managed care enrollment question

[Guest guest]

I know I am late to this conversation. I have not been fully paying attention to

the posts about managed care because my son(22 yrs old) is still on our private

insurance and we never have actually used his medicaid. We live in Lake County

and he has not rcvd an enrollment packet. After looking at the file that Ellen

just posted I am wondering

if I need to be requesting a packet and enrolling him in a plan regardless of

whether we are actually using the medicaid right now? We

also have not rcvd any notification that he has been randomly assigned to either

group. Any ideas ?

Thanks,

Maureen

[Guest guest]

My son is 21 and we have him on both systems.  Some of his dr. do not take

medicaid and then we use private insurance.  The medicaid helps with his

meds.  Most of them are covered 100%.

Maureen

From: autismmom58 <bittomom@...>

Subject: managed care enrollment question

IPADDUnite

Date: Wednesday, August 10, 2011, 10:57 PM

 

I know I am late to this conversation. I have not been fully paying

attention to the posts about managed care because my son(22 yrs old) is still on

our private insurance and we never have actually used his medicaid. We live in

Lake County and he has not rcvd an enrollment packet. After looking at the file

that Ellen just posted I am wondering

if I need to be requesting a packet and enrolling him in a plan regardless of

whether we are actually using the medicaid right now? We

also have not rcvd any notification that he has been randomly assigned to either

group. Any ideas ?

Thanks,

Maureen

[Guest guest]

I have a related question for any of our online experts, and it’s this:

Somewhere I heard that there’s a unit of state government, who’s reason for

being is to take processed/approved Medicaid claims and file with whatever

private insurance carrier the individual may also be covered by...I’m assuming

this is mostly for prescription drugs, since when I go to my local Walgreens,

for example, they give me a choice (they’ll only bill one vendor) and they say

‘if we put it thru to your BCBS, it’ll cost $495, if we bill it to Medicaid

it’s zero.’

Well, that was always an easy answer, right? That was before I understood,

though, that Medicaid is always the payer of last resort, and that they will

approve bills but then have to go after our BCBS after the fact. Is this true?

Does this make sense? And if no, what is the fix? Can an individual respond to

a Walgreens pharmacist by saying ‘Please bill both BCBS and Medicaid and let

them sort it out’?

I hate thinking that we’re doing something wrong if in fact we’re abusing

the Medicaid system. What should we be doing?

Thanks.

L.

From: Maureen Hartnett

Sent: Thursday, August 11, 2011 9:08 AM

IPADDUnite

Subject: Re: managed care enrollment question

My son is 21 and we have him on both systems. Some of his dr. do not take

medicaid and then we use private insurance. The medicaid helps with his meds.

Most of them are covered 100%.

Maureen

From: autismmom58 <mailto:bittomom%40sbcglobal.net>

Subject: managed care enrollment question

mailto:IPADDUnite%40

Date: Wednesday, August 10, 2011, 10:57 PM

I know I am late to this conversation. I have not been fully paying attention to

the posts about managed care because my son(22 yrs old) is still on our private

insurance and we never have actually used his medicaid. We live in Lake County

and he has not rcvd an enrollment packet. After looking at the file that Ellen

just posted I am wondering

if I need to be requesting a packet and enrolling him in a plan regardless of

whether we are actually using the medicaid right now? We

also have not rcvd any notification that he has been randomly assigned to either

group. Any ideas ?

Thanks,

Maureen

[Guest guest]

If your son is on your own insurance, than Medicaid is secondary and you aren't

being forced onto the new program.

>

> I know I am late to this conversation. I have not been fully paying attention

to the posts about managed care because my son(22 yrs old) is still on our

private insurance and we never have actually used his medicaid. We live in Lake

County and he has not rcvd an enrollment packet. After looking at the file that

Ellen just posted I am wondering

> if I need to be requesting a packet and enrolling him in a plan regardless of

whether we are actually using the medicaid right now? We

> also have not rcvd any notification that he has been randomly assigned to

either group. Any ideas ?

> Thanks,

> Maureen

>

[Guest guest]

My son is also on our insurance and will be 22 next week.  Is that why we

haven't received any info on the new program?  Been reading the post and I've

been totally confused.  It doesn't take much to confuse me these days.

