Medicare
Contingency Plans to Address Potential Problems with the Transition of Dual-Eligible Beneficiaries from Medicaid to Medicare Drug Coverage
Gao ID: GAO-06-278R December 16, 2005
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) established a voluntary outpatient prescription drug benefit, known as Medicare Part D. The Centers for Medicare & Medicaid Services (CMS) is responsible for implementing this benefit. This new drug coverage will be provided through competing private Part D plans sponsored by health care organizations, which may charge premiums, deductibles, or copayments for drugs. As a result of MMA, on January 1, 2006, drug coverage for dual-eligible beneficiaries will transition from Medicaid to Medicare Part D. This transition will occur for approximately 6 million full-benefit dual-eligible beneficiaries--Medicare beneficiaries who receive full Medicaid benefits for services not covered by Medicare. CMS is in the process of implementing this transition. During May and June 2005, CMS mailed notices to these beneficiaries informing them of the transition in coverage and that they will receive a subsidy to cover their entire deductible and help cover any prescription drug plan (PDP) premiums. During October and November 2005, CMS automatically assigned dual-eligible beneficiaries to PDPs and mailed notices to these beneficiaries informing them of the assignment and also that they may select a different PDP if they wish. If they do not switch from their assigned PDP by December 31, 2005, CMS will automatically enroll them in that drug plan with coverage effective January 1, 2006. MMA provides that, after that date, dual-eligible beneficiaries may switch PDPs at any time. Dual-eligible beneficiaries are poorer and tend to have far more extensive health care needs than other Medicare beneficiaries. They are also more likely to be disabled, at least 85 years old, or to have cognitive impairments. Congress raised concerns that the single-day transition from one type of drug coverage to another could create difficulties in ensuring that prescriptions for this vulnerable population are filled. Congress asked us to review (1) the potential problems that may arise during the transition and (2) the contingency plans that CMS, PDPs, and states have developed to respond to potential problems with the transition.
We identified three potential problems that may leave some dual-eligible beneficiaries facing difficulties immediately obtaining necessary drugs beginning January 1, 2006. The likelihood and magnitude of these potential problems is not known. First, some individuals may not be identified for automatic enrollment in a PDP due to potential inaccuracies in state or federal data. Second, not all beneficiaries who become dually eligible in late 2005 and beyond may be identified and automatically enrolled by the date they become dually eligible. Third, given that MMA and implementing regulations require that dual-eligible beneficiaries be randomly enrolled in PDPs using two criteria--the region in which the beneficiary resides and the amount of the PDP premium--beneficiaries' prescription drugs may not be on their PDP formulary or their customary pharmacy may not be in their PDP pharmacy network. CMS, PDP, and state contingency plans address potential problems with the transition. Although each of these contingency plans is useful in mitigating risks for dual-eligible beneficiaries, their effectiveness is uncertain. For dual-eligible beneficiaries who do not have Medicare drug coverage because they were either not identified and enrolled on January 1, 2006 or are newly qualified dual-eligible beneficiaries, CMS has developed a point-of-sale enrollment mechanism designed to enable pharmacies to assist these beneficiaries in obtaining immediate Part D coverage. The agency signed a contract with a designated PDP on November 22, 2005 to implement this mechanism. Because these arrangements were completed less than 6 weeks before the transition is to occur, limited time remains to educate all pharmacies about its availability and details of its operation. For beneficiaries who were enrolled in a PDP but do not have their PDP information, CMS has facilitated a new information-technology process, known as the Eligibility Transaction, that will allow pharmacies to identify a beneficiary's PDP and provide the beneficiary with the PDP's contact information. As with the point-of-sale enrollment mechanism, it is unclear to what extent pharmacies are informed about the Eligibility Transaction and will use it. Despite CMS efforts to publicize this tool to industry organizations, a pharmacy industry association representative stated that it is unclear how many independent drug stores, which dispense the majority of the nation's retail prescription drugs, plan to use the Eligibility Transaction. To assist dual-eligible beneficiaries with prescriptions for drugs not on their PDP's formulary, according to CMS, all PDPs will offer dual-eligible beneficiaries at network pharmacies first fills of prescriptions for drugs not covered by formularies. First fills will give beneficiaries time to work with a physician to switch to a formulary drug, file an appeal for a formulary exception with their PDP, or switch PDPs. However, in order to obtain a first fill without paying out-of-pocket, beneficiaries must be at a network pharmacy. CMS officials stated that PDP formularies are robust and access to PDP pharmacy networks is broad. However, they noted that PDP formularies typically include upwards of 80 percent of the 100 most commonly used drugs. We did not evaluate the extensiveness of PDP formularies or pharmacy networks. To provide beneficiaries with time to resolve problems they may encounter and thereby minimize disruptions in treatment, state Medicaid agencies have the option to offer early or extended drug refills to dual-eligible beneficiaries prior to January 1, 2006. However, because of financial disincentives associated with the transition, state officials indicated that not all states are expected to provide such refills.
