New York Fully Integrated Duals Advantage (FIDA) Demonstration

Frequently Asked Questions for Pharmacists

Question 1: What is FIDA?

Question 2: What services will FIDA cover?

Question 3: Does FIDA include drug coverage?

Question 4: Does FIDA cover outpatient and inpatient drugs?

Question 5: How does FIDA cover outpatient drugs?

Question 6: Who is eligible for FIDA?

Question 7: When can participants enroll in FIDA?

Question 8: Is FIDA mandatory for dually eligible participants in New York State?

Question 9: How do I join the FIDA Plan´s networks?

Question 10: Can I continue to dispense drugs to patients who join a FIDA Plan if the drug he/she has been receiving is not on the FIDA Plan´s formulary?

Question 11: How should I submit a claim for a newly enrolled FIDA Participant who has proof of coverage but who does not have his/her BIN, PCN, RxGRP or RxID information (also known as 4Rx data)?

Question 12: How should I submit a claim for a FIDA participant who does not have proof of coverage?

Question 13: How should I proceed if a claim has been denied at the point of sale for a FIDA Participant?

Question 14: If a client has recently left a FIDA Plan and he/she has not selected or is not enrolled into a new Medicare Part D plan yet, how should I bill for their drugs?

Question 15: How can my clients get help understanding their coverage options?

Question 16: How can I find out more about FIDA and the continuity of care protections?


Question 1: What is FIDA?

Answer 1: FIDA is a joint Medicare and Medicaid demonstration designed to integrate care for New Yorkers who have both Medicare and Medicaid and who reside in the targeted geographic area. Beneficiaries who choose to participate will receive both Medicare and Medicaid coverage, including Part D prescription drugs, from a single, integrated FIDA managed care plan. FIDA builds off the existing Managed Long Term Care (MLTC) program. FIDA will be jointly administered by the federal Centers for Medicare & Medicaid Services (CMS) and the New York State Department of Health (NYSDOH).

We have developed this frequently asked questions (FAQ) document for pharmacists in New York because pharmacists are often the first providers a participant encounters after joining a new plan like FIDA, when participant confusion and system transaction issues are most likely to occur. We hope this information will help you understand FIDA, and be prepared to help former, current, or prospective FIDA participants who come to you for services.

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Question 2: What services will FIDA cover?

Answer 2: In FIDA, participants will get all their covered Medicare and Medicaid services from one plan, including long–term services and supports (LTSS), physician visits, hospital services, and prescription drugs. Their FIDA Plan will help improve the coordination of their Medicare and Medicaid benefits.

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Question 3: Does FIDA include drug coverage?

Answer 3: Yes. FIDA includes all the drug coverage guaranteed by Medicare Parts A, B, and D, the drug benefits provided by the New York State Medicaid program, and any additional supplemental drug coverage offered by an individual FIDA Plan above and beyond the required benefits.

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Question 4: Does FIDA cover outpatient and inpatient drugs?

Answer 4: Yes. FIDA covers outpatient prescription drugs and other medications and equipment (such as over the counter (OTC) diabetic supplies) covered under Medicare Part D and Medicaid, physician delivered drugs covered by Medicare Part B, and drugs given to beneficiaries while they are in hospitals or nursing facilities covered by Medicare Part A. FIDA participants have no costs for any covered drugs, including those covered by Medicare Part D.

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Question 5: How does FIDA cover outpatient drugs?

Answer 5: FIDA Plans will usually cover drugs at no cost to participants as long as the participant follows these rules which are extremely similar to those followed by Medicare Part D plans:

  • The participant must have a doctor or other provider write his/her prescription. A written prescription is required for both prescription and OTC drugs.
  • The participant generally must use a network pharmacy to fill his/her prescription unless the FIDA Plan or care team has authorized him/her to use an out–of–network pharmacy.
  • The participant´s prescribed drugs must be on the FIDA Plan´s List of Covered Drugs which is available on the FIDA Plan´s website. If the drug is not on the drug list, the FIDA Plan may be able to cover it by giving an exception.
  • The participant´s drug must be used for a medically accepted indication. This means that the use of the drug is either approved by the Food and Drug Administration or supported by certain reference books.
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Question 6: Who is eligible for FIDA?

Answer 6: FIDA builds upon the existing New York State Managed Long Term Care (MLTC) program. As such, the vast majority of people eligible for FIDA are already enrolled in a plan participating in the MLTC program. In general, individuals who meet all of the following criteria will be eligible to enroll in a FIDA Plan:

  • Reside in one of eight counties: Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk or Westchester;
  • Age 21 or older at the time of enrollment;
  • Entitled to benefits under Medicare Part A, enrolled in Medicare Part B, eligible to enroll in Part D, receiving full Medicaid benefits; and
  • Individuals must also meet one of the two following criteria:
    1. Require community–based long term care services for more than 120 days, or
    2. Be eligible for but not already receiving facility–based or community–based LTSS ("New to Service").
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Question 7: When can participants enroll in FIDA?

