On August 4, 2008, the Centers for Medicare and Medicaid Services (CMS) issued a memo about a new process to the Best Available Evidence (BAE) policy to all sponsors of Medicare prescription drug plans. This memo is part of the Situ vs. Leavitt proposed settlement agreement (see lawsuit article). In previous guidance, CMS explained that the policy requires plan sponsors to accept evidence presented by a Medicare beneficiary that he or she is eligible for the low-income subsidy (LIS) or extra help, even though Medicare records show otherwise. In this memo, CMS clarified requirements of the BAE policy when a beneficiary produces such evidence, and also addressed the situation when a beneficiary claims to be eligible for the LIS but cannot provide any documentation. Below are some of the memo’s key points. You can also view the CMS memo online.
When beneficiary produces evidence of LIS eligibility
CMS reminded plan sponsors of the process already in place when a beneficiary provides evidence that he/she is eligible for the LIS. In this situation, plan sponsors must:
- Accept the evidence (see below for lists of acceptable evidence);
- Provide Part D covered-drugs at a reduced cost-sharing level;
- Update the sponsor’s system to reflect the beneficiary’s correct LIS status within 48-72 hours of receipt of the beneficiary’s evidence of LIS eligibility; and
- If the CMS system does not already reflect the beneficiary’s correct LIS status, submit a request for correction.
Acceptable evidence
Acceptable evidence of LIS eligibility differs depending on whether a Medicare beneficiary was deemed eligible because of his or her qualification for Medicaid or determined eligible by the Social Security Administration (SSA).
Dually eligible beneficiaries
Plan sponsors must accept the following evidence presented by Medicare beneficiaries who are also eligible for full Medicaid (Medi-Cal in California) benefits:
- A copy of the beneficiary’s Medicaid card that includes the beneficiary’s name and an eligibility date during a month after June of the previous calendar year;
- A copy of a state document that confirms active Medicaid status during a month after June of the previous calendar year;
- A print out from the State electronic enrollment file showing Medicaid status during a month after June of the previous calendar year;
- A screen print from the State’s Medicaid systems showing Medicaid status during a month after June of the previous calendar year; or
- Other documentation provided by the State showing Medicaid status during a month after June of the previous calendar year.
Beneficiaries in institutions
Plan sponsors must accept the following evidence presented by Medicare beneficiaries who are institutionalized and qualifies for $0 copayments:
- A remittance from the facility showing Medicaid payment for a full calendar month for that individual during a month after June of the previous calendar year;
- A copy of a state document that confirms Medicaid payment on behalf of the individual to the facility for a full calendar month after June of the previous calendar year; or
- A screen print from the State’s Medicaid systems showing that individual’s institutional status based on at least a full calendar month stay for Medicaid payment purposes during a month after June of the previous calendar year.
Beneficiaries determined eligible by SSA
Plan sponsors must accept a copy of the award letter from SSA presented by Medicare beneficiaries who applied and were found eligible for the LIS.
When beneficiary cannot produce evidence of LIS eligibility
CMS established a new process to address the situation when a beneficiary claims to be eligible for the LIS but cannot provide any acceptable evidence (listed above). The process requires the plan sponsor to:
- Complete the “BAE Assistance worksheet” which collects the beneficiary’s information;
- Ask the beneficiary when he or she will run out of medication;
- Send the worksheet to the CMS Regional Office where the beneficiary resides within one business day of being contacted by a beneficiary;
- Notify the beneficiary of the results of CMS’ inquiry within one business day of receiving the results from CMS.
If CMS finds that a beneficiary is eligible, the plan sponsor may use the “Determination of LIS Eligibility” model notice to notify the beneficiary. Furthermore, the plan sponsor must provide Part D covered-drugs at a reduced cost-sharing level. If CMS finds that a beneficiary is not eligible, the plan sponsor may use the “Determination of LIS Ineligibility” model notice to notify the beneficiary.
Plan sponsors are required to develop appropriate member services and train their representatives to identify cases where the BAE policy applies and allow beneficiaries to submit the accept evidence. CMS has established a section on its website regarding the BAE policy, and plan sponsors are required to link to that section from their websites. CMS has also established a separate category in its Complaint Tracking Module to track issues involving the BAE policy and alerted plan sponsors that it will closely monitor their compliance with this policy.