Liz

________________________________

From: cmfinato <cmfinato@...>

IPADDUnite

Sent: Thursday, August 11, 2011 9:58 AM

Subject: Re: managed care enrollment question

 

If your son is on your own insurance, than Medicaid is secondary and you aren't

being forced onto the new program.

>

> I know I am late to this conversation. I have not been fully paying attention

to the posts about managed care because my son(22 yrs old) is still on our

private insurance and we never have actually used his medicaid. We live in Lake

County and he has not rcvd an enrollment packet. After looking at the file that

Ellen just posted I am wondering

> if I need to be requesting a packet and enrolling him in a plan regardless of

whether we are actually using the medicaid right now? We

> also have not rcvd any notification that he has been randomly assigned to

either group. Any ideas ?

> Thanks,

> Maureen

>

[Guest guest]

Liz,

You are correct. If your son/daughter is still covered under private insurance,

and is also Medicaid-eligible, you do not go into this Managed Care Pilot.

L.

From: Liz Youhana

Sent: Thursday, August 11, 2011 10:07 AM

IPADDUnite

Subject: Re: Re: managed care enrollment question

My son is also on our insurance and will be 22 next week. Is that why we

haven't received any info on the new program? Been reading the post and I've

been totally confused. It doesn't take much to confuse me these days.

Liz

________________________________

From: cmfinato <mailto:cmfinato%40>

mailto:IPADDUnite%40

Sent: Thursday, August 11, 2011 9:58 AM

Subject: Re: managed care enrollment question

If your son is on your own insurance, than Medicaid is secondary and you aren't

being forced onto the new program.

>

> I know I am late to this conversation. I have not been fully paying attention

to the posts about managed care because my son(22 yrs old) is still on our

private insurance and we never have actually used his medicaid. We live in Lake

County and he has not rcvd an enrollment packet. After looking at the file that

Ellen just posted I am wondering

> if I need to be requesting a packet and enrolling him in a plan regardless of

whether we are actually using the medicaid right now? We

> also have not rcvd any notification that he has been randomly assigned to

either group. Any ideas ?

> Thanks,

> Maureen

>

[Guest guest]

Laurie is correct that those people who are currently covered under private

insurance are not part of the Integrated Care pilot...Laurie's question about

Medicaid and private insurance, in respect to medications is an interesting one.

Perhaps Sherri Schneider knows the answer to this one?

I have a related question for any of our online experts, and it’s this:

Somewhere I heard that there’s a unit of state government, who’s reason for

being is to take processed/approved Medicaid claims and file with whatever

private insurance carrier the individual may also be covered by...I’m assuming

this is mostly for prescription drugs, since when I go to my local Walgreens,

for example, they give me a choice (they’ll only bill one vendor) and they say

‘if we put it thru to your BCBS, it’ll cost $495, if we bill it to Medicaid it’s

zero.’

Well, that was always an easy answer, right? That was before I understood,

though, that Medicaid is always the payer of last resort, and that they will

approve bills but then have to go after our BCBS after the fact. Is this true?

Does this make sense? And if no, what is the fix? Can an individual respond to a

Walgreens pharmacist by saying ‘Please bill both BCBS and Medicaid and let them

sort it out’?

I hate thinking that we’re doing something wrong if in fact we’re abusing the

Medicaid system. What should we be doing?

Ellen

Ellen Garber Bronfeld

egskb@...

[Guest guest]

There are actually two different departments within Medicaid:

 

1) The TPL unit  (Third Party Liability Unit)

 - this unit ensures that correct & current OTHER payors are attached to a

Medicaid case

- you can look at your Medi-plan card to find your TPL code - back side - upper

right.

- each payor has a 3 digit code which lets Springfield know to ONLY pay AFTER

this other payor pays

- many of my clients are receiving Integrated Care packages - despite the fact

that they have commercial insurance. I call this unit, first, to ensure that

Medicaid has the other health insurance information.

- this is the unit that puts on the TPL, updates the TPL (in case the health

insurance changes) and removes the TPL

 

2) The Department of Collections

- this is the department that collects money FROM the other payors - if Medicaid

paid first

- ie: I have Blue Cross & Blue Shield & Medicaid. Medicaid paid first and now

Medicaid is aware of Blue Cross & Blue Shield. This department seeks

reimbursement from Blue Cross & Blue Shield.

