the Centers for Medicare & Medicaid Services (CMS) created the
"Point-of-Sale Facilitated Enrollment" (POS) process, administered
by WellPoint. The purpose of the POS is to assist people who are
dually eligible for Medicare and Medicaid (dual eligibles) in
filling their prescriptions at the pharmacy if they have not yet
been assigned to a Part D prescription drug plan (PDP).
Effective January 1, 2010, the POS process will be enhanced by a new
process for providing retroactive and temporary drug coverage for
all Low-Income Subsidy (LIS) eligible individuals. The new process,
referred to as the "Limited Income Newly Eligible Transition"
program (LI NET or Limited Income NET), will be administered by
Humana, and will do more than the previous POS system.
will operate as a temporary PDP for low-income Medicare
beneficiaries who are not enrolled in a prescription drug plan and
who are entitled to either prospective and/or retroactive coverage.
LI NET will cover all Part D drugs without prior authorization or
other utilization management requirements, such as step therapy or
quantity limits (other than FDA-required quantity limits). Because
LI NET will serve LIS-eligible individuals, there will be no premium
or deductible. There also will be no pharmacy network restrictions.
NET Will Have Three Responsibilities
- Auto-enrollment into LI NET for Dual Eligibles Who are
Entitled to Retroactive Coverage
will serve as the initial PDP for full benefit dual eligibles who
are entitled to retroactive coverage. This group includes people who
have Medicaid and become newly eligible for Medicare, people who
have Medicare and become eligible for Medicaid, and people with SSI
and Medicare. Medicare beneficiaries who are new to Medicaid and
who do not have an existing PDP, Medicaid recipients who are new to
Medicare and have not chosen a PDP during their initial enrollment
period, and SSI recipients who do not have Medicaid and are new to
Medicare will be automatically enrolled in LI NET by CMS. The
effective date will correspond to their date of Medicaid
eligibility, if they had Medicare first, or to the date of their
Medicare entitlement, if they had Medicaid first. For people with
SSI but no Medicare, the effective date will correspond to the
effective date of their Medicare eligibility.
beneficiary has been enrolled in LI NET, LI NET will go through the
process of auto-enrolling him/her into a PDP that qualifies as a
Part D "Benchmark" plan for the region in which the beneficiary
lives. Enrollment will become effective on the first day of the
month following the month of LI NET enrollment. Thus, the
beneficiary will remain in LI NET only for about two months. An
individual cannot remain in LI NET beyond this two month initial
All dually eligible beneficiaries retain the option of choosing
their own prescription drug plans. Those with Medicaid who choose a
PDP during their initial enrollment period before they become
entitled to Medicare will be enrolled in the PDP of their choice and
will not be enrolled in LI NET. Beneficiaries who choose a PDP on
their own after they have been enrolled in LI NET will be enrolled
in the plan they elect, effective the first day of the month
following their election of that plan. A beneficiary election
should always take precedence for future drug coverage.
The LI NET auto-enrollment process applies only to full benefit dual
eligibles and to people with Medicare and people with SSI who do not
also have Medicaid and who are also entitled to retroactive Part D
coverage. The existing facilitated enrollment process will remain
in effect for all other eligible people who apply for LIS.
- LI NET at the Pharmacy Counter
When a beneficiary goes to the pharmacy to get a prescription filled
or refilled, the pharmacist submits a claim through the Part D
electronic claims system in order to get reimbursed by the
beneficiary's drug plan. CMS established the POS system so that
LIS-eligible beneficiaries could get their medications when the
electronic claims system did not show them as enrolled in any
prescription drug plan. Effective January 1, 2010, the POS process
will be run through LI NET. As with the previous POS system, and
unlike auto-enrollment into LI NET, the LI NET POS process will be
available to all LIS-eligible beneficiaries, regardless of how they
became eligible for LIS.
The LI NET POS process is very similar to the earlier WellPoint POS
process. It consists of four steps:
The pharmacist asks the beneficiary for a Part D identification card
or information showing enrollment in a drug plan. This could
include a letter from a plan confirming enrollment or a letter from
LI NET confirming auto-enrollment.
If the beneficiary does not have this information, the pharmacist
submits an E1 query through the Part D electronic claims system to
find the plan in which the beneficiary is enrolled.
If the E1 query shows no plan enrollment, the pharmacist establishes
LIS-eligibility. LIS-eligibility may be established through the
electronic claims system or by paper documentation from the
Once LIS-eligibility has been established, the pharmacist submits
the claim through LI NET, and the beneficiary will be enrolled in LI
LIS eligibility may be a sticking point for some beneficiaries.