Answer 7: NY started to send notices to eligible individuals about their enrollment options in December 2014. Eligible participants who sign up for a FIDA Plan can be covered by the FIDA Plan as early as January 1, 2015 in the Bronx, Kings, Nassau, New York, Queens, and Richmond Counties (Region I) and as early as April 1, 2015 in Suffolk and Westchester Counties (Region II). Current MLTC enrollees who have not already made an affirmative choice of FIDA Plan and have not chosen to opt–out of FIDA, will be automatically enrolled into a FIDA Plan starting as soon as April 1, 2015 in Region 1 and as soon as July 1, 2015 in Region II through a process called "passive enrollment." Participants can opt–out of passive enrollment at any time up to the effective date and can disenroll or switch plans at any time, effective the first of the following month. MLTC enrollees will receive notices with his/her FIDA Plan name, important information and phone numbers about the program and information on how to opt–out.

Passive enrollment procedures will result in a change of Part D coverage, so pharmacists should be particularly attentive to potential confusion and system transaction issues during this time period. We encourage you to keep this FAQ readily accessible during this period.

Some individuals are eligible to sign up for a FIDA Plan but will not be passively enrolled. In particular, some groups of people will not be passively enrolled but are eligible to opt–in, including but not limited to: Native Americans, PACE program enrollees, enrollees in a Medicare Advantage Special Needs Plan for institutionalized individuals, individuals participating in the CMS Independence at Home demonstration, enrollees in Employer or Union Sponsored coverage for employees or retirees, enrollees in a Health Home, individuals with coverage mandated by the Aliessa federal court decision, individuals eligible for the Medicaid coverage buy–in for working disabled, and individuals who are eligible for the Nursing Home Transition & Diversion (NHTD) 1915(c) waiver.

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Question 8: Is FIDA mandatory for dually eligible participants in New York State?

Answer 8: No. FIDA is not mandatory for anyone in New York State. Individuals can opt–out of FIDA at any time, before or after passive enrollment, to keep their Medicare and Medicaid the same as it is today. Eligible participants who disenroll from FIDA will continue to receive Medicaid services through the MLTC program, and will continue to have a choice of Original Medicare or Medicare Advantage and a prescription drug plan.

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Question 9: How do I join the FIDA Plan´s networks?

Answer 9: You are encouraged to consider joining the networks of one or more of the FIDA Plans in order to provide continuous care to eligible participants and to be part of this important initiative to coordinate care for Medicare–Medicaid beneficiaries. As with many Medicare Advantage plans, many FIDA Plans offer outpatient drug coverage through Pharmacy Benefits Management (PBM) companies with which you are already working or are familiar. The FIDA Plans are currently directly contracting with pharmacies.

If you represent a pharmacy serving New Yorkers who have both Medicare and Medicaid and who reside in one of the eight FIDA counties, you can reach out to the FIDA Plans directly for more information. Please visit: http://www.cms.gov/Medicare/Prescription–Drug–Coverage/PrescriptionDrugCovContra/PartDContacts.html. Once you open the zip file the first file contains specific points of contact for contracting for all Part D plans including the FIDA Plans.

In addition, a list of FIDA Plans is included with this letter below.

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Question 10: Can I continue to dispense drugs to patients who join a FIDA Plan if the drug he/she has been receiving is not on the FIDA Plan´s formulary?

Answer 10: Yes, for a limited amount of time (and possibly longer for patients whose care team or FIDA Plan has authorized them to continue to receive the drug). FIDA includes important formulary transition provisions that in some cases are more generous than those required under Medicare Part D.