 

********* I have been hearing, repeatedly, that many pharmacies will NOT bill

two payors. That means we cannot take advantage of Medicaid's lower co-pays for

drugs. I have just spoken with " the powers that be " in Medicaid. They would like

some examples of: which Walgreens store, which Osco store, which CVS

store...etc...so that they can fix this problem for us.   PLEASE send me

examples, asap, so that they can correct this for all of us*********

 

-Sherri

From: ELLEN BRONFELD <egskb@...>

IPADDUnite

Sent: Friday, August 12, 2011 7:20 AM

Subject: Re: managed care enrollment question

Laurie is correct that those people who are currently covered under private

insurance are not part of the Integrated Care pilot...Laurie's question about

Medicaid and private insurance, in respect to medications is an interesting

one.  Perhaps Sherri Schneider knows the answer to this one?

I have a related question for any of our online experts, and it’s this:

Somewhere I heard that there’s a unit of state government, who’s reason for

being is to take processed/approved Medicaid claims and file with whatever

private insurance carrier the individual may also be covered by...I’m assuming

this is mostly for prescription drugs, since when I go to my local Walgreens,

for example, they give me a choice (they’ll only bill one vendor) and they say

‘if we put it thru to your BCBS, it’ll cost $495, if we bill it to Medicaid

it’s zero.’

Well, that was always an easy answer, right? That was before I understood,

though, that Medicaid is always the payer of last resort, and that they will

approve bills but then have to go after our BCBS after the fact. Is this true?

Does this make sense? And if no, what is the fix? Can an individual respond to a

Walgreens pharmacist by saying ‘Please bill both BCBS and Medicaid and let

them sort it out’?

I hate thinking that we’re doing something wrong if in fact we’re abusing

the Medicaid system. What should we be doing?

Ellen

Ellen Garber Bronfeld

egskb@...

[Guest guest]

Sherri,

Thanks for confirming my worst fears! But before I go ‘turning in’ my

favorite Walgreens store – and by the way, this is NOT limited to just one

store but is, I gather, a corporate policy about ‘only 1 billing’ – please

help us understand what role DOES Medicaid play, then, in helping poor people

like our adults with DDs pay for their medications?

Could we work through an example for the group?

My husband’s BCBS work/group plan is a high deductible plan – including

scripts – so we pay the first $6,000/year of medical costs, including 100% of

any scripts, until we reach that $6,000 out-of-pocket deductible. After that we

have a $30/co-pay per prescription per month.

So in ’s case, she is dual eligible for BCBS and Medicaid. She CANNOT

afford to pay for her own scripts. But...what I’m hearing you say is that BCBS

should be billed for her meds FIRST by the Walgreens store and NOT Medicaid.

Okay, so what happens after BCBS either a) pays $0 while we’re still working

towards that $6,000/deductible or when they charge the $30 per script per

month (which would be $120/month for all four scripts). Does Medicaid factor in

anywhere to make up the difference between the cost of the drug and the

co-pays/deductibles?

Is (or her guardian) expected to then submit the receipts for meds to

Medicaid? I don’t think so.

There’s got to be a better way. Are the pharmacies under any obligation to

double bill? Are there pharmacies that do this currently?

Did I just open up a HUGE can of worms here????????????????????

Laurie

From: Sherri Schneider

Sent: Monday, August 15, 2011 9:37 AM

IPADDUnite

Subject: Re: Re: managed care enrollment question

There are actually two different departments within Medicaid:

1) The TPL unit (Third Party Liability Unit)

- this unit ensures that correct & current OTHER payors are attached to a

Medicaid case

- you can look at your Medi-plan card to find your TPL code - back side - upper

right.

- each payor has a 3 digit code which lets Springfield know to ONLY pay AFTER

this other payor pays

- many of my clients are receiving Integrated Care packages - despite the fact

that they have commercial insurance. I call this unit, first, to ensure that

Medicaid has the other health insurance information.

- this is the unit that puts on the TPL, updates the TPL (in case the health

insurance changes) and removes the TPL

2) The Department of Collections

- this is the department that collects money FROM the other payors - if Medicaid

paid first

- ie: I have Blue Cross & Blue Shield & Medicaid. Medicaid paid first and now

Medicaid is aware of Blue Cross & Blue Shield. This department seeks

reimbursement from Blue Cross & Blue Shield.