GAO-06-278R, Medicare: Contingency Plans to Address Potential Problems with the Transition of Dual-Eligible Beneficiaries from Medicaid to Medicare Drug Coverage
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entitled 'Medicare: Contingency Plans to Address Potential Problems
with the Transition of Dual-Eligible Beneficiaries from Medicaid to
Medicare Drug Coverage' which was released on December 16, 2005.
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December 16, 2005:
The Honorable Max Baucus:
Ranking Minority Member:
Committee on Finance:
United States Senate:
Subject: Medicare: Contingency Plans to Address Potential Problems with
the Transition of Dual-Eligible Beneficiaries from Medicaid to Medicare
Drug Coverage:
Dear Senator Baucus:
The Medicare Prescription Drug, Improvement, and Modernization Act of
2003 (MMA) established a voluntary outpatient prescription drug
benefit, known as Medicare Part D.[Footnote 1] The Centers for Medicare
& Medicaid Services (CMS) is responsible for implementing this benefit.
This new drug coverage will be provided through competing private Part
D plans sponsored by health care organizations, which may charge
premiums, deductibles, or copayments for drugs.[Footnote 2] As a result
of MMA, on January 1, 2006, drug coverage for dual-eligible
beneficiaries will transition from Medicaid to Medicare Part D. This
transition will occur for approximately 6 million full-benefit dual-
eligible beneficiaries--Medicare beneficiaries who receive full
Medicaid benefits for services not covered by Medicare.[Footnote 3]
CMS is in the process of implementing this transition. During May and
June 2005, CMS mailed notices to these beneficiaries informing them of
the transition in coverage and that they will receive a subsidy to
cover their entire deductible and help cover any prescription drug plan
(PDP) premiums. During October and November 2005, CMS automatically
assigned dual-eligible beneficiaries to PDPs and mailed notices to
these beneficiaries informing them of the assignment and also that they
may select a different PDP if they wish.[Footnote 4] If they do not
switch from their assigned PDP by December 31, 2005, CMS will
automatically enroll them in that drug plan with coverage effective
January 1, 2006. MMA provides that, after that date, dual-eligible
beneficiaries may switch PDPs at any time.[Footnote 5]
Dual-eligible beneficiaries are poorer and tend to have far more
extensive health care needs than other Medicare beneficiaries.[Footnote
6] They are also more likely to be disabled, at least 85 years old, or
to have cognitive impairments.[Footnote 7] You raised concerns that the
single-day transition from one type of drug coverage to another could
create difficulties in ensuring that prescriptions for this vulnerable
population are filled. You asked us to review (1) the potential
problems that may arise during the transition and (2) the contingency
plans that CMS, PDPs, and states have developed to respond to potential
problems with the transition. Enclosure I contains information we
provided during our November 14, 2005 briefing to your staff. You also
expressed concerns that dual-eligible beneficiaries in the areas
affected by Hurricane Katrina may not be able to obtain necessary drugs
on and after January 1, 2006.[Footnote 8] Enclosure II contains
information we provided during our briefing to your staff on
contingency plans related to this concern.
To address these objectives, we interviewed officials from CMS and from
Medicaid agencies in California, Montana, and Texas--states with large
urban or rural populations. We interviewed representatives from three
organizations offering Medicare PDPs, eleven drug-store chains, and the
CMS contractor responsible for implementing the Eligibility
Transaction--a contingency plan designed to identify the PDP in which a
beneficiary is enrolled. In addition, we reviewed CMS's plan for
managing the transition and the transition plans of three organizations
offering PDPs, which outline their plans to assist beneficiaries who
are transitioning to Medicare drug coverage. We spoke with officials
from the American Association of Homes and Services for the Aging, the
Center for Medicare Advocacy, the Commonwealth Fund, the Kaiser Family
Foundation, the Long Term Care Pharmacy Alliance, the Medicare Rights
Center, the National Association of Chain Drug Stores, and the National
Community Pharmacists Association. We also spoke with two independent
researchers. We conducted our work from September 2005 through December
2005 in accordance with generally accepted government auditing
standards.