  • In outpatient settings, the FIDA Plan will cover up to ninety (90) days´ worth of temporary supply(ies) of drugs from a network pharmacy, when the participant requests a refill of a non–formulary drug (including drugs that are on the FIDA Plan´s formulary but require Prior Authorization or step therapy under the FIDA Plan´s Utilization Management rules) that otherwise meets the definition of a Medicare Part D drug during the first ninety (90) days following Enrollment in the FIDA Plan.
    1. In comparison, Medicare Part D outpatient setting transition policy calls for a one–time, temporary supply of non–formulary Part D drugs for at least 30 days of medication.
  • In long–term care settings, the FIDA Plan will cover a temporary supply of at least ninety–one (91) days and up to ninety–eight (98) days of non–formulary drugs from a network pharmacy including drugs that are on the FIDA Plan´s formulary but require Prior Authorization or step therapy under the FIDA Plan´s Utilization Management rules that otherwise meet the definition of a Medicare Part D drug.
  • For all other non–Part D drugs that are covered by Medicaid, the FIDA Plan will cover a ninety (90) day supply of the drugs.
  • The FIDA plan will honor all prior authorizations for non–Part D drugs, therapies, or other services existing in Medicare or Medicaid at the time of enrollment for ninety (90) calendar days after enrollment. The FIDA plan will also not terminate prior authorizations at the end of ninety (90) calendar days without advance notice to the Participant and transition to other services, if needed.
  • Except as otherwise noted above, Medicare Part D transition rules and rights will continue as provided for outside the demonstration. This includes a requirement that, at the end of the 90–day continuity of care period, the FIDA Plan must provide an appropriate transition process for Participants who are prescribed Part D drugs that are not on its formulary (including drugs that are on the FIDA Plan´s formulary but require Prior Authorization or step therapy under the FIDA Plan´s Utilization Management rules).
    1. Please see Chapter 6 of the Medicare Prescription Drug Benefit Manual for detailed guidance on the Medicare Part D transition policy: http://www.cms.gov/Medicare/Prescription–Drug–Coverage/PrescriptionDrugCovContra/Downloads/Chapter6.pdf.
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Question 11: How should I submit a claim for a newly enrolled FIDA Participant who has proof of coverage but who does not have his/her BIN, PCN, RxGRP or RxID information (also known as 4Rx data)?

Answer 11: Please perform an eligibility (E1) query at the point of sale to Medicare´s on–line eligibility/enrollment query system, called the TrOOP Facilitator. The query will return the 4Rx data and will confirm the enrollment and contract number. Please see below for the contract numbers for each FIDA Plan. You can also call the FIDA Plan´s pharmacy helpline.

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Question 12: How should I submit a claim for a FIDA participant who does not have proof of coverage?

Answer 12: As above, please perform an E1 query to the TrOOP Facilitator. The query will return the 4Rx data and will confirm the enrollment and contract number. Please see below for the contract numbers for each FIDA Plan.

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Question 13: How should I proceed if a claim has been denied at the point of sale for a FIDA Participant?

Answer 13: If the denial is because the claim did not include the necessary 4Rx data, please follow the procedure described above. If you disagree with the decision, you can help the participant appeal. To ask for instructions on how to appeal, call the Participant Services line for the FIDA Plan or the Independent Consumer Advocacy Network (ICAN) for free help at 1–844–614–8800 (TTY:711). The participant can also read Chapter 9 of the Participant Handbook to learn how to appeal a decision. You can also call the FIDA Plan´s pharmacy help–line. The Participant Handbook can be found at the following link under State–Specific Information, New York: http://www.cms.gov/Medicare–Medicaid–Coordination/Medicare–and–Medicaid–Coordination/Medicare–Medicaid–Coordination–Office/FinancialAlignmentInitiative/InformationandGuidanceforPlans.html

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Question 14: If a client has recently left a FIDA Plan and he/she has not selected or is not enrolled into a new Medicare Part D plan yet, how should I bill for their drugs?

Answer 14: If the individual remains eligible for Medicaid and Medicare Part D benefits, they will have access to the Limited Income Newly Eligible Transition (LINET) program. The LINET program is designed to eliminate gaps in coverage for low income Medicare beneficiaries by providing immediate need coverage at the point of sale, retroactive coverage for out of pocket expenses and to help beneficiaries enroll into a Medicare Part D plan. We have included some key details and instructions for the LINET Program:

  • There are no pharmacy network restrictions on LINET benefits for Medicare Part D covered drugs.
  • Please use the LINET 4Rx data printed on the top of the beneficiary´s LINET coverage confirmation letter. If that letter is not available, the data may be obtained through an E1 query to Medicare´s on–line eligibility/enrollment query system, called the TrOOP Facilitator. The query will return the 4Rx data; if a phone number for contract "X0001" is returned, the beneficiary is enrolled in the Limited Income NET Program, but the 4Rx data are not yet available on Medicare´s system. If this is the case, please contact LINET (contact provided below) and use the following:
    1. BIN: 015599
    2. PCN: 05440000
    3. Cardholder ID: Medicare claim number on the red, white and blue Medicare Card (MBI)
    4. Group ID: May be left blank
    5. Patient ID (optional): Medicaid ID or Social Security number
  • You should continue to perform an E1 query on these individuals monthly because Medicare will enroll them into a standard Medicare Part D plan within two months.
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Question 15: How can my clients get help understanding their coverage options?