********* I have been hearing, repeatedly, that many pharmacies will NOT bill

two payors. That means we cannot take advantage of Medicaid's lower co-pays for

drugs. I have just spoken with " the powers that be " in Medicaid. They would like

some examples of: which Walgreens store, which Osco store, which CVS

store...etc...so that they can fix this problem for us. PLEASE send me

examples, asap, so that they can correct this for all of us*********

-Sherri

From: ELLEN BRONFELD <mailto:egskb%40sbcglobal.net>

mailto:IPADDUnite%40

Sent: Friday, August 12, 2011 7:20 AM

Subject: Re: managed care enrollment question

Laurie is correct that those people who are currently covered under private

insurance are not part of the Integrated Care pilot...Laurie's question about

Medicaid and private insurance, in respect to medications is an interesting one.

Perhaps Sherri Schneider knows the answer to this one?

I have a related question for any of our online experts, and it’s this:

Somewhere I heard that there’s a unit of state government, who’s reason for

being is to take processed/approved Medicaid claims and file with whatever

private insurance carrier the individual may also be covered by...I’m assuming

this is mostly for prescription drugs, since when I go to my local Walgreens,

for example, they give me a choice (they’ll only bill one vendor) and they say

‘if we put it thru to your BCBS, it’ll cost $495, if we bill it to Medicaid

it’s zero.’

Well, that was always an easy answer, right? That was before I understood,

though, that Medicaid is always the payer of last resort, and that they will

approve bills but then have to go after our BCBS after the fact. Is this true?

Does this make sense? And if no, what is the fix? Can an individual respond to a

Walgreens pharmacist by saying ‘Please bill both BCBS and Medicaid and let

them sort it out’?

I hate thinking that we’re doing something wrong if in fact we’re abusing

the Medicaid system. What should we be doing?

Ellen

Ellen Garber Bronfeld

mailto:egskb%40sbcglobal.net

[Guest guest]

Medical providers who accept IL Medicaid have a contract with IL Medicaid. Most

contracts state that the medical provider should bill the other payor(s) first &

then ALSO bill Medicaid. We  need to see which stores are only billing one

payor and then Medicaid will review their contract with Medicaid. They may be

doing what they are supposed to but they may NOT be doing what they are supposed

to.  Medicaid has asked me to provide stores that will only bill one payor.

From: Jerue Family <jeruefamily@...>

IPADDUnite

Sent: Monday, August 15, 2011 12:34 PM

Subject: Re: Re: managed care enrollment question

 

Sherri,

Thanks for confirming my worst fears! But before I go ‘turning in’ my

favorite Walgreens store – and by the way, this is NOT limited to just one

store but is, I gather, a corporate policy about ‘only 1 billing’ – please

help us understand what role DOES Medicaid play, then, in helping poor people

like our adults with DDs pay for their medications?

Could we work through an example for the group?

My husband’s BCBS work/group plan is a high deductible plan – including

scripts – so we pay the first $6,000/year of medical costs, including 100% of

any scripts, until we reach that $6,000 out-of-pocket deductible. After that we

have a $30/co-pay per prescription per month.

So in ’s case, she is dual eligible for BCBS and Medicaid. She CANNOT

afford to pay for her own scripts. But...what I’m hearing you say is that BCBS

should be billed for her meds FIRST by the Walgreens store and NOT Medicaid.

Okay, so what happens after BCBS either a) pays $0 while we’re still working

towards that $6,000/deductible or when they charge the $30 per script per

month (which would be $120/month for all four scripts). Does Medicaid factor in

anywhere to make up the difference between the cost of the drug and the

co-pays/deductibles?

Is (or her guardian) expected to then submit the receipts for meds to

Medicaid? I don’t think so.

There’s got to be a better way. Are the pharmacies under any obligation to

double bill? Are there pharmacies that do this currently?

Did I just open up a HUGE can of worms here????????????????????

Laurie

From: Sherri Schneider

Sent: Monday, August 15, 2011 9:37 AM

IPADDUnite

Subject: Re: Re: managed care enrollment question

There are actually two different departments within Medicaid:

1) The TPL unit (Third Party Liability Unit)

- this unit ensures that correct & current OTHER payors are attached to a

Medicaid case

- you can look at your Medi-plan card to find your TPL code - back side - upper

right.

