Medicare Compliance & Reimbursement

You should have fewer headaches related to beneficiaries' low-income status in the coming months -- if you keep this tip sheet on hand.

To clear up confusion about what constitutes acceptable documentation for a beneficiary's low-income status, the Centers for Medicare & Medicaid Services (CMS) issued a related guidance on Nov. 1.

"Part D plans must accept any one of the following forms of evidence from beneficiaries or pharmacists to make a change to a beneficiary's low-income status," says CMS' Chris Worrall:

• A copy of the member's Medicaid card which includes the member's name and an eligibility date during the discrepant period;

• A report of contact including the date a verification call was made to the state Medicaid agency and the name, title and telephone number of the state staff person who verified the Medicaid status during the discrepant period;

• A copy of a state document that confirms active Medicaid status during the discrepant period;

• A printout from the state electronic enrollment file showing Medicaid status during the discrepant period;

• A screen print from the state's Medicaid systems showing Medicaid status during the discrepant period; or

• Other documentation provided by the state showing Medicaid status during the discrepant period.

Don't forget verification: Part D plans must accept any one of the following forms of evidence from beneficiaries or pharmacists to establish that a beneficiary is institutionalized and qualifies for zero cost-sharing:

• A remittance from the facility showing Medicaid payment for a full calendar month for that individual during the discrepant period;

• A copy of a state document that confirms Medicaid payment to the facility for a full calendar month on behalf of the individual; 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 the discrepant period.

CMS will be closely monitoring Part D plan compliance with the new policy, says Worrall.