In accordance with the statutory requirement to provide a cost-sharing subsidy to Part D eligible individuals who are full-benefit dual eligible individuals or recipients of supplemental security income (SSI), Senior Care Plus must provide access to Part D drugs at the correct LIS cost-sharing level when presented with evidence of LIS eligibility, even if our systems and CMS’ systems do not yet reflect that eligibility.
Senior Care Plus also must update our systems to reflect the LIS status indicated by the best available evidence and, if necessary, must submit a request to CMS so that, for the deemed population, the agency’s systems can be updated as well. These requirements apply to all beneficiaries who are “deemed” subsidy eligible (including full benefit Medicare/ Medicaid eligibles, partial dual eligibles, and people receiving SSI) as well as those who must apply and are awarded LIS by the Social Security Administration (SSA).
Senior Care Plus is required to accept any of the following forms of evidence to establish the subsidy status of a full benefit dual eligible beneficiary when provided by the beneficiary or the beneficiary’s pharmacist, advocate, representative, family member or other individual acting on behalf of the beneficiary:
Senior Care Plus must also 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:
As soon as one of the forms of BAE listed above is presented, Senior Care Plus must provide the beneficiary access to covered Part D drugs at a reduced cost-sharing level which is no greater than the higher of the LIS cost-sharing levels for full subsidy eligibles (in 2018, this level is $3.35 per generic or preferred brand name drug; $8.35 per brand name drug), or at zero cost-sharing if the BAE also verifies the beneficiary’s institutional status.
Once Best Available Evidence is supplied, Senior Care Plus will update our systems to reflect the correct LIS status, override standard cost-sharing, and maintain an exceptions process for the beneficiary to obviate the need to require the re-submission of documentation each month pending the correction of the beneficiary’s LIS status in CMS systems. We will update our systems within 48-72 hours of our receipt of BAE documentation. This is in addition to the requirement that we provide access to covered Part D drugs as soon as BAE is presented.
In addition to the requirements clarified above, there is also a process for assisting individuals who claim to be subsidy eligible based on being full or partial dual eligibles but who cannot provide the documentation described above. As part of this process, Senior Care Plus is required to take the following actions:
For more information regarding “Best Available Evidence” Click Here to visit the CMS website address.
Material ID: Y0039_2019_SCPWebsite_M (CMS Accepted) Last Updated 10/08/2018