Results in Brief:
We identified three potential problems that may leave some dual-
eligible beneficiaries facing difficulties immediately obtaining
necessary drugs beginning January 1, 2006. The likelihood and magnitude
of these potential problems is not known. First, some individuals may
not be identified for automatic enrollment in a PDP due to potential
inaccuracies in state or federal data. Second, not all beneficiaries
who become dually eligible in late 2005 and beyond may be identified
and automatically enrolled by the date they become dually eligible.
Third, given that MMA and implementing regulations require that dual-
eligible beneficiaries be randomly enrolled in PDPs using two criteria-
-the region in which the beneficiary resides and the amount of the PDP
premium--beneficiaries' prescription drugs may not be on their PDP
formulary or their customary pharmacy may not be in their PDP pharmacy
network.
CMS, PDP, and state contingency plans address potential problems with
the transition. Although each of these contingency plans is useful in
mitigating risks for dual-eligible beneficiaries, their effectiveness
is uncertain.
For dual-eligible beneficiaries who do not have Medicare drug coverage
because they were either not identified and enrolled on January 1, 2006
or are newly qualified dual-eligible beneficiaries, CMS has developed a
point-of-sale enrollment mechanism designed to enable pharmacies to
assist these beneficiaries in obtaining immediate Part D coverage. The
agency signed a contract with a designated PDP on November 22, 2005 to
implement this mechanism. Because these arrangements were completed
less than 6 weeks before the transition is to occur, limited time
remains to educate all pharmacies about its availability and details of
its operation.
For beneficiaries who were enrolled in a PDP but do not have their PDP
information, CMS has facilitated a new information-technology process,
known as the Eligibility Transaction, that will allow pharmacies to
identify a beneficiary's PDP and provide the beneficiary with the PDP's
contact information. As with the point-of-sale enrollment mechanism, it
is unclear to what extent pharmacies are informed about the Eligibility
Transaction and will use it. Despite CMS efforts to publicize this tool
to industry organizations, a pharmacy industry association
representative stated that it is unclear how many independent drug
stores, which dispense the majority of the nation's retail prescription
drugs, plan to use the Eligibility Transaction.
To assist dual-eligible beneficiaries with prescriptions for drugs not
on their PDP's formulary, according to CMS, all PDPs will offer dual-
eligible beneficiaries at network pharmacies first fills of
prescriptions for drugs not covered by formularies. First fills will
give beneficiaries time to work with a physician to switch to a
formulary drug, file an appeal for a formulary exception with their
PDP, or switch PDPs. However, in order to obtain a first fill without
paying out-of-pocket, beneficiaries must be at a network
pharmacy.[Footnote 9] CMS officials stated that PDP formularies are
robust and access to PDP pharmacy networks is broad. However, they
noted that PDP formularies typically include upwards of 80 percent of
the 100 most commonly used drugs. We did not evaluate the extensiveness
of PDP formularies or pharmacy networks.
To provide beneficiaries with time to resolve problems they may
encounter and thereby minimize disruptions in treatment, state Medicaid
agencies have the option to offer early or extended drug refills to
dual-eligible beneficiaries prior to January 1, 2006. However, because
of financial disincentives associated with the transition, state
officials indicated that not all states are expected to provide such
refills.
Agency Comments and Our Response:
CMS reviewed a draft of this report and provided written comments,
which appear in enclosure III.
In its comments, CMS objected to any implication that it has not taken
all steps to keep potential problems to a minimum. Furthermore, the
agency asserted that its contingency plans fully address the problems
we describe and that they will ensure that dual-eligible beneficiaries
will have immediate access to needed drugs. While we credit CMS for
taking steps to mitigate potential risk for dual-eligible
beneficiaries, we believe that the agency's complete confidence in
contingency plans that have yet to be fully tested, publicized, or
implemented may be premature. Our report provides valid reasons why the
effectiveness of these plans is uncertain at this time.