Answer 15: For questions about FIDA, participants can call New York Medicaid Choice at: 1–855–600–3432 (TTY users: 1–888–329–1541; for a free interpreter: 1–855–600–3432). New York Medicaid Choice is available Monday–Friday, 8:30 am – 8:00 pm and Saturday, 10:00 am – 6:00 pm. The call and the help are free. New York Medicaid Choice also has a website at: www.nymedicaidchoice.com.

In addition, New York State has created an ombudsman program called the Independent Consumer Advocacy Network (ICAN) to provide free, confidential assistance on any services offered by FIDA. ICAN may be reached toll–free at 1–844–614–8800 or online at www.icannys.org.

For questions about Medicare benefits, patients can also call Medicare at: 1–800–MEDICARE (1–800–633–4227). (TTY users: 1–877–486–2048). 1–800–MEDICARE is available 24 hours a day, 7 days a week. The call and the help are free. Online: www.medicare.gov.

For questions about the LINET program, pharmacists can call LI NET Program Help Desk: 1–800–783–1307, by email at MedicareLINET@cms.hhs.gov, or visit the website at: WWW.Humana.com/LINET . There is a dedicated LINET line for SHIPs, Caseworkers and Medicaid Ombudsman offices at: 1–866–934–2019.

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Question 16: How can I find out more about FIDA and the continuity of care protections?

Answer 15: If you have questions regarding FIDA, please email the New York State Department of Health at fida@health.ny.gov or visit the MRT 101 website at https://www.health.ny.gov/health_care/medicaid/redesign/mrt_101.htm.

For more information on the continuity of care provisions, please refer to Section 2.6.6 on page 68 of the FIDA Three–Way Contract at: http://www.cms.gov/Medicare–Medicaid–Coordination/Medicare–and–Medicaid–Coordination/Medicare–Medicaid–Coordination–Office/FinancialAlignmentInitiative/Downloads/NewYorkContract.pdf.

The following twenty–one plans are participating in FIDA:

Contract # Organization Name FIDA Plan Name Counties ∗
H8056 Aetna Better Health of New York Aetna Better Health FIDA Plan Kings, Nassau, New York, Queens, Suffolk
H6308 AgeWell New York, LLC AgeWell New York FIDA Bronx, Kings, Nassau, New York, Queens, Suffolk, Westchester
H6974 AlphaCare of New York, Inc. AlphaCare Signature FIDA Plan Bronx, Kings, New York, Queens
H8417 Amerigroup New York, LLC HealthPlus Amerigroup FIDA Plan Bronx, Kings, New York, Queens, Richmond
H4740 Archcare Community Life ArchCare Community Advantage FIDA Plan Bronx, Kings, New York, Queens, Richmond, Westchester
H8420 Centerlight Healthcare, Inc. CenterLight Healthcare FIDA Plan Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk, Westchester
H3018 Centers Plan for Healthy Living, LLC FIDA Care Complete Bronx, Kings, New York, Queens, Richmond
H8029 Elderplan, Inc. Elderplan FIDA Total Care Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk, Westchester
H6435 Elderserve Health, Inc. RiverSpring FIDA Plan (used to be Elderserve ) Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk, Westchester
H0811 GuildNet, Inc. GuildNet Gold Plus FIDA Plan Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk, Westchester
H6263 Health Insurance Plan of Greater New York (HIP) EmblemHealth Dual Assurance FIDA Plan Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk, Westchester
H4465 Independence Care Systems, Inc. ICS Community Care Plus FIDA MMP Bronx, Kings, New York, Queens
H8150 Integra MLTC Inc. Integra FIDA Plan Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk, Westchester
H5441 Managed Health (HealthFirst) Healthfirst AbsoluteCare FIDA Plan Bronx, Kings, Nassau, New York, Queens, Richmond, Westchester
H9115 MetroPlus Health Plan MetroPlus FIDA Plan Bronx, Kings, New York, Queens
H3129 NorthShore–LIJ Health System, Inc. North Shore–LIJ FIDA LiveWell Kings, Nassau, New York, Queens, Richmond, Suffolk
H8851 Senior Whole Health of New York, Inc. SWH Whole Health FIDA Bronx, Kings, New York, Queens
H1916 Fidelis Care of NY (NYS Catholic Health Plan) Fidelis Care FIDA Plan Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk, Westchester
H9345 VillageCareMAX VillageCareMAX Full Advantage FIDA Plan Bronx, Kings, New York, Queens
H8490 VNS Choice VNSNY Choice FIDA Complete Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk, Westchester
H2751 Wellcare of NY, Inc. WellCare Advocate Complete FIDA Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk, Westchester
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