Information For Participants

As a member of CenterLight Healthcare's Program of All-Inclusive Care for the Elderly (PACE), our healthcare team of physicians, nurses, social workers and rehab specialists will help you stay safely in your own home and community for as long as possible, and will make sure you receive high quality, complete care.

In this section, you will find the tools you need to understand and manage your healthcare benefits. Click on the links below to access information available to you as a participant of our program. Materials are listed in alphabetical order.

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Grievance and Appeal Process

All of us at CenterLight Healthcare PACE want you to be satisfied with the care that you receive. We want to know your concerns, so we can make improvements and resolve any problems you may have as quickly as possible.

We encourage you to discuss your concerns first with your nurse or social worker, however, you may file a grievance or an appeal with any staff member at any time through the grievance and appeal process.

You have the right to designate a family member or representative to file grievances and appeals on your behalf. If you do not speak English or need other assistance, we will make every reasonable effort to assist you with the process.

A. CenterLight Healthcare PACE’s Grievance and Appeal Policy

CenterLight Healthcare PACE assures you that we will not retaliate or take any discriminatory action against you because you make a grievance or appeal a decision that we made. You can voice your grievances without discrimination or reprisal, and without fear of discrimination or reprisal. Grievances and appeals will be kept confidential.

B. Grievance Process

The grievance process will be reviewed with you and provided in writing upon enrollment, and on an annual basis. CenterLight Healthcare PACE will continue to furnish all required services during the grievance process.

1. Submitting a Grievance
   A “grievance” is a complaint, either oral or written, expressing dissatisfaction with service delivery or the quality of care furnished, regardless of whether remedial action is requested.
   
   An oral grievance may be filed at any time with any staff member, or with any CenterLight Healthcare PACE contracted provider. This includes your driver, and the providers who care for you in your home. If you discuss your grievance with a contracted provider, they will let a CenterLight Healthcare PACE staff person know the details of your complaint. The staff person will make sure that your grievance is thoroughly documented. You may also call CenterLight Healthcare PACE Service Coordination Team at 1-833-CL-CARES (1-833-252-2737), Monday-Friday, 8AM through 8PM. TTY users should call 711.
   
   A written grievance may be filed at any time by sending a letter to:
   CenterLight Healthcare PACE
   Appeals and Grievances Department
   555 Albany Avenue, Amityville, NY 11701
   
   CenterLight Healthcare PACE staff can explain the grievance process to you and help you to make a complaint if needed.
   
2. Grievance Review
   CenterLight Healthcare PACE will discuss with you and your legal representative (if applicable), and will provide in writing, the specific steps, including timeframes for response, that will be taken to resolve your grievance. The notice will tell you if we need additional information in order to resolve the grievance. The staff member who receives your grievance will coordinate the investigation when the cause of your issue needs to be looked into, and investigation of your grievance will begin immediately to find solutions and take appropriate action. All information related to your grievance will be kept strictly confidential, including from other CenterLight Healthcare PACE staff and contracted providers when appropriate. Please note, if you do not wish to be notified of the grievance resolution, let us know at the time you make your grievance. We will still investigate, but we will note your wishes and will not send you any further notifications.
   
3. Grievance Resolution
   If your grievance is regarding a home care complaint, we will send you a written response within 15 calendar days of receiving your grievance. All other grievances will be resolved as quickly as your case requires, but no later than thirty (30) calendar days after receipt of your grievance. CenterLight Healthcare PACE will notify you of the resolution as quickly as your case requires, but no later than three (3) calendar days after the date we resolve your grievance. We will notify you either orally or in writing based on your preference. The exception is for grievances related to quality of care, for which we will always provide written notification of the grievance resolution. The notification we provide will include a summary of your grievance, what we found as a result of our investigation, what actions we have taken or are going to take to resolve the issue, and when you can expect those actions to occur.
   