Instructions from Humana to pharmacists
indicate that Medicare entitlement may be verified by pharmacists
through an E1query or by calling the Medicare pharmacy eligibility
hot line (1-866-835-7595). The instructions also suggest asking
customers for a recent Medicare Summary Notice (MSN) to verify
Medicare entitlement, though beneficiaries have reported problems in
the past when trying to use an MSN to verify Medicare eligibility.
Medicaid status or LIS eligibility can be verified by showing the
pharmacist a Medicaid card, a state document or a screen from the
state's Medicaid system, or by an LIS award or announcement from the
Social Security Administration.
advises pharmacists to refer beneficiaries who cannot establish
eligibility for Medicare and Medicaid or LIS to their State Health
Insurance Assistance Program (SHIP). Moreover, CMS indicates in a
fact sheet that a Medicaid worker can call LI NET at 1-800-783-1307
to verify eligibility.
Humana will notify a beneficiary for whom it cannot prove LIS
eligibility and ask the beneficiary to submit proof. If eligibility
is not verified, or the beneficiary is found not to be LIS-eligible,
and the pharmacy treated the beneficiary as if s/he were LIS
eligible, the beneficiary will be responsible for the costs that
should not have been paid by LI NET.
Reimbursement through LI NET
will provide retroactive reimbursement for out-of-pocket
expenditures to beneficiaries who were not enrolled in a drug plan
but who were LIS-eligible. Retroactive reimbursement through LI NET
will be available to all LIS beneficiaries who are owed money,
regardless of whether they are enrolled in LI NET or enrolled in
another prescription drug plan. Beneficiaries may submit receipts
for out-of-pocket costs to LI NET, which then has 72 hours to make a
decision on the request for reimbursement. Favorable claims must be
paid within 14 days. LI NET will reconcile claims with other Part D
plans so that neither the beneficiary nor the pharmacist will be
Eligibles and People with Medicare and SSI: Retroactive LIS
eligibility may occur if a Medicare beneficiary is awarded Medicaid
retroactively; if a Medicaid recipient receives a retroactive Social
Security disability award such that Medicare becomes effective
immediately; or if a Medicare beneficiary receives a retroactive SSI
award that does not automatically establish Medicaid eligibility.
LI NET may reimburse dual eligibles for claims up to 36 months in
the past, and, in limited situations, even longer if Medicaid is
retroactive for more than 36 months.
Other LIS-Eligible Individuals: Non-dual eligible individuals
may also be eligible for retroactive reimbursement of costs they
paid out of pocket that should have been covered by LIS. Claims for
reimbursement for non-duals are limited to the past 30 days.
Notice of Retroactive Coverage for Beneficiaries Who are Newly
Eligible for Medicaid or SSI: CMS will send beneficiaries who
are newly eligible for Medicaid or SSI a yellow notice that advises
them of their automatic enrollment into a prescription drug plan and
of the effective date of their Part D coverage. CMS will use two
different yellow notices, Notice 11154 (the standard auto-assignment
notice) and Notice 11429. Both notices will inform beneficiaries of
the drug plan to which they will be auto-assigned for future drug
coverage. Notice 11429 also contains LI NET contact information for
dates of retroactive coverage, and will only be sent to
beneficiaries who are entitled to such coverage. LI NET will send a
separate notice to this group explaining the reimbursement process.
Notice of retroactive coverage for other LIS-eligible beneficiaries:
CMS has made no provision to send notice to other LIS-eligible
beneficiaries about the process for seeking retroactive
reimbursement from LI NET. A CMS fact sheet states:
People who learn they are eligible for retroactive coverage should
contact Limited Income NET at 1-800-783-1307 for information about
how to get reimbursed for any covered Part D drug expenses they had
during months they were eligible for retroactive coverage.
NET process holds promise for low-income Medicare beneficiaries. If
all new duals who are retroactively eligible for LIS are assigned to
LI NET on a temporary basis, and then auto-assigned to a benchmark
drug plan, the number of duals who fall through the cracks may be
reduced. This, in turn, would reduce the number of beneficiaries
who need to use the POS process. The retroactive reimbursement
component of LI NET should help new duals receive reimbursement for
money they spent for prescriptions. It is unclear, however, how
effective the process for retroactive reimbursement will be for
non-duals who are LIS-eligible. Such beneficiaries are unlikely to
know of the process.
Beneficiary advocates should monitor the new LI NET process for its
effectiveness for their clients. The Center for Medicare Advocacy
asks advocates to share with us their client and advocate
experiences with LI NET, both good and bad.