ofHealth Services
SANDRA SHEWRYDirector
ARNOLDSCHWARZENEGGERGovernor
DATE June21,2006
MMCD All Plan Letter 06003
TO: 1WO PLAN MODEL CONTRACTORS, GEOGRAPHIC MANAGED CARECONTRACTORS, KAISER PRE-PAID HEALTH PLAN, SCAN HEALTHPLAN, PACE PLANS, AIDS HEAL THCARE FOUNDATION
SUBJECT: MEDICARE PART D UPDATE
On December 29, 2005, the California Department of Health Services (CDHS) sent outMedi-Cal Managed Care Division (MMCD) All Plan letter 05015 to inform you of recentchanges to the Fiscal Intermediary Access to Medi-Cal Eligibility (FAME) File layout dueto the implementation of the Medicare Prescription Drug Improvement andModernization Act of 2003 (MMA). The primary ch.ange to the monthly FAME files andthe daily FAME updates was the addition of the Medicare Part D Status Code, whichidentifies a beneficiary's Part D eligibility status. On January 12, 2006, GovernorSchwarzenegger signed emergency legislation, AB132, to ensure that allMedicare/Medi-Cal dual eligible beneficiaries receive their drug benefits.
The purpose of this letter is to provide information regarding
The Medicare Part D Status Code values;
.
The location of the Medicare Part D Status Code on the Non-COHS FAME Files;
.
The State's Emergency Part D Prescription Drug fill process and beneficiaryclaims;
.
The State's notification process for Medicare Part 0 eligible beneficiaries; and
Improvements to the Non-COHS FAME File..
.
Medi-Cal Managed Care Division1501 Capitol Avenue, P.O. Box 997413, MS 4400
Sacramento, CA 95899-7413Phone: (916) 449-5000 Fax: (916) 449-5005
Internet Address: www.dhs.ca.QOV
ARNOLD SCHWARZENEGGER Governor
DATE June 21, 2006
TWO PLAN MODEL CONTRACTORS, GEOGRAPHIC MANAGED CARE CONTRACTORS, KAISER PRE-PAID HEALTH PLAN, SCAN HEALTH PLAN, PACE PLANS, AIDS HEALTHCARE FOUNDATION
MMCD All Plan Letter 06003Medicare Part 0 Update -Non-COHS PlansPage 2 of 4
June21,2006
How to Identify the Medicare Part D Status
The Medicare Part D Status Code is a 1-byte field that occurs at the end of each monthlysegment on the FAME files. The value in this field identifies whether the beneficiary hasPart D eligibility for the month in review. Please note that the Other Health Coverage(OHC) Code may contain a Part D value; however, the OHC Code should not be used toidentify a beneficiary's Part D status.
The valid Part D Status Code values are:
Blank or "0" Indicates that the beneficiary is not eligible for Medicare Part D;
.
"1", "2", or "3": Indicates that the beneficiary is eligible for Medicare Part D andhas been enrolled in a Part D Prescription Drug Plan (PDP);
.
"7": Indicates that the beneficiary is presumed to be eligible. The status of"Presumed Eligible" is applied when a beneficiary has all indications of beingeligible for Medicare Part D but has not been enrolled in a POP; and
"9": Indicates that the beneficiary has decided to opt out of Medicare Part D andinstead has alternate, approved coverage outside of Medi-Cal.
.
Please refer to Attachment A, MMA Part D Quick Reference Guide for additionalinformation regarding the Part 0 Status Code and OHC values.
As mandated, Medicare Part D is effective beginning the month that the Medicare Part DCode displays a valid Part D value in the FAME File. Regardless of a beneficiary'sMedicare Part A and B status, the Health Care Plan should not assume that thebeneficiary is participating in Medicare Part D.
The health care plan will be responsible for the beneficiary's drug coverage and will receivefull capitation payments until the Medicare Part D Status Code displays a valid value ("1", "2"or "3"). If a valid value of "9" is displayed, the beneficiary has affirmatively declined MedicarePart D and is entitled to receive only Part D excluded drugs from the managed care healthplan. Also, a beneficiary with a valid value of "9" will not be able to utilize the Medi-CalEmergency Drug Coverage. Health care plans will not receive capitation for Part D drugs forbeneficiaries with a valid value of "9". Please refer to Attachment A, MMA Part D Quick
Reference Guide.