   If you have Medicare and your grievance is related to Medicare covered services, you, your family or caregiver, or your designated representative have the right to file a written complaint with the quality improvement organization (QIO). If you submit a complaint to the QIO, CenterLight Healthcare PACE must cooperate with them to resolve the complaint. This information will also be included in the resolution notification you receive if you have submitted your grievance to CenterLight Healthcare PACE as an additional option available to you.
   
   If you are not satisfied with the resolution, please let us know so that we can continue to work towards a resolution that is acceptable. You can also make a complaint to the New York State Department of Health by calling 212-417-5888 at any time. Complaints may also be submitted in writing to: NYS Department of Health at 90 Church Street,14th Floor, New York, NY 10007. You may also contact 1–800–MEDICARE for information and assistance, including to make a complaint related to the quality of care or the delivery of a service.

Private Pay
If you are paying privately for CenterLight Healthcare PACE services, call us at 1-833-252-2737 to submit a complaint, or you may call the New York State Department of Health at 212-417-5888.

C. Internal Appeal Process

An "appeal" is a request you would make for a review of an initial non-coverage or non-payment decision taken by the IDT, related to a service including denials, reductions, or termination of services. The appeal process will be reviewed with you and provided in writing when you enroll, on an annual basis, and whenever your request for a service or payment has been denied. CenterLight Healthcare PACE will continue to furnish all services previously approved by the IDT during the appeal process. You or your legal representative can submit your appeal in writing to:

CenterLight Healthcare PACE
Appeals and Grievances Department
555 Albany Avenue
Amityville, NY 11701

You can also verbally request an appeal by calling CenterLight Healthcare PACE at 1-833-CL-CARES (1-833-252-2737), Monday-Friday, 8AM through 8PM. TTY users should call 711. Appeal requests are accepted either verbally or in writing within 60 calendar days of the of the written denial of services, notification of non-payment, termination, or reduction in services. If you believe that you have information that will help us to decide in your favor, you may present it in person as well as in writing. The appeal review and decision is made by an appropriate third-party reviewer or committee. An appropriate third-party reviewer or member of a review committee is an individual who meets all of the following:

a. Appropriately credentialed in the field(s) or discipline(s) related to the appeal.
b. Was not involved in the original action related to the request for services or payment.
c. Does not have a stake in the outcome of the appeal.

If you are appealing a decision to reduce or terminate a service you have been receiving, you can request that CenterLight Healthcare PACE continue to the provide the disputed service(s) while the appeal is pending, with the understanding that you may be liable for the cost of those services if the appeal is not resolved in your favor. CenterLight Healthcare PACE will continue to provide all of your other required services.

1. Expedited Appeal
   Your appeal will be handled on an expedited basis if you indicated on your appeal that you believe your life, health or ability to regain or maintain maximum function could be seriously jeopardized without the disputed service. CenterLight Healthcare PACE will respond as quickly as your health condition requires, but no later than 72 hours after our receipt of your expedited appeal. We may extend this timeframe by up to 14 calendar days if you request an extension, or if CenterLight Healthcare PACE can justify to the New York State Department of Health (NYSDOH) the need for additional information and how the delay is in your best interest.
   
2. Standard Appeal
   All other appeals will be resolved as quickly as your health condition requires, but no later than 30 calendar days from our receipt of your appeal.
   
   CenterLight Healthcare PACE will provide you with a written notice of the appeal decision and the reasons. If the appeal is resolved in your favor, CenterLight Healthcare PACE will provide the disputed service as quickly as your health condition requires, or pay for the disputed service immediately. If your appeal is denied, you will be notified in writing. The denial notification will include the specific reason(s) for the denial, why the service would not improve or maintain your overall health status, information on your right to appeal the decision, and a description of your external appeal rights

D. External Appeal Process

If you are not satisfied with the decision made on your internal appeal, you can pursue your external appeal rights under either Medicaid or Medicare. The next level of appeal is an external process and involves a new and impartial review of your case through either the Medicare or Medicaid program. Your request to file an external appeal can be made either verbally or in writing, and we will help you to file your external appeal with the appropriate entity. If you are enrolled in both Medicare and Medicaid, we can help you choose which appeal process to follow, as you may not use both processes.

