Medicare Compliance & Reimbursement

Carelessness could mean trouble when it comes to Part D plan selection.

Long-term care facilities that fail to deal with the advent of Medicare Part D could cause residents to suffer gaps in prescription drug coverage, insiders say.

The Centers for Medicare and Medicaid Services "is being very aggressive in getting the program up and running," comments Chuck Sheets, an attorney in Foley & Lardner's new long-term care group in Chicago.

With the initial enrollment period set to commence Oct. 15, providers should be drafting their to-do lists now, recommends Betsy Anderson with FR&R Health care Consulting in Deerfield, IL.

Despite CMS' reputation for false starts and delays in many programs, Part D will progress as scheduled, warns Sheets - at a rapid-fire pace. Providers should start sorting out likely scenarios to prepare for dual-eligible residents' shift from the longstanding Medicaid drug benefit to Medicare's new Part D.

When that change rolls in with the New Year on Jan. 1, Medicare Part D will assume its role as the primary payer for dual-eligibles' prescription drugs.

Others may also be affected, including private-pay residents and low-income residents near the Medicaid threshold. Part D's biggest impact, however, will be its effect on dual-eligibles, residents who qualify for both Medicaid and Medicare. By Jan. 1, every dual-eligible will be enrolled in one of Part D's new Prescription Drug Plans. Dually eligible residents will wind up with a PDP in one of two ways:

Scenario 1: Some residents will handpick a PDP, often with the help of family members or a guardian. In some states, the nursing home itself may act as a "personal representative" influencing plan choice, but that's not likely to affect many beneficiaries, reports Anderson. That's because a nursing home could only choose a PDP if it has been named as an incompetent resident's legal representative according to state law.

Scenario 2: For some dually eligible residents, the feds will assign a PDP randomly. This default option kicks in when a dual eligible and/or his representatives fail to choose a plan by the Dec. 31 deadline.