- each payor has a 3 digit code which lets Springfield know to ONLY pay AFTER

this other payor pays

- many of my clients are receiving Integrated Care packages - despite the fact

that they have commercial insurance. I call this unit, first, to ensure that

Medicaid has the other health insurance information.

- this is the unit that puts on the TPL, updates the TPL (in case the health

insurance changes) and removes the TPL

2) The Department of Collections

- this is the department that collects money FROM the other payors - if Medicaid

paid first

- ie: I have Blue Cross & Blue Shield & Medicaid. Medicaid paid first and now

Medicaid is aware of Blue Cross & Blue Shield. This department seeks

reimbursement from Blue Cross & Blue Shield.

********* I have been hearing, repeatedly, that many pharmacies will NOT bill

two payors. That means we cannot take advantage of Medicaid's lower co-pays for

drugs. I have just spoken with " the powers that be " in Medicaid. They would like

some examples of: which Walgreens store, which Osco store, which CVS

store...etc...so that they can fix this problem for us. PLEASE send me examples,

asap, so that they can correct this for all of us*********

-Sherri

From: ELLEN BRONFELD <mailto:egskb%40sbcglobal.net>

mailto:IPADDUnite%40

Sent: Friday, August 12, 2011 7:20 AM

Subject: Re: managed care enrollment question

Laurie is correct that those people who are currently covered under private

insurance are not part of the Integrated Care pilot...Laurie's question about

Medicaid and private insurance, in respect to medications is an interesting one.

Perhaps Sherri Schneider knows the answer to this one?

I have a related question for any of our online experts, and it’s this:

Somewhere I heard that there’s a unit of state government, who’s reason for

being is to take processed/approved Medicaid claims and file with whatever

private insurance carrier the individual may also be covered by...I’m assuming

this is mostly for prescription drugs, since when I go to my local Walgreens,

for example, they give me a choice (they’ll only bill one vendor) and they say

‘if we put it thru to your BCBS, it’ll cost $495, if we bill it to Medicaid

it’s zero.’

Well, that was always an easy answer, right? That was before I understood,

though, that Medicaid is always the payer of last resort, and that they will

approve bills but then have to go after our BCBS after the fact. Is this true?

Does this make sense? And if no, what is the fix? Can an individual respond to a

Walgreens pharmacist by saying ‘Please bill both BCBS and Medicaid and let

them sort it out’?

I hate thinking that we’re doing something wrong if in fact we’re abusing

the Medicaid system. What should we be doing?

Ellen

Ellen Garber Bronfeld

mailto:egskb%40sbcglobal.net

[Guest guest]

Ok, I will send it to you privately. So each individual Walgreens or CVS or

whatever pharmacy signs THEIR OWN Medicaid contract with the state? That’s

wild. I would have thought that was negotiated and contracted at the corporate

level. I sure hope this inquiry doesn’t result in my pharmacy deciding not to

take Medicaid at all!

I just HAD to ask that question, didn’t I?

From: Sherri Schneider

Sent: Monday, August 15, 2011 4:07 PM

IPADDUnite

Subject: Re: Re: managed care enrollment question

Medical providers who accept IL Medicaid have a contract with IL Medicaid. Most

contracts state that the medical provider should bill the other payor(s) first &

then ALSO bill Medicaid. We need to see which stores are only billing one payor

and then Medicaid will review their contract with Medicaid. They may be doing

what they are supposed to but they may NOT be doing what they are supposed to.

Medicaid has asked me to provide stores that will only bill one payor.

From: Jerue Family <mailto:jeruefamily%40comcast.net>

mailto:IPADDUnite%40

Sent: Monday, August 15, 2011 12:34 PM

Subject: Re: Re: managed care enrollment question

Sherri,

Thanks for confirming my worst fears! But before I go ‘turning in’ my

favorite Walgreens store – and by the way, this is NOT limited to just one

store but is, I gather, a corporate policy about ‘only 1 billing’ – please

help us understand what role DOES Medicaid play, then, in helping poor people

like our adults with DDs pay for their medications?

Could we work through an example for the group?

My husband’s BCBS work/group plan is a high deductible plan – including

scripts – so we pay the first $6,000/year of medical costs, including 100% of

any scripts, until we reach that $6,000 out-of-pocket deductible. After that we

have a $30/co-pay per prescription per month.