MMCD All Plan Letter 06003Medicare Part D Update -Non-COHS PlansPage 3 of 4
June21,2006
Where to Locate the Medicare Part D Status Code
Non-COHS monthly FAME file: The Non-COHS FAME file consists of the currentmonth and 12 months of prior eligibility. The current month's Part D value is locatedin position 239, Please refer to Attachment B. Medicare Part D PDP Non-COHSFAME File Lavout effective 3/24/2006. page 1.
.
The Medicare Part 0 Status Code also appears in the corresponding position for eachmonth of prior eligibility on the FAME files.
How to Determine Emergency Part D Claims
The Emergency Part D Prescription Drug fill process should only be used in one of thefollowing situations:
If a beneficiary is enrolled in a Part D POP but experiences problems (such asexcessive co-pays or POP records containing errors); or
If a beneficiary has a valid Medicare Part D Status Code value but has not beenassigned to a PDP, and the WellPoint drug fill system is not approving the claims.
Claims for Medi-Cal Managed Care dual eligibles without an eligible Part D Status Codewill not be approved for payment through the Emergency Prescription Drug fill process.Such claims should be adjudicated by the Managed Care Health Plans.
Notice of Action Process for Part D Eligible Beneficiaries
By federal mandate, CDHS must send all Part 0 eligible beneficiaries a Notice of Action(NOA) letter that explains the change in their Medi-Cal benefits as they transfer toMedicare Part D. The Reduction of Benefits NOA must provide at least 10 days of notice.Part 0 coverage can begin on the first day of the month following the completion of the 10days. The beneficiary's Medicare Part 0 status will then be updated to reflect the change
in coverage.
Improvements to the Non-COHS FAME File
After March 24, 2006, three new fields were available on the Non-COHS FAME File:
The 5-byte Federal Contract Number;
The 4-byte State Carrier Code; and
.
The 8-byte Policy Start Date (in CCYYMMDD format)
MMCD All Plan Letter 06003Medicare Part D Update -Non-COHS PlansPage 4 of 4
June21,2006
The 8-byte Policy Start Date (in CCYYMMDD format)
.
Only the current month's POP data will be included Ion each FAME file. Retaining priorfiles will provide a historical reference for POP information. Please refer to AttachmentB. Medicare Part D PDP Non-COHS FAME File Lavout effective 3/24/2006. paae 8.
For more information on the addition of these fields to the Non-COHS FAME File, pleaserefer to the FAME File layout and the Carrier Cross Reference Table. These documentswill soon be available on the HIPAA web site:
http://hipaa.dhs.ca.qov/834.htm#FAME Medicare Part 0 link to "MMA Part 0 CarrierCross Reference Table new 03/22/06" and http://www.medi-cal.ca.gov link to "MedicarePart 0" then link to "MMA Part 0 Carrier Cross Reference File New".
If you have questions about the MMA Part 0 implementation or the information in thisletter, please contact your contract manager. Thank you for your continued cooperation,
Sincerely,
() ~<- rrV\. _R '\~fIn~ssa M. Baird, MP~rchterMedi-Cal Managed Care Division
Attachments
Vanessa M. Baird, MPPA, Cheif Medi-Cal Managed Care Division
ATTACHMENT A
MMA PART D QUICK RI:FERENCE GUIDE
MEDICARE STATUS CODE~
~
iit 1st
2nd
3m
~e
NOTE: Medicare Part A and/or Part B eligibility is arequiremerlt for Medicare Part D eligibility. It is notpossible for a beneficiary to have Medicare Part D
coverage only.
Part A (!:!Qspital)
Part B (~edical)
Part D (Prescription Druo)
MEDICARE STATUS CODE VALIJES (PARTS A, 8, & D)
Part A(Hospital)
Part B(Medical)
Value Part D(Prescription Drug)
blank NOT ELIGIBLENo Medicare Entitlement
NOT ELlGrBLENo Medicare Entitlement-
0
NOT EUGIBIZENo Medicare Entitlement
NOT ElZrGIBLENot entitled to Medicare Part
A in reported month
NOT ELIGIBLENot entitled to Medicare Part
B in reported month
NOT ELIGIBLENot entitled to Medicare Part D in reported
month; Part D eligibility unknown.
