Helping New Dual Eligibles Get Medications Before Extra Help Is Updated
Dual eligibles (people that have both Medicare and Medicaid) sometimes experience delays with getting their automatic Extra Help when they are new to either the Medicare or Medicaid system. This can cause problems when people try to get their medications refilled – sometimes people miss doses because they cannot afford to get their medications, or they pay higher costs than they should for their medications. We wanted to remind readers about what new dual eligibles can do if they need to get medications and the Extra Help information isn’t yet showing in the Medicare system or their drug plan’s system.
Extra Help limits what people pay for their Medicare Part D drug coverage and for their medications. People who are dual eligibles automatically qualify for Extra Help. This includes people who get full Medicaid benefits as well as people who only get the help with the Medicare Part B premiums and/or Medicare cost-sharing. When someone has full Medicaid benefits and starts to get Medicare, Medicaid stops covering most of their prescription drugs and they must go through the Medicare Part D system for their drug coverage. People can also qualify for Extra Help by applying for it and meeting certain income and resource limits. Click here to see a fact sheet about qualifying for Extra Help in 2023.
LINET
The LINET (Limited Income Newly Eligible Transition) Program provides temporary, safety-net drug coverage for people eligible for Extra Help who are not yet enrolled in a Medicare prescription drug plan. LINET is available to people in original Medicare. It will not work for someone who is enrolled in a Medicare Advantage plan (regardless of whether the plan includes drug coverage) or already enrolled in a Medicare Part D plan.
Sometimes Medicare enrolls people in LINET for temporary prescription drug coverage. Individuals can also be enrolled at the pharmacy counter (using information available here) or by reaching out to the LINET program Help Desk for coverage at 1-800-783-1307. Advocates helping people access LINET coverage can call LINET’s Advocacy Line at 1-866-934-2019.
People seeking help through LINET must show proof that they are eligible for Extra Help unless the system is already showing Medicaid coverage. This proof could be a Medicaid eligibility notice, an Extra Help eligibility letter, a print-out from the Medicaid eligibility verification system, or a person’s Medicaid card. If someone has an urgent need for medications, the pharmacy can get an override from LINET and the medications will be covered at the lower Extra Help copay while proof is submitted and the LINET system is updated. Individuals who paid out of pocket for medications after becoming eligible for Extra Help can contact LINET for instructions about seeking reimbursement.
People enrolled in LINET receive a welcome letter with information about LINET coverage, enrollment dates, and Medicare Part D enrollment information. Once a beneficiary enrolls in a Part D plan, LINET coverage will end when the new coverage begins. If a beneficiary does not choose a plan, Medicare will auto-enroll them into a stand-alone Part D plan.
Best Available Evidence
If someone is enrolled in a Part D plan, either through a stand-alone Part D plan or a Medicare Advantage plan that covers medications, but their Extra Help status is not showing in the system, they can provide proof of their Medicaid eligibility to their plan. When the plan gets this proof, they must update the Extra Help information in the system. The Medicaid proof serves as “Best Available Evidence” that someone automatically qualifies for full Extra Help. Examples of proof of Medicaid coverage include an eligibility notice showing that someone was approved for Medicaid or one of the Medicare Savings Programs on or after July 1st of the previous year or a screen print out from the Medicaid Eligibility Verification System showing active coverage on or after July 1st of the previous year. People who are in nursing homes whose stay is being paid for by Medicaid can show a bill from the nursing home showing Medicaid payment for a full calendar month on or after July 1st of the previous year.
People can contact their Part D plan’s member services number to find out more about the Best Available Evidence process. Member services should give beneficiaries a fax number where they can send proof of Medicaid coverage. Upon receiving the proof, the Part D plan must update their system within 48-72 hours. If needed, they must provide immediate access to covered Part D drugs at the Extra Help copay level. This is typically done through an override process between the pharmacy and the Part D plan.
Extra Help should start as of the month that someone became a dual eligible. Individuals in a Part D plan who paid for medications before the Extra Help information was updated in the plan’s system should be able to seek reimbursement from the plan. Member services should be able to give people instructions on how to request a refund.
New dual eligibles who are having problems getting medications can contact PA MEDI at 1-800-783-7067 or PHLP’s Helpline at 1-800-274-3258 or staff@phlp.org.