So in ’s case, she is dual eligible for BCBS and Medicaid. She CANNOT

afford to pay for her own scripts. But...what I’m hearing you say is that BCBS

should be billed for her meds FIRST by the Walgreens store and NOT Medicaid.

Okay, so what happens after BCBS either a) pays $0 while we’re still working

towards that $6,000/deductible or when they charge the $30 per script per

month (which would be $120/month for all four scripts). Does Medicaid factor in

anywhere to make up the difference between the cost of the drug and the

co-pays/deductibles?

Is (or her guardian) expected to then submit the receipts for meds to

Medicaid? I don’t think so.

There’s got to be a better way. Are the pharmacies under any obligation to

double bill? Are there pharmacies that do this currently?

Did I just open up a HUGE can of worms here????????????????????

Laurie

From: Sherri Schneider

Sent: Monday, August 15, 2011 9:37 AM

mailto:IPADDUnite%40

Subject: Re: Re: managed care enrollment question

There are actually two different departments within Medicaid:

1) The TPL unit (Third Party Liability Unit)

- this unit ensures that correct & current OTHER payors are attached to a

Medicaid case

- you can look at your Medi-plan card to find your TPL code - back side - upper

right.

- each payor has a 3 digit code which lets Springfield know to ONLY pay AFTER

this other payor pays

- many of my clients are receiving Integrated Care packages - despite the fact

that they have commercial insurance. I call this unit, first, to ensure that

Medicaid has the other health insurance information.

- this is the unit that puts on the TPL, updates the TPL (in case the health

insurance changes) and removes the TPL

2) The Department of Collections

- this is the department that collects money FROM the other payors - if Medicaid

paid first

- ie: I have Blue Cross & Blue Shield & Medicaid. Medicaid paid first and now

Medicaid is aware of Blue Cross & Blue Shield. This department seeks

reimbursement from Blue Cross & Blue Shield.

********* I have been hearing, repeatedly, that many pharmacies will NOT bill

two payors. That means we cannot take advantage of Medicaid's lower co-pays for

drugs. I have just spoken with " the powers that be " in Medicaid. They would like

some examples of: which Walgreens store, which Osco store, which CVS

store...etc...so that they can fix this problem for us. PLEASE send me examples,

asap, so that they can correct this for all of us*********

-Sherri

From: ELLEN BRONFELD <mailto:egskb%40sbcglobal.net>

mailto:IPADDUnite%40

Sent: Friday, August 12, 2011 7:20 AM

Subject: Re: managed care enrollment question

Laurie is correct that those people who are currently covered under private

insurance are not part of the Integrated Care pilot...Laurie's question about

Medicaid and private insurance, in respect to medications is an interesting one.

Perhaps Sherri Schneider knows the answer to this one?

I have a related question for any of our online experts, and it’s this:

Somewhere I heard that there’s a unit of state government, who’s reason for

being is to take processed/approved Medicaid claims and file with whatever

private insurance carrier the individual may also be covered by...I’m assuming

this is mostly for prescription drugs, since when I go to my local Walgreens,

for example, they give me a choice (they’ll only bill one vendor) and they say

‘if we put it thru to your BCBS, it’ll cost $495, if we bill it to Medicaid

it’s zero.’

Well, that was always an easy answer, right? That was before I understood,

though, that Medicaid is always the payer of last resort, and that they will

approve bills but then have to go after our BCBS after the fact. Is this true?

Does this make sense? And if no, what is the fix? Can an individual respond to a

Walgreens pharmacist by saying ‘Please bill both BCBS and Medicaid and let

them sort it out’?

I hate thinking that we’re doing something wrong if in fact we’re abusing

the Medicaid system. What should we be doing?

Ellen

Ellen Garber Bronfeld

mailto:egskb%40sbcglobal.net

[Guest guest]

It is the corporate that signs the Medicaid contract - not each store. When I

explained that some stores are not billing BOTH insurances, they asked me which

stores. I told them Walgreens and they asked for examples in case Walgreens

corporate told them that this is not the case. No one is in trouble. They just

want examples in case the corporate entity does not believe us.

From: Jerue Family <jeruefamily@...>

IPADDUnite

Sent: Monday, August 15, 2011 5:41 PM

Subject: Re: Re: managed care enrollment question

 

Ok, I will send it to you privately. So each individual Walgreens or CVS or

whatever pharmacy signs THEIR OWN Medicaid contract with the state? That’s

wild. I would have thought that was negotiated and contracted at the corporate

level. I sure hope this inquiry doesn’t result in my pharmacy deciding not to

take Medicaid at all!