1. Medicaid Appeal Process
   The Medicaid program conducts appeals through the New York State Fair Hearing process. Fair hearings are conducted by the New York State Office of Hearings and Appeals. If you are enrolled in Medicaid only, or in both Medicare and Medicaid and choose to appeal under Medicaid, we will inform you of your New York Fair Hearing rights. You must file your Fair Hearing within 120 calendar days from the date of the decision by the third party reviewer.
   
   Fair Hearing requests may be sent to:
   Fair Hearing Section
   NYS Office of Temporary and Disability Assistance
   PO Box 22023
   Albany, NY 12201-2023
   FAX: (518) 473-6735
   
   You may also call the Office of Temporary and Disability Assistance at 1-800-342-3334.
   
2. Medicare Appeal Process
   If you are enrolled in Medicare only or in both Medicare and Medicaid, you may choose to appeal using Medicare’s external appeal process. A written request for reconsideration must be filed with the independent review entity within 60 calendar days from the date of the decision by the third party reviewer. We will assist you in submitting your external appeal.
   
   Note: For appeals under both Medicare and Medicaid, the appeal determination is binding and supersedes any other decisions regarding the matter under appeal.
   

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How to Appoint a Representative

As a CenterLight Healthcare PACE Participant, you can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to make your coverage decisions for you or to make an appeal.

There may be someone who is already legally authorized to act as your representative under State law.

If you want a friend, relative, your doctor or other provider, or other person to be your representative, call the Service Coordination Team at 1-833-CL-CARES (1-833-252-2737) (TTY 711), Monday-Friday, 8:00 a.m. to 8:00 p.m., and ask for the “Appointment of Representative” form, or download by clicking on the links provided below. The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must give us a copy of the signed form.

Appointment of Representative Form

Appointment of Representative Form (Spanish)

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Participant Rights and Responsibilities

When you join a PACE program, you have certain rights and protections. CenterLight Healthcare PACE, as your PACE program, must fully explain and provide your rights to you or someone acting on your behalf in a way you can understand at the time you join.

At CenterLight Healthcare PACE, we are dedicated to providing you with quality health care services so that you may remain as independent as possible. This includes providing all Medicaid and Medicare-covered items and services, and other services determined to be necessary by the interdisciplinary team across all care settings, 24 hours a day, 7 days a week.

Our staff and contractors seek to affirm the dignity and worth of each participant by assuring the following rights:

You have the right to treatment.

You have the right to treatment that is both appropriate for your health conditions and provided in a timely manner. You have the right:

• To receive all the care and services you need to improve or maintain your overall health condition, and to achieve the best possible physical, emotional, and social well-being.
• To get emergency services when and where you need them without the PACE program’s approval. A medical emergency is when you think your health is in serious danger— when every second counts. You may have a bad injury, sudden illness or an illness quickly getting much worse. You can get emergency care anywhere in the United States and you do not need to get permission from CenterLight Healthcare PACE prior to seeking emergency services.

You have a right to protection against discrimination.

You have the right to be treated with respect.

You have the right to be treated with dignity and respect at all times, to have all of your care kept private and confidential, and to get compassionate, considerate care. You have the right:

• To get all of your health care in a safe, clean environment and in an accessible manner.
• To be free from harm. This includes excessive medication, physical or mental abuse, neglect, physical punishment, being placed by yourself against your will, and any physical or chemical restraint that is used on you for discipline or convenience of staff and that you do not need to treat your medical symptoms.
• To be encouraged and helped to use your rights in the PACE program.
• To get help, if you need it, to use the Medicare and Medicaid complaint and appeal processes, and your civil and other legal rights.
• To be encouraged and helped in talking to PACE staff about changes in policy and services you think should be made.
• To use a telephone while at the PACE center.
• To not have to do work or services for the PACE program.
• To have all information about your choices for PACE services and treatment explained to you in a language you understand, and in a way that takes into account and respects your cultural beliefs, values, and customs.