CMS also suggested that we restructure the report. It proposed that (1)
the discussion of potential problems be provided as set-up or
background information, (2) the finding on potential problems focus on
the efforts CMS has taken that ensure continuity of coverage for dual-
eligible beneficiaries, and (3) the "Results in Brief" section be
expanded to more fully describe CMS contingency plans. We organized
this report to address the two objectives set forth by our requester--
to review potential problems associated with the transition and to
review contingency plans developed to address them. In this way, the
reader is first given information on anticipated problems that may
arise from MMA transition provisions as context for understanding the
strengths and weaknesses of various contingency plans. Our "Results in
Brief" provides a balanced description of what each contingency plan is
designed to do and its potential effectiveness.
In addition, CMS contended that we did not adequately take into account
new information provided to us on November 18, 2005. The agency
referred specifically to our discussion of its point-of-sale enrollment
mechanism to guarantee immediate access to needed drugs for any dual-
eligible beneficiary not already enrolled in a PDP. At our meeting on
November 18, agency officials reported that negotiations for the point-
of-sale enrollment mechanism had not been finalized and details about
the prospective contract could not be discussed. Our draft described
the design and prospective nature of this contingency plan. While the
draft report was at CMS for review, the agency signed and publicly
announced the contract with its designated point-of-sale PDP. We have
revised our report to reflect this new information.
CMS provided technical comments which we incorporated as appropriate.
Also, the agency asked us to publish several informational documents
attached to its comments. We reviewed these documents and determined
that they did not address our findings and conclusions.
We are sending a copy of this report to the Administrator of CMS and
appropriate congressional committees. We will also make copies
available to others on request. In addition, the report is available at
no charge on GAO's Web site at http://www.gao.gov.
If you or your staff have any questions, please contact me at (202) 512-
7119 or kingk@gao.gov. Contact points for our Offices of Congressional
Relations and Public Affairs may be found on the last page of the
report. GAO staff who made major contributions to this report are
listed in enclosure IV.
Sincerely yours,
Signed by:
Kathleen M. King:
Director, Health Care:
Enclosures--4:
Enclosure I:
[See PDF for images]
[End of slide presentation]
[End of section]
Enclosure II: Potential Problems and Contingency Plans Related to the
Transition of Dual-Eligible Beneficiaries Affected By Hurricane
Katrina:
On August 29, 2005, Hurricane Katrina made landfall on the U.S. Gulf
Coast, causing widespread devastation, particularly in Alabama,
Louisiana, and Mississippi. Concerns have been raised related to dual-
eligible beneficiaries in the areas affected by the hurricane and
whether they will be able to obtain necessary drugs through Medicare
Part D on or after January 1, 2006.[Footnote 10] Specifically, these
beneficiaries may have evacuated and may no longer live in the region
in which they were assigned to a prescription drug plan (PDP).
Alternatively, certain dual-eligible beneficiaries may still reside in
the region in which they were assigned to a PDP, but the extent to
which pharmacies in the hurricane-affected areas will be available to
fill prescriptions is not known.
To address problems dual-eligible beneficiaries affected by Hurricane
Katrina may have in obtaining drugs, the Centers for Medicare &
Medicaid Services (CMS) has created a system that allows beneficiaries
assigned to PDPs in Alabama, Louisiana, or Mississippi to immediately
obtain drugs from any pharmacy they visit. Under this plan, pharmacies
will electronically submit a bill for the drugs to the beneficiary's
PDP.[Footnote 11] If the PDP's network does not include that pharmacy,
the PDP will reject the bill. In addition, if the PDP serves the
hurricane-affected areas of Alabama, Louisiana, or Mississippi, it will
notify the pharmacy that the beneficiary may be a hurricane evacuee and
advise the pharmacy to contact the PDP.
The pharmacy will contact the beneficiary's PDP and work with it to
submit an out-of-network bill. Submitting an out-of-network bill may
take up to 24 hours, but the pharmacy will immediately collect the
beneficiary's copayment and immediately dispense their drugs. To
compensate the out-of-network pharmacies for the additional effort they
must make in these cases, PDPs will reimburse them the retail price for
the drug, with Medicare contributing the difference between the retail
price and the PDP's negotiated price for network pharmacies.
CMS has directed PDPs to follow up with beneficiaries it identifies
through this process. The agency reported that if the original PDP
determines that the beneficiary has permanently relocated, that PDP
will assist them in switching to another PDP that serves their region.
