16 Del. Admin. Code § 50000-50100
Services provided by the CRDP can consist of payment for medications, nutritional supplements, transportation, and payment of Medicare Part D costs. Electronic Data Systems (EDS) is the CRDP's fiscal agent. They are responsible for processing all eligible CRDP claims.
9 DE Reg. 774 (11/01/05)
The CRDP has the ability to fund prescription medications, over-the-counter medications (OTC's) or both. As participation in Medicare Part D or proof of creditable coverage became a condition of CRDP eligibility, the CRDP program no longer provides primary pharmacy benefit coverage for many medications. As such, to improve access to prescription and OTC medications, benefits may be offered to all CRDP eligible clients, regardless of individual need review. Services covered include generic and brand name prescription drugs that have been approved as safe and effective by the Federal Food and Drug Administration as well as cost effective over-the-counter drugs prescribed by a licensed practitioner.
Reimbursement for medications will be made only for clients currently eligible and approved for participation in CRDP.
Prescription medications will be funded as described above if prescribed by a physician or licensed practitioner for eligible CRDP clients. Refills may be authorized in compliance with appropriate pharmacy laws and are subject to Division of Medicaid and Medical Assistance (DMMA) formulary restrictions.
Reimbursements for OTC products for eligible clients are those, which the physician/practitioner has provided a legal prescription to the pharmacist. OTCs are covered based on the DMMA policy with an exception for nutritional supplements (for additional information, refer to "DSSM 50100.2 Nutritional Supplements").
At point of sale, the pharmacist will determine electronically if another funding source is available, and bill that vendor(s) first, and then will determine if CRDP will fund the requested product. In order for the pharmacy to receive CRDP payment, they must be a participating Delaware Medicaid provider, with a valid provider identification number.
9 DE Reg. 775 (11/01/05)
10 DE Reg. 347 (08/01/06)
Reimbursement for nutritional supplements will be made only for clients currently eligible and approved for participation in CRDP. All third party resources must be used before CRDP funds are utilized.
Nutritional supplements will be funded as described above if prescribed by a physician or licensed practitioner for eligible CRDP clients. Refills may be authorized in compliance with appropriate pharmacy laws and are subject to Division of Medicaid and Medical Assistance (DMMA) formulary restrictions. Reimbursements for nutritional supplements for eligible clients are those, which the physician/practitioner has provided a legal prescription to the pharmacist.
At the point of sale, the pharmacist will determine electronically if another funding source is available, and bill that vendor(s) first, and then will determine if CRDP will fund the requested product. In order for the pharmacy to receive CRDP payment, they must be a participating Delaware Medicaid provider, with a valid provider identification number.
At the point of sale, the pharmacist will be alerted if program quantity limits for nutritional supplements have been exceeded and if prior authorization is needed by EDS.
Prior authorization criteria for eligible clients:
The client must be diagnosed with ESRD, is on dialysis or has received a kidney transplant, and, exhibits signs and symptoms of malnutrition as determined by documentation of specific laboratory values. Additionally, approval of funding nutritional supplements is subject to Division of Medicaid and Medical Assistance formulary restrictions.
Other criteria that must be met include:
| · | it is reasonable and necessary part of the client's treatment plan; |
| · | ordered by a physician or certified nurse practitioner as indicated by completion of a Medical Necessity Form; |
| · | not furnished for the convenience of the client, client's family, attending practitioner, or other practitioner or supplier; |
| · | necessary and consistent with generally accepted professional medical standards; |
| · | monitored and assessed regularly by the attending practitioner to determine effectiveness and necessity. |
The CRDP will fund oral nutritional supplements for a period as prescribed by the physician or licensed practitioner.
10 DE Reg. 347 (08/01/06)
Transportation services for eligible CRDP clients are arranged by the Division of Medicaid & Medical Assistance (DMMA) Transportation Broker. Transportation may be provided to and from the dialysis unit, transplant hospital, or in exceptional cases, related medical appointments. DMMA's transportation broker will explore all types of reimbursable transportation for cost effectiveness.
The types of transportation that may be provided are:
Mileage Reimbursement - mileage reimbursement may be provided to the client, client's spouse, caregiver, or anyone who consistently transports clients. There is no restriction on the minimum amount of miles to be eligible.
Delaware Authority for Regional Transit (DART) tickets - DART tickets will be purchased for client use. A monthly supply of DART tickets is sent to the dialysis social worker for distribution. These tickets are replaced monthly based on the previous month's usage.
Private Transportation Companies - private transportation companies may provide transportation if they have a contract with DMMA's transportation broker.
Volunteer - a volunteer trained by DMMA's transportation broker may provide transportation utilizing a company vehicle.
9 DE Reg. 1558 (04/01/06)
The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) established the Medicare Prescription Drug Program, also known as Medicare Part D, making prescription drug coverage available to individuals who are entitled to receive Medicare benefits under Part A or Part B, beginning on January 1, 2006.
The MMA provides for a Low Income Subsidy (LIS) for individuals with limited income and resources. The LIS is assistance provided by the Centers for Medicare and Medicaid Services to pay Medicare Part D costs for eligible individuals. The LIS will provide payment assistance with the monthly premium, the yearly deductible, and the coverage gap. The LIS will also provide payment assistance for co-payments after an individual with income below 135% of the Federal Poverty Level reaches a total of $5100 in drug expenses.
The CRDP will provide coverage for Medicare Part D costs including monthly premiums, yearly deductible, drug costs that fall into the Part D coverage gap, and co-payments. If an individual is eligible for the LIS, this assistance will be primary to CRDP assistance.
9 DE Reg. 774 (11/01/05)
16 Del. Admin. Code § 50000-50100