Wellcare | Important SEP Reminder for State Pharmaceutical Assistance Programs
Important SEP Reminder for State Pharmaceutical Assistance Programs
As a reminder, CMS guidelines permit a Special Election Period (SEP) for beneficiaries in qualified State Pharmaceutical Assistance Programs (SPAPs) under certain circumstances and in states where SPAPs are available. The chart below summarizes these qualifying SEP conditions:
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Important Information & Recommendations
It is imperative that you take steps before enrolling a beneficiary using the SPAP SEP to confirm that the beneficiary meets the SPAP SEP’s eligibility requirements. The SPAP SEP is not available unless the beneficiary is enrolled in or is losing eligibility for coverage under a qualified SPAP.
We recommend that you take the following steps before enrolling a beneficiary using the SPAP SEP:
- Explain that a qualified SPAP is a program offered by certain states to provide financial assistance for pharmaceutical expenses to Part D eligible residents and that the beneficiary may be eligible for a SEP if the beneficiary is enrolled in a qualified SPAP or is losing eligibility for coverage in a qualified SPAP.
- Provide the beneficiary with the list of qualified SPAPs. See the list of qualified SPAPs below.
- Confirm that the beneficiary can attest to meeting the eligibility requirements based on the list of qualified SPAPs.
- If the beneficiary attests to meeting the eligibility requirements for an SPAP SEP, check that the beneficiary resides in one of the states listed below that have a qualified SPAP. In the event that the beneficiary does not reside in one of the states listed below with a qualified SPAP, check to see whether the beneficiary recently moved from one of the states listed below with a qualified SPAP and is therefore losing SPAP eligibility.
Qualified SPAPs
The following are qualified SPAPs:
- Delaware:Â Delaware Prescription Assistance Program
- Indiana:Â HoosierRx
- Maine:Â Maine Drugs for the Elderly and Disabled
- Maryland:Â Maryland Senior Drug Assistance Program
- Massachusetts:Â Prescription Advantage
- Missouri:Â MoRx
- New Jersey:Â NJ Pharmaceutical Assistance to the Aged & Disabled Program; NJ Senior Gold Discount Card Program
- New Mexico:Â New Mexico Medical Insurance Pool
- New York: Elderly Pharmaceutical Insurance Coverage Program (EPIC)
- Pennsylvania:Â Pharmaceutical Assistance for the Elderly
- Rhode Island:Â Rhode Island State Pharmaceutical Assistance to the Elderly (RIPAE)
- Texas:Â Texas Kidney Health Care Program
- Vermont:Â Vpharm
- Wisconsin:Â SeniorCare
Please refer to the SEP section in the CMS Enrollment and Disenrollment Guidance, Medicare Advantage (MA) (Section 30.4), for detailed descriptions of the various types of SEPs and their eligibility criteria.