You have a right to protection against discrimination.

Discrimination is against the law. Every company or agency that works with Medicare and Medicaid must obey the law. They cannot discriminate against you because of your:

• Race
• Ethnicity
• National Origin
• Religion
• Age
• Sex
• Mental or physical disability
• Sexual Orientation
• Source of payment for your health care (For example, Medicare or Medicaid)

If you think you have been discriminated against for any of these reasons, contact a staff member at the PACE program to help you resolve your problem.

If you have any questions, you can call the Office for Civil Rights at 1-800-368-1019. TTY users should call 1-800-537-7697.

You have a right to information and assistance.

You have the right to get accurate, easy-to-understand information, to have this information shared with your designated representative, who is the person you choose to act on your behalf, and to have someone help you make informed health care decisions. You have the right:

• To have someone help you if you have a language or communication barrier so you can understand all information given to you.
• To have the PACE program interpret the information into your preferred language in a culturally competent manner, if your first language is not English and you can’t speak English well enough to understand the information being given to you.
• To get marketing materials and PACE participant rights in English and in any other frequently used language in your community. You can also get these materials in Braille, if necessary.
• To have the enrollment agreement fully explained to you in a manner understood by you.
• To get a written copy of your rights from the PACE program. The PACE program must also post these rights in a public place in the PACE center where it is easy to see them.
• To be fully informed, in writing, of the services offered by the PACE program. This includes telling you which services are provided by contractors instead of the PACE staff. You must be given this information before you join, at the time you join, and when you need to make a choice about what services to receive.
• To be provided with a copy of individuals who provide care-related services not provided directly by CenterLight Healthcare PACE upon request.
• To look at, or get help to look at, the results of the most recent review of your PACE program. Federal and State agencies review all PACE programs. You also have a right to review how the PACE program plans to correct any problems that are found at inspection.

Before CenterLight Healthcare PACE starts providing palliative care, comfort care, and end-of-life care services, you have the right to have information about these services fully explained to you. This includes your right to be given, in writing, a complete description of these services and how they are different from the care you have been receiving, and whether these services are in addition to, or instead of, your current services. The information must also explain, in detail, how your current services will be affected if you choose to begin palliative care, comfort care, or end-of-life services. Specifically, it must explain any impact to:

• Physician services, including specialist services.
• Hospital services
• Long-term care services
• Nursing services
• Social services
• Dietary services
• Transportation
• Home care
• Therapy, including physical, occupational, and speech therapy
• Behavioral health
• Diagnostic testing, including imaging and laboratory services
• Medications
• Preventative healthcare services
• PACE center attendance

You have the right to change your mind and take back your consent to receive palliative care, comfort care, or end-of-life care services at any time and for any reason by letting CenterLight Healthcare PACE know either verbally or in writing.

You have a right to a choice of providers.

You have the right to choose a health care provider, including your primary care provider and specialists, from within the PACE program’s network and to get quality health care. Women have the right to get services from a qualified women’s health care specialist for routine or preventive women’s health care services.

You have the right to have reasonable and timely access to specialists as indicated by your health condition.

You also have the right to receive care across all care settings, up to and including placement in a long-term care facility when CenterLight Healthcare PACE can no longer maintain you safely in the community.

You have a right to participate in treatment decisions.

You have the right to fully participate in all decisions related to your health care. If you cannot fully participate in your treatment decisions or you want to have someone you trust help you, you have the right to choose that person to act on your behalf as your designated representative.

