Mental Health Safety Net
Frequently Asked Questions

Mental Health Safety Net Covered Services

QUESTION: Currently people with no insurance who are admitted to a RMHI have been eligible to use TennCare transportation at no charge. Will this be the case for the disenrolled safety net population?

ANSWER: Persons who are admitted to a RMHA with no insurance are known as “state onlys.” Coverage for state onlys will be handled the same as it has always been until further notice. Transportation is not a covered service under the mental health safety net for persons disenrolled from TennCare.

Eligibility

QUESTION: Are persons with SPMI who have Medicare and are losing TennCare Standard eligible for safety net services?

ANSWER: Persons who are SPMI and have Medicare and are losing their TennCare Standard are eligible for safety net services assuming they meet all other eligibility requirements. Medicare will be the primary payor and then safety net services can be rendered in accordance to the contract for services not covered by Medicare.

QUESTION: Is an individual who has been identified as eligible for safety net services still eligible for safety net services even if they are now covered through their spouse’s group health insurance?

ANSWER: Private insurance will be the primary payor and then safety net services can be rendered in accordance to the contract for services not covered by private insurance.

QUESTION: Does Safety Net coverage preclude Medicare eligibility?

ANSWER: No, the safety net was designed to allow dual eligibles who are disenrolled to have medication coverage until Medicare Part D goes into effect January 1, 2006.

Registration

QUESTION: Do consumers who are registering for safety net services have to register with the CMHA in their county or can they choose one in another county?

ANSWER: They can sign up with any participating CMHA and be seen at any satellite of the CMHA. However, the consumer must stay with that CMHA unless they move out of their CMHA’s service area.

Pharmacy

QUESTION: Are individuals who still have TennCare Standard due to the fact that they have appealed their disenrollment eligible for pharmacy assistance services through the safety net?

ANSWER: For individuals on TennCare Standard who have not been disenrolled due to an appeal, they will be affected by the August 1 benefit changes that includes no pharmacy benefits. For these individuals, they are not eligible for safety net services since they are still active for TennCare Standard coverage. However, they can access the Express Scripts, Inc. pharmacy assistance. So, even though the person is not registered in the safety net system, they would still be able to work with the Pharmacy Assistance Coordinator with the safety net provider to access the Express Scripts services.

QUESTION: For those individuals who are appealing and can utilize Express Scripts, do they have the same benefits as the safety net group or do they have to pay the $18 co-pay for medication?

ANSWER: These persons will have the same opportunities for ESI services as any disenrolled person.

QUESTION: What pharmacy benefits do SPMI safety net registrants get that standard disenrollees do not get?

ANSWER: One of the key differences is that SPMIs have all costs covered through 6/30/06. SPMIs also have access with the $5 co-pay for specific atypical antipsychotic medications through the RX Outreach formulary that are not available for the general disenrolled group as well as lithium and Depakote with a $5 co-pay. Everyone else will have to pay for ESI RX Outreach after 12/31/05.

QUESTION: Will the state pay for co-pays that may be required by the manufacturer?

ANSWER: The state will not pay for any co-pays required by the manufacturer.

QUESTION: Does RX Outreach provide an unlimited number of free generic prescriptions through 12/31 or 6/30?

ANSWER: Rx Outreach provides an unlimited number of scripts, but it is a limited generic formulary so not every medication is on it. The state funded Rx Outreach ends on 12/31/05 for individuals who will be eligible for the Medicare drug benefit after that time. For individuals who are SPMI, state funded Rx Outreach is available until 6/30/06.

QUESTION: If someone remains eligible for Medicaid, does he/she have access to the Rx Outreach program?

ANSWER: Anyone can apply for Rx Outreach, but the state will not pay for the cost of the drug for a Medicaid person.

QUESTION: Why are there not more atypicals or bipolar medications available through the safety net?

ANSWER: At the time of development of the safety net pharmacy service, the decision was made to place on the discount card (with a copay) the most expensive medications used by disenrollees. The most expensive medications are the atypical antipsychotic drugs. The funding for pharmacy services was enough to fund only one atypical antipsychotic drug. However, we have been able to add lithium and Depakote with a $5 co-pay for those persons eligible for the safety net pharmacy.

QUESTION: Where can an agency get a listing of participating pharmacies in the ESI network?

ANSWER: You may call the member services number at 1-877-214-3469 for information on participating pharmacies. In addition, the letters mailed to disenrollees from ESI lists the ESI Network Chain Pharmacies.

QUESTION: Do the Rx Outreach forms need to be completed if we are using our local pharmacy to fill the prescription?

ANSWER: No. The Rx Outreach form is only used to order prescriptions via mail.

QUESTION: What is the turnaround time for Rx Outreach to get out prescription orders that they receive?

ANSWER: The turnaround time is 10-14 days. However, applications that are not complete can cause a delay. The most common reasons for delay are an address that is not verifiable, not having a presciber signature, and missing information on the application.

QUESTION: Will pharmaceutical companies accept only the original prescription?

ANSWER: Most require an original prescription but that may vary by manufacturer. At least one pharmacy assistance coordinator has found the following manufacturers that have accepted by fax:

Bristol fax: 1-800-736-1611
Eli Lilly fax: 703-310-2534
Abbott fax: 866-898-1473
Jansen fax: 888-526-5168

QUESTION: My local pharmacy states that their regular prices are better than what a person can get with the Express Scripts card. Is this true?

ANSWER: The average discount on generic brand prescriptions averages close to 50%. The average discount on name brand prescriptions is 10%. Some drugs may be advertised at a less expensive price than one can secure through Express Scripts. Nevertheless, the agreement signed by participating pharmacies requires them to provide even these drugs at a minimum one dollar cheaper than their best price.

QUESTION: Is Rx Outreach available to anyone?

ANSWER: Anyone can enroll in Rx Outreach for a fee and medication co-pays through its website (www.rxoutreach.com/en/). The website also has a list of the medications. However, the State has made arrangements through its safety net program for free medication for those persons enrolled in the safety net. SPMIs enrolled in the safety net have coverage through June 30, 2006. Disenrolled individuals who have both Medicare and Medicaid will have access to free medications until December 30, 2005. This service must be accessed through a participating safety net provider.

Reimbursement

QUESTION: What is the impact of revenue from Medicare or private insurance on the TDMHDD reimbursement of safety net services?

ANSWER: Medicare or private insurance will be the primary payor and then safety net services can be rendered in accordance to the contract for services not covered by Medicare or private insurance.