I just HAD to ask that question, didn’t I?

From: Sherri Schneider

Sent: Monday, August 15, 2011 4:07 PM

IPADDUnite

Subject: Re: Re: managed care enrollment question

Medical providers who accept IL Medicaid have a contract with IL Medicaid. Most

contracts state that the medical provider should bill the other payor(s) first &

then ALSO bill Medicaid. We need to see which stores are only billing one payor

and then Medicaid will review their contract with Medicaid. They may be doing

what they are supposed to but they may NOT be doing what they are supposed to.

Medicaid has asked me to provide stores that will only bill one payor.

From: Jerue Family <mailto:jeruefamily%40comcast.net>

mailto:IPADDUnite%40

Sent: Monday, August 15, 2011 12:34 PM

Subject: Re: Re: managed care enrollment question

Sherri,

Thanks for confirming my worst fears! But before I go ‘turning in’ my

favorite Walgreens store – and by the way, this is NOT limited to just one

store but is, I gather, a corporate policy about ‘only 1 billing’ – please

help us understand what role DOES Medicaid play, then, in helping poor people

like our adults with DDs pay for their medications?

Could we work through an example for the group?

My husband’s BCBS work/group plan is a high deductible plan – including

scripts – so we pay the first $6,000/year of medical costs, including 100% of

any scripts, until we reach that $6,000 out-of-pocket deductible. After that we

have a $30/co-pay per prescription per month.

So in ’s case, she is dual eligible for BCBS and Medicaid. She CANNOT

afford to pay for her own scripts. But...what I’m hearing you say is that BCBS

should be billed for her meds FIRST by the Walgreens store and NOT Medicaid.

Okay, so what happens after BCBS either a) pays $0 while we’re still working

towards that $6,000/deductible or when they charge the $30 per script per

month (which would be $120/month for all four scripts). Does Medicaid factor in

anywhere to make up the difference between the cost of the drug and the

co-pays/deductibles?

Is (or her guardian) expected to then submit the receipts for meds to

Medicaid? I don’t think so.

There’s got to be a better way. Are the pharmacies under any obligation to

double bill? Are there pharmacies that do this currently?

Did I just open up a HUGE can of worms here????????????????????

Laurie

From: Sherri Schneider

Sent: Monday, August 15, 2011 9:37 AM

mailto:IPADDUnite%40

Subject: Re: Re: managed care enrollment question

There are actually two different departments within Medicaid:

1) The TPL unit (Third Party Liability Unit)

- this unit ensures that correct & current OTHER payors are attached to a

Medicaid case

- you can look at your Medi-plan card to find your TPL code - back side - upper

right.

- each payor has a 3 digit code which lets Springfield know to ONLY pay AFTER

this other payor pays

- many of my clients are receiving Integrated Care packages - despite the fact

that they have commercial insurance. I call this unit, first, to ensure that

Medicaid has the other health insurance information.

- this is the unit that puts on the TPL, updates the TPL (in case the health

insurance changes) and removes the TPL

2) The Department of Collections

- this is the department that collects money FROM the other payors - if Medicaid

paid first

- ie: I have Blue Cross & Blue Shield & Medicaid. Medicaid paid first and now

Medicaid is aware of Blue Cross & Blue Shield. This department seeks

reimbursement from Blue Cross & Blue Shield.

********* I have been hearing, repeatedly, that many pharmacies will NOT bill

two payors. That means we cannot take advantage of Medicaid's lower co-pays for

drugs. I have just spoken with " the powers that be " in Medicaid. They would like

some examples of: which Walgreens store, which Osco store, which CVS

store...etc...so that they can fix this problem for us. PLEASE send me examples,

asap, so that they can correct this for all of us*********

-Sherri

From: ELLEN BRONFELD <mailto:egskb%40sbcglobal.net>

mailto:IPADDUnite%40

Sent: Friday, August 12, 2011 7:20 AM

Subject: Re: managed care enrollment question

Laurie is correct that those people who are currently covered under private

insurance are not part of the Integrated Care pilot...Laurie's question about

Medicaid and private insurance, in respect to medications is an interesting one.