If the original PDP determines that the beneficiary may return to their
home in Alabama, Louisiana, or Mississippi, or never left but cannot
access a network pharmacy, it will attempt to incorporate the pharmacy
that the beneficiary accessed into its network.
One PDP representative we spoke with stated that this plan was quite
feasible. Another stated that it was cumbersome, but useful. Two
pharmacy industry organizations we spoke with did not express concern
about this plan, and one stated that it was useful and workable.
[End of section]
Enclosure III: Comments from the Centers for Medicare & Medicaid
Services:
DEPARTMENT OF HEALTH & HUMAN SERVICES:
Centers for Medicare & Medicaid Services:
Administrator:
Washington, DC 20201:
DEC 1 2005:
TO: Kathleen M. King:
Director, Health Care:
Government Accountability Office:
FROM: Mark B. McClellan, M.D., Ph.D.:
Administrator:
Centers for Medicare & Medicaid Services:
SUBJECT: GAO Draft Correspondence: MEDICARE: Contingency Plans to
Address Potential Problems with the Transition of Dual-Eligible
Beneficiaries from Medicaid to Medicare Drug Coverage (GAO-06-278R):
Thank you for the opportunity to review and comment on the GAO draft
correspondence entitled, MEDICARE: Contingency Plans to Address
Potential Problems with the Transition of Dual-Eligible Beneficiaries
from Medicaid to Medicare Drug Coverage.
The Centers for Medicare & Medicaid Services (CMS) has significant
concerns about the GAO findings. CMS has been working diligently on the
transition from Medicaid to Medicare drug coverage for full-benefit
dual eligible beneficiaries, and as a result, these individuals will
get effective, comprehensive prescription drug coverage when the new
Medicare prescription drug benefit begins on January 1, 2006.
Establishing a standard of absolute perfection for this transition,
when dealing with over 6 million dual eligible individuals, is clearly
untenable-and certainly State Medicaid programs do not meet such a
standard with access to drugs today. Yet even in GAO's own analysis,
GAO notes in slide 24 that CMS contingency plans will allow a dual
eligible beneficiary to "immediately" obtain needed drugs.
Consequently, we object to any implication that we have not taken all
steps to keep potential problems to a minimum, including establishing a
point-of-sale safety net for any dual eligible individual that somehow
are not identified and assigned to a plan in advance of January 1,
2006. Thus, we believe that the CMS contingency plans have fully
addressed the problems that GAO was asked to investigate, and that they
will produce prescription drug coverage for the dual eligible
population that is at least as accessible and comprehensive as the
coverage they have had in the past.
As discussed in detail below, CMS has provided a great deal of
information to answer the two key questions raised by the Senate
Finance Committee's Ranking Minority Member. Thus, we believe that both
the letter to Senator Baucus and the report's major findings should be
revised to reflect the fact that CMS has developed appropriate
contingency plans to address potential problems, and that these
contingency plans will ensure that dual eligible beneficiaries will
have immediate access to needed drugs.
Moreover, CMS remains concerned with the inappropriate and premature
distribution of the preliminary GAO findings, which prompted inaccurate
press coverage of the correspondence in the November 18, 2005
Washington Post concerning the GAO's alleged findings.
General Comments:
CMS has made an intensive effort to identify and auto-enroll dual
eligible individuals prior to the effective date of their Medicare Part
D eligibility. However, it is possible that some individuals may go to
pharmacies before they have been auto-enrolled in a Part D plan. For
this reason CMS has developed a process for a point-of-sale interaction
to ensure full-benefit dual eligible beneficiaries experience no
coverage gap. Beneficiaries who present at a pharmacy with evidence of
both Medicaid and Medicare eligibility, but without current enrollment
in a Part D plan, can have the claim for their medication submitted to
a single account for payment. The beneficiary can leave the pharmacy
with a filled prescription, and a CMS contractor will immediately
follow up to validate eligibility and facilitate enrollment of the full-
benefit dual eligible into a Part D plan. We described this process to
the GAO at our exit conference on November 18, 2005 (a detailed
description of this process is attached). Therefore, as we stated at
the time, CMS believes the first formal finding of the report should
reflect the fact that CMS has established effective contingency plans
to ensure that dual-eligible beneficiaries will be able to obtain
comprehensive coverage and obtain necessary drugs beginning January 1,
2006.
