6. How long does it take for an LIS recipient who had to pay full price to fill prescriptions in January to get reimbursed after submitting a request? Is the request treated like a coverage determination, or is there an informal process? Will the beneficiary be told by the plan whether and when s/he will be reimbursed?
Section 423.566 (b)(1)–(5) of the MMA Regulations define coverage determination as:
(b) Actions that are coverage determinations. The following actions by a Part D plan sponsor are coverage determinations: (1) A decision not to provide or pay for a Part D drug (including a decision not to pay because the drug is not on the plan's formulary, because the drug is determined not to be medically necessary, because the drug is furnished by an out-of-network pharmacy, or because the Part D plan sponsor determines that the drug is otherwise excludable under section 1862(a) of the Act if applied to Medicare Part D) that the enrollee believes may be covered by the plan; (2) Failure to provide a coverage determination in a timely manner, when a delay would adversely affect the health of the enrollee; (3) A decision concerning an exceptions request under § 423.578(a); (4) A decision concerning an exceptions request under § 423.578(b); or (5) A decision on the amount of cost sharing for a drug.
The fifth action listed in the Regulations as a coverage determination is a "decision on the amount of cost sharing for a drug." This means that individuals (including those with the low-income subsidy) who paid more for covered prescription drugs than the set prices as determined by the plan should be able to ask the plan to refund the difference in cost by asking the plan for a coverage determination. Coverage determinations have a set timeframe in which they must be decided. A decision on this type of coverage determination (request for payment) must be made by the plan within 72 hours. [Section 423.568: b) Timeframe for requests for payment. When a party makes a request for payment, the Part D plan sponsor must notify the enrollee of its determination no later than 72 hours after receipt of the request.] An unfavorable decision by the plan is subject to the same appeal rights as other types of coverage determinations (Redetermination, Reconsideration, Administrative Law, Judge, Medicare Appeals Council). Further, if the plan fails to notify the enrollee within the 72-hour timeframe, the plan must forward the request directly to the Independent Review Entity. [Section 423.568: e) Effect of failure to meet the adjudicatory timeframes. If the Part D plan sponsor fails to notify the enrollee of its determination in the appropriate timeframe under paragraphs (a) or (b) of this section, the failure constitutes an adverse coverage determination, and the plan sponsor must forward the enrollee's request to the IRE within 24 hours of the expiration of the adjudication timeframe.] We know that redetermination that reverse adverse coverage determinations must be implemented within 30 days. [Section 423.636: (2) Requests for payment. If, on redetermination of a request for payment, the Part D plan sponsor reverses its coverage determination, the Part D plan sponsor must authorize payment for the benefit within 7 calendar days from the date it receives the request for redetermination, and make payment no later than 30 calendar days after the date the plan sponsor receives the request for redetermination.] No specific information about the timeframe for an initial coverage determination reimbursement is provided in the regulations. On a CMS conference call for SHIP MMA Forum on March 7, 2006, a subject matter expert from CMS answered that reimbursement from a Part D plan for overpayment would take four to six weeks.
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