Perhaps Sherri Schneider knows the answer to this one?

I have a related question for any of our online experts, and it’s this:

Somewhere I heard that there’s a unit of state government, who’s reason for

being is to take processed/approved Medicaid claims and file with whatever

private insurance carrier the individual may also be covered by...I’m assuming

this is mostly for prescription drugs, since when I go to my local Walgreens,

for example, they give me a choice (they’ll only bill one vendor) and they say

‘if we put it thru to your BCBS, it’ll cost $495, if we bill it to Medicaid

it’s zero.’

Well, that was always an easy answer, right? That was before I understood,

though, that Medicaid is always the payer of last resort, and that they will

approve bills but then have to go after our BCBS after the fact. Is this true?

Does this make sense? And if no, what is the fix? Can an individual respond to a

Walgreens pharmacist by saying ‘Please bill both BCBS and Medicaid and let

them sort it out’?

I hate thinking that we’re doing something wrong if in fact we’re abusing

the Medicaid system. What should we be doing?

Ellen

Ellen Garber Bronfeld

mailto:egskb%40sbcglobal.net

[Guest guest]

The Osco in Elmhurst always billed a third payer insurance first and then

Medicaid. Beth only paid the Medicaid co pay. Terrill

From: IPADDUnite [mailto:IPADDUnite ] On Behalf

Of Sherri Schneider

Sent: Monday, August 15, 2011 9:37 AM

IPADDUnite

Subject: Re: Re: managed care enrollment question

There are actually two different departments within Medicaid:

1) The TPL unit (Third Party Liability Unit)

- this unit ensures that correct & current OTHER payors are attached to a

Medicaid case

- you can look at your Medi-plan card to find your TPL code - back side - upper

right.

- each payor has a 3 digit code which lets Springfield know to ONLY pay AFTER

this other payor pays

- many of my clients are receiving Integrated Care packages - despite the fact

that they have commercial insurance. I call this unit, first, to ensure that

Medicaid has the other health insurance information.

- this is the unit that puts on the TPL, updates the TPL (in case the health

insurance changes) and removes the TPL

2) The Department of Collections

- this is the department that collects money FROM the other payors - if Medicaid

paid first

- ie: I have Blue Cross & Blue Shield & Medicaid. Medicaid paid first and now

Medicaid is aware of Blue Cross & Blue Shield. This department seeks

reimbursement from Blue Cross & Blue Shield.

********* I have been hearing, repeatedly, that many pharmacies will NOT bill

two payors. That means we cannot take advantage of Medicaid's lower co-pays for

drugs. I have just spoken with " the powers that be " in Medicaid. They would like

some examples of: which Walgreens store, which Osco store, which CVS

store...etc...so that they can fix this problem for us. PLEASE send me

examples, asap, so that they can correct this for all of us*********

-Sherri

From: ELLEN BRONFELD <egskb@... <mailto:egskb%40sbcglobal.net> >

IPADDUnite <mailto:IPADDUnite%40>

Sent: Friday, August 12, 2011 7:20 AM

Subject: Re: managed care enrollment question

Laurie is correct that those people who are currently covered under private

insurance are not part of the Integrated Care pilot...Laurie's question about

Medicaid and private insurance, in respect to medications is an interesting one.

Perhaps Sherri Schneider knows the answer to this one?

I have a related question for any of our online experts, and it’s this:

Somewhere I heard that there’s a unit of state government, who’s reason for

being is to take processed/approved Medicaid claims and file with whatever

private insurance carrier the individual may also be covered by...I’m assuming

this is mostly for prescription drugs, since when I go to my local Walgreens,

for example, they give me a choice (they’ll only bill one vendor) and they say

‘if we put it thru to your BCBS, it’ll cost $495, if we bill it to Medicaid

it’s zero.’

Well, that was always an easy answer, right? That was before I understood,

though, that Medicaid is always the payer of last resort, and that they will

approve bills but then have to go after our BCBS after the fact. Is this true?

Does this make sense? And if no, what is the fix? Can an individual respond to a

Walgreens pharmacist by saying ‘Please bill both BCBS and Medicaid and let

them sort it out’?

I hate thinking that we’re doing something wrong if in fact we’re abusing

the Medicaid system. What should we be doing?

Ellen

Ellen Garber Bronfeld

egskb@... <mailto:egskb%40sbcglobal.net>