Moving to New MAPD Mid Year & Rx

[saintstigers]

Have a prospect who is moving to another area and qualifying for an SEP; question on Rx:

1) if someone had met their Rx deductible on their plan and moved to a new mapd plan mid-year (that also has a Rx ded), does the Rx deductible that has been met carryover to the new mapd plan?

2) furthermore, if the person was in the donut hole with their former mapd plan, would the Rx costs carryover to the new mapd plan?

I would think yes on both cases?

 

[WCMason]

Have a prospect who is moving to another area and qualifying for an SEP; question on Rx: 1) if someone had met their Rx deductible on their plan and moved to a new mapd plan mid-year (that also has a Rx ded), does the Rx deductible that has been met carryover to the new mapd plan? 2) furthermore, if the person was in the donut hole with their former mapd plan, would the Rx costs carryover to the new mapd plan? I would think yes on both cases?

You would think correctly on both cases. Deductibles and out of pocket expenses of the new plan pick up where the old plan left off.

 

[somarco]

Deductibles and out of pocket expenses of the new plan pick up where the old plan left off.

Even if changing carriers?

How does that work? Does the applicant have to get a report from the prior carrier? How long does that take and how long before the new carrier incorporates the data into their system?

 

[TwoCents]

Even if changing carriers?

How does that work? Does the applicant have to get a report from the prior carrier? How long does that take and how long before the new carrier incorporates the data into their system?

Pretty sure Rx data is tracked at the CMS level as far as the gap goes. Not sure how they control deductible "resets" though.

 

[kgmom219]

Pretty sure Rx data is tracked at the CMS level as far as the gap goes. Not sure how they control deductible "resets" though.

RX Coverage Gap Data IS tracked by CMS. Deductible data (to my knowledge) is not. There's a max deductible, but not a minimum. And if the old plan has a $250 deductible and the new plan has a $360 deductible, she's going to have to meet the additional $110. That's a carrier issue. And I would make sure you see the fine print before telling the client that her deductible would feed over.

The above is the correct answer.

The PRACTICAL answer is this:

Tell the client upfront that the information is going to feed over, but it takes a while. Get a minimum 30 day supply (90 if possible) on the last possible day of the old plan. (Its going to depend on the date of the last fill.) Then go back to the pharmacy, with a minimum of a 2 week supply in hand, to get refills on the new plan. (If she isn't on anything controlled, I would send her on the 1st day of the new plan.) If it doesn't work (and it probably won't), then the pharmacy has time to call the PBM, who is going to have to get info from CMS, then call the pharmacy back to get the RX's re-run. That's a minimum 7 day turnaround. Just let her know that it will work, but it might be a bit of a hassle.