CMS Secret Shopper Question

[SukiSays]

Question: If my aunt enrolls in your Medicare Advantage plan and she just received her entitlement letter from Medicaid, can she save money immediately by presenting that letter to the pharmacy?

Will the MA member get the LIS/Dual eligible low rx copay by providing the pharmacy the letter from Medicaid and the pharmacy will enter the info in their system that will subsequently notify the MA plan of the member's dual eligible status?

 

[Josh]

Have the provider (in this case pharmacy) contact the carrier. Odds are just presenting the letter won't be enough, but stranger things have happened.

 

[yogooglethis]

Question: If my aunt enrolls in your Medicare Advantage plan and she just received her entitlement letter from Medicaid, can she save money immediately by presenting that letter to the pharmacy?

Will the MA member get the LIS/Dual eligible low rx copay by providing the pharmacy the letter from Medicaid and the pharmacy will enter the info in their system that will subsequently notify the MA plan of the member's dual eligible status?

How long have you been a secret shopper?

Social Security not Medicaid funds the LIS.If she has been approved for LIS for lets say 2/1/12( it always reverts to first day of month) then the co pays are set depending on what level of LIS she was awarded and pharmacy will charge accordingly as long as its an in network pharmacy and drugs are on the formulary.

 

[SukiSays]

How long have you been a secret shopper?

Social Security not Medicaid funds the LIS.If she has been approved for LIS for lets say 2/1/12( it always reverts to first day of month) then the co pays are set depending on what level of LIS she was awarded and pharmacy will charge accordingly as long as its an in network pharmacy and drugs are on the formulary.

I'm not a shopper. This is a question posed by a shopper and they require a yes or no answer. According to your explanation the correct answer would by 'yes', correct?

Thank you,
Suki

 

[Franz Kafka]

I'm not a shopper. This is a question posed by a shopper and they require a yes or no answer. According to your explanation the correct answer would by 'yes', correct?

If I say "I have no idea", will they send me to Guantanamo?

 

[djs]

Actually, the answer is NO.
If you answer yes, you get sent to remedial CMS classes for 6 months, much worse than Guantanomo!

Why is it NO? As YoGoogle said, there is a start date for the benefit. Providing a copy of the letter doesn't allow you to start early. Crossing that date allows you to start.

Dan

P.S. I did not certify this year. I am not subject to secret shoppers. I can answer anything I want

 

[Josh]

Secret shoppers are uneducated members of a witch hunt.

 

[xrac]

Secret shoppers are uneducated members of a witch hunt.

They are the blind led by the blind.

 

[G.Gordon]

As with my experience with Extra Help Status... it can vary.

Having a letter and giving that to the pharmacy/provider does not give the beneficiary a 100% guarantee that they will experience LIS copays. It depends on IF the whole claim processing system is updated with that bene's info.

And there are other situations. I have a client, got a letter from Social Security of a 100% status for 2012. Goes to pharmacy, pays full copay, bitches to me and the plan. Investigation shows that Medicaid "deemed" him eligible... he never applied to social sec... so his drugs do not get the reduced copay... he does not pay a premium for his pdp since medicaid is paying for it. What does he have to do... apply via social security for extra help.

LIS is a multi leveled and f'd up situation to understand.

Right answer for you SS... "Every beneficiary is different, there are several eligibility factors that go into play as well as system updates to make one's extra help status "work" for that beneficiary."

 

[SportsNut]

And there are other situations. I have a client, got a letter from Social Security of a 100% status for 2012. Goes to pharmacy, pays full copay, bitches to me and the plan. Investigation shows that Medicaid "deemed" him eligible... he never applied to social sec... so his drugs do not get the reduced copay... he does not pay a premium for his pdp since medicaid is paying for it. What does he have to do... apply via social security for extra help.

LIS is a multi leveled and f'd up situation to understand."

If I understand the situation above, I would say that someone in M'caid who qualified your client screwed up and didn't fill out the SSA form. They should have finsihed the job for the beneficiary. How would a client know that they need to apply to SSA for extra help...? They don't, and consequently this is part of what social services should be doing for them, IMO.

Additionally, if you as the Agent knew that the client was eligible, or would be based on income, you should have made certain that the SSA appl was completed...

I guess I don't share your opinion that LIS is messed up... I see it work for many ppl and really haven't seen any downside as long as the simple 5 min appl is filled out; (online). Yes, SSA isn't going to offer LIS unless the appl is submitted... so if that is messed up then we are worse off than I thought we were.