PACE / PACENET PROGRAM

PROVIDER BULLETIN

NEW LEGISLATION

CARDHOLDER IMPACT

December 26, 2003

On January 1, 2004, new PACE/PACENET legislation becomes effective.

PACE recognizes that many providers assist cardholders in answering PACE or PACENET questions. The following is a brief overview of how the new legislation affects both potential and current cardholders.

• Income limits increase:

PACE Single applicant - Increased to $14,500 PACENET Single - Increased to $23,500

PACE Married applicant - Increased to $17,700 PACENET Married - Increased to $31,500

· Co-Pays:

Generics PACE - $6.00; PACENET - $8.00

Single-source / Brand PACE - $9.00; PACENET - $15.00

• Generics: When a drug has an A-rated generic, PACE/PACENET requires the use of the generic. Claims for “brand” name products having an A-rated generic will be denied unless a medical exception is approved by PACE,
• The “generic differential” calculation (entry of DAW code “2” or “4”) is discontinued effective January 1, 2004.
• PACE/PACENET cardholders will be responsible for the entire cost of their prescription if they insist on the brand name product in the absence of a medical exception. (DAW 2)
• PACE/PACENET providers will be responsible for the U&C minus the copay if the brand name product is dispensed for the generic because the product is not in stock (DAW 4).

· PACENET claims processing

• PACENET cardholders must pay a $40.00 monthly cumulative deductible based on the cardholder’s ENROLLMENT month.

Example: Cardholder enrolls with an effective date January 1, 2004; does not use PACENET benefit until March 1. A deductible of $120.00 ($40 X 3 months) must be paid before the PACENET reimbursement.

o ALL PACENET claims are subject to PACE edits.

• Denied deductible PACENET claims are not included in the monthly deductible.

• Potential PACE/PACENET Applicants
• Applicants denied solely for being over-income have had their applications reprocessed by PACE and sent their PACE or PACENET card. These new cardholders’ eligibility becomes effective January 1, 2004.
• Applicants denied for being over-income, but had other documents missing have been sent letters informing them of the necessary documents to enroll in the Program.
• To encourage potential applicants to apply, the Program is accepting income documents from 2002 until March 31, 2004.
• Applicants may obtain enrollment forms from providers, legislative offices, Area Agency on Aging offices or the Department’s website at www.aging.state.pa.us .
• Additional questions can be answered by calling 1-800-225-7223.

PPB-03-016