1 ELIGIBLEMedicare Part A paid for by
Beneficiary
ELIGIBLEMedicare Part B paid for by
Beneficiary --
ELlG1BLEApproved Low Income Subsidy (LIS) Status
2ELIGIBLEMedicare Part A paid for bythe State of California
ELIGIBLEMedicare Part B paid for by
the State of California
ELIGIBLEBeneficiary is eligible for Medi-Cal but not
eligible for Medi-Cal payment of Medicare~rt
D formulary d~~
ELIGIBLEBeneficiary entitled to free
Medicare Part A
N/A3 ELIGIBLE
Medicare Savings Program EligibleBeneficiary Dee~ LIS EliQible
N/A N/A4 ELIGIBLEMedicare Part B paid for byState other than California-
N/A5ELIGIBLEMedicare Part A paid for byPension Fund
ELIGIBLEMedicare Part B paid for by
Pension Fund
ELIGIBLEBeneficiary is presumed
eligible. Cost Avoidance
reported -State pays Part B
premium
ELIGIBLEBeneficiary is presumed eligible. Cost
Avoidance reported for Medicare Part D
fom1ulary drugs
7
ELIGIBLEBeneficiary is presumedeligible. Cost Avoidancereported -State pays Part Apremium
NOT ELIGIBLEAged alien ineligible for
Medicare Part A
NOT ELIGIBLEAged alien ineligible for
Medicare Part B
ELIGIBLEBeneficiary is eligible for Part A or B but has
refused Part D. No prescription benefit
under Medi-Cal for Medicare Part D
formulary d~~!:eceived.
9
Note: Medicare Status Values "6" and "8" (for Parts A & B) have been removed becausethey are no longer valid values.
MMA Part D Quick Reference Guide, v1.2Revised by DHS-ITSD, 2/11/06
Page 1 of 2
MMA PART D QUICK REFERENCE GUIDEMEDICARE STATUS CODE:
Digit Value
1st Part A (Hospital)
2nd Part B (Medical)3rd Part D (Prescription Drug)
MEDICARE STATUS CODE VALUES (PARTS A, B, & D)
Value Part A (Hospital) Part B (Medical) Part D (Prescription Drug)
blank NOT ELIGIBLE No Medicare Entitlement
NOT ELIGIBLE No Medicare Entitlement
NOT ELIGIBLE No Medicare Entitlement
0 NOT ELIGIBLE Not entitled to Medicare Part A in reported month
NOT ELIGIBLE Not entitled to Medicare Part B in reported month
NOT ELIGIBLE Not entitled to Medicare Part D in reported month; Part D eligibility unknown.
1 ELIGIBLE Medicare Part A paid for by Beneficiary
ELIGIBLE Medicare Part B paid for by Beneficiary
ELIGIBLE Approved Low Income Subsidy (LIS) Status
2 ELIGIBLE Medicare Part A paid for by the State of California
ELIGIBLE Medicare Part B paid for by the State of California
ELIGIBLE Beneficiary is eligible for Medi-Cal but not eligible for Medi-Cal payment of Medicare Part D formulary drugs.
3 ELIGIBLE Beneficiary entitled to free Medicare Part A
N/A ELIGIBLE Medicare Savings Program Eligible Beneficiary Deemed LIS Eligible
4 N/A ELIGIBLE Medicare Part B paid for by State other than California
N/A
5 ELIGIBLE Medicare Part A paid for by Pension Fund
ELIGIBLE Medicare Part B paid for by Pension Fund
N/A
7 ELIGIBLE Beneficiary is presumed eligible. Cost Avoidance reported - State pays Part A premium
ELIGIBLE Beneficiary is presumed eligible. Cost Avoidance reported - State pays Part B premium
ELIGIBLE Beneficiary is presumed eligible. Cost Avoidance reported for Medicare Part D formulary drugs
9 NOT ELIGIBLE Aged alien ineligible for Medicare Part A
NOT ELIGIBLE Aged alien ineligible for Medicare Part B
ELIGIBLE Beneficiary is eligible for Part A or B but has refused Part D. No prescription benefit under Medi-Cal for Medicare Part D formulary drugs is received.