Similarly, we recommend that the second finding of the report should be
revised substantially. Currently, the "Results in Brief" section of the
cover letter to the report includes only one sentence noting that CMS
contingency plans "address potential problems with the transition but
have limitations." This statement is preceded by a full paragraph
laying out the potential problems under investigation and then another
paragraph describing the alleged limitations. Instead, we believe that
this key section of the letter should (1) clarify that the potential
problems identified in the first paragraph were the intended subject of
the report-not the findings; and (2) prominently describe the CMS
contingency plans.
Thus, despite extensive discussions at the November 18, 2005, GAO exit
conference, we do not believe GAO has adequately taken into account the
new information provided by CMS. Most notably, although additional
technical information was incorporated into both the GAO letter to
Senator Baucus and the GAO report itself, these documents continue to
assert that (1) some dual-eligible beneficiaries will encounter
difficulties immediately obtaining necessary drugs, and (2) some dual-
eligible beneficiaries will face 1-2 month coverage gaps. Neither of
these assertions is accurate and the GAO's own slide presentation
recognizes this. For example, slide 24 of the report states that, "The
pharmacy will submit a bill to a designated PDP, which will provide
interim coverage to allow the beneficiary to immediately obtain drugs
while a CMS contractor officially verifies their eligibility."
(Emphasis added.) CMS' point of sale enrollment system guarantees
immediate access to needed drugs for any dual eligible beneficiary not
already enrolled in a prescription drug plan.
[End of section]
Enclosure IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
Kathleen M. King, (202) 512-7119 or kingk@gao.gov.
Acknowledgments:
In addition to the contact named above, Rosamond Katz, Assistant
Director; Joanna L. Hiatt; and Grace A. Materon made key contributions
to this report.
(290493):
FOOTNOTES
[1] Pub. L. No. 108-173, § 101, 117 Stat. 2066, 2071-2152.
[2] MMA and CMS regulations require that each Part D plan meet
standards as to the categories of drugs it must cover, or include on
its formulary, and the extent of its pharmacy networks. Within these
standards, the specific formulary and pharmacy network of each plan may
vary. However, CMS required all plans to cover all or substantially all
drugs in six categories, including antidepressants, antipsychotics,
anticonvulsants, anticancer drugs, immunosuppressants, and human
immunodeficiency virus and acquired immunodeficiency syndrome drugs.
[3] Of these 6 million beneficiaries, approximately 0.6 million are
enrolled in managed care organizations and other plans and will not be
addressed in this report. There are also approximately 1 million other
dual-eligible beneficiaries, known as partial-benefit dual-eligible
beneficiaries, who do not receive Medicaid drug coverage, and thus, are
not involved in this transition.
[4] According to CMS, as of November 2005, the agency had identified
approximately 6.1 million dual-eligible beneficiaries. Of these,
approximately 5.5 million individuals have been automatically assigned
to a PDP. Most of the remaining 0.6 million beneficiaries are enrolled
in and will receive drug coverage through managed care organizations or
other plans.
[5] According to CMS, beneficiaries' choices will only be effective the
first day of the month following the month in which their new PDP
receives their completed application.
[6] Medicare Payment Advisory Commission, Report to the Congress: New
Approaches in Medicare (Washington, D.C.: June 2004). Includes all dual-
eligible beneficiaries, both full-and partial-benefit.
[7] Medicare Payment Advisory Commission, Report to the Congress.
Includes all dual-eligible beneficiaries, both full-and partial-
benefit.
[8] On August 29, 2005, Hurricane Katrina made landfall on the U.S.
Gulf Coast, causing widespread devastation, particularly in Alabama,
Louisiana, and Mississippi.
[9] At out-of-network pharmacies, beneficiaries may pay the retail
price out-of-pocket for their drugs and submit a claim for
reimbursement to their PDP. However, CMS acknowledged that it is
unlikely that dual-eligible beneficiaries will be able to pay the
retail price out-of-pocket.
[10] Major hurricanes also made landfall in other areas of the United
States in 2005. However, contingency plans related to the transition
are in place only with respect to Alabama, Louisiana, and Mississippi.
[11] If necessary, pharmacies will first use the Eligibility
Transaction to determine the PDP to which the beneficiary belongs.