The Centers for Medicare and Medicaid Services (CMS) announced a new system to help beneficiaries who receive the Part D low-income subsidy (LIS) have better access to their prescription drugs when they’re not enrolled in a Part D plan. As of January 1, 2010, this system will replace the current Point of Sale (POS) system operated by WellPoint. The new system is called Limited Income Newly Eligible Transition (LI NET) program, and Humana has been awarded the CMS contract to operate it.
The POS system is designed to provide temporary prescription drug coverage when someone who is enrolled in the LIS is not enrolled in a Part D plan. This can happen for a variety of reasons, including if there’s a glitch in the system and people who are supposed to be auto-enrolled in a Part D plan aren’t, or if a beneficiary experiences a time gap from when they are found LIS eligible and when their Part D plan enrollment becomes effective. The POS system gives people coverage and therefore access to their prescription drugs AND at the same time randomly enrolls the people using the POS system into a Part D benchmark prescription drug plan.
Starting in 2010, the new system, LI NET (whose plan name is One (# X0001), in addition to offering temporary drug coverage and prospective random enrollment into a Part D plan for uncovered LIS-eligible beneficiaries, will also offer some retroactive coverage to uncovered LIS eligible beneficiaries and full-benefit dual eligible and SSI-only beneficiaries. Uncovered full-benefit dual-eligible and SSI-only beneficiaries will have retroactive coverage up to at least 36 months, while all other beneficiaries with LIS will have retroactive coverage for 30 days.
This retroactive coverage is different than the present system in several ways:
- Currently all retroactive coverage is provided by the Part D plan into which the beneficiary is automatically enrolled. This means that different plan rules and formularies apply to beneficiaries depending on into which Part D plan they’re enrolled. The new LI NET system is simplier in that all retroactive coverage is provided through one plan, LI NET. Also, the LI NET plan has an open formulary, no prior authorization requirements, no network pharmacy restrictions nor timely filing deadlines.
- The current process provides 90 days of retroactive coverage (through the Part D plan into which the beneficiary is enrolled). LI NET, as mentioned above, will provide: up to 36 months of retroactive covearge for uncovered full benefit dual eligible beneficiaries; up to 30 days for partial benefit dual eligibles (those who qualify for a Medicare Savings Program but not full Medi-Cal) and LIS applicants; and up to 7 days for “unconfirmed beneficiaries” –meaning they do not show up as having LIS in CMS’ systems.
- Exceptions requests are currently made only through CMS caseworkers. Under LI NET, anyone can request an eligibility review.
Effective January 1, 2010, the LI NET program can be reached at:
Questions on the LI NET program can be sent to CMS atMedicareLINET@cms.hhs.gov. For more information on LI NET, see CMS’ webpage. It contains a helpful fact sheet (PDF) and ppt presentation on the new LI NET program. It also has two fact sheets for pharmacists and a document (PDF) for uisng the POS exceptions (appeals) process.