You have the right:

• To be fully informed of your health status and how well you are doing, to make health care decisions, and to have all treatment options fully explained to you. This includes the right not to get treatment or take medications. If you choose not to get treatment, you must be told how this may affect your physical and mental health.
• To fully understand CenterLight Healthcare PACE’s palliative care, comfort care, and end-of-life care services. Before CenterLight Healthcare PACE can start providing you with palliative care, comfort care, and end-of-life care services, the PACE program must explain all of your treatment options, give you written information about these options, and get written consent from you or your designated representative.
• To have the PACE program help you create an advance directive, if you choose. An advance directive is a written document that says how you want medical decisions to be made in case you cannot speak for yourself. You should give it to the person who will

carry out your instructions and make health care decisions for you.

• To participate in making and carrying out your plan of care. You can ask for your plan of care to be reviewed at any time.
• To be given advance notice, in writing, of any plan to move you to another treatment setting and the reason you are being moved.

You have a right to have your health information kept private.

• You have the right to talk with health care providers in private and to have your personal health care information kept private and confidential, including health data that is collected and kept electronically, as protected under State and Federal laws.
• You have the right to look at and receive copies of your medical records and request amendments.
• You have the right to be assured that your written consent will be obtained for the release of information to persons not otherwise authorized under law to receive it.
• You have the right to provide written consent that limits the degree of information and the persons to whom information may be given.

There is a patient privacy rule that gives you more access to your own medical records and more control over how your personal health information is used. If you have any questions about this privacy rule, call the Office for Civil Rights at 1-800-368-1019. TTY users should call 1-800- 537- 7697.

You have a right to make a complaint.

You have a right to complain about the services you receive or that you need and don’t receive, the quality of your care, or any other concerns or problems you have with your PACE program. You have the right to a fair and timely process for resolving concerns with your PACE program. You have the right:

• To a full explanation of the complaint process.
• To be encouraged and helped to freely explain your complaints to PACE staff and outside representatives of your choice. You must not be harmed in any way for telling someone your concerns. This includes being punished, threatened, or discriminated against.
• To contact 1-800-Medicare for information and assistance, including to make a complaint related to the quality of care or the delivery of a service.

You have the right to request additional services or file an appeal.

You have the right to request services from CenterLight Healthcare PACE, its employees, or contractors, that you believe are necessary. You have the right to a comprehensive and timely process for determining whether those services should be provided.

You also have the right to appeal any denial of a service or treatment decision by the PACE program, staff, or contractors.

You have a right to leave the program.

If, for any reason, you do not feel that the PACE program is what you want, you have the right to leave the program at any time and have such disenrollment be effective the first day of the month following the date CenterLight Healthcare PACE receives your notice of voluntary disenrollment.

Additional Help:

If you have complaints about your PACE program, think your rights have been violated, or want to talk with someone outside your PACE program about your concerns, call 1-800-MEDICARE (1-800-633-4227) to get the name and phone number of someone in your State Administering Agency.

As a Participant of CenterLight Healthcare PACE, you are responsible for:

• Being seen by your doctor if a change in your health status occurs.
• Sharing complete and accurate health information with your health care providers.
• Informing staff of any change in your health and making it known if you do not understand or are unable to follow instructions.
• Following the treatment plan recommended by CenterLight Healthcare PACE.
• Cooperating with and being respectful to staff, and not discriminating against staff because of race, color, national origin, religion, age, sex, or mental or physical ability.
• Notifying CenterLight Healthcare PACE in advance whenever you will not be home to receive services or care that have been arranged for you.
• Informing CenterLight Healthcare PACE before permanently moving out of the service area or any lengthy absence from the service area.
• Being responsible for your actions if you refuse treatment or do not follow CenterLight Healthcare PACE’s instructions.
• Being responsible for paying your financial obligations.

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Transition Policy

This policy is developed to abide by the Centers for Medicare & Medicaid Services (CMS) guidelines. CenterLight will maintain an appropriate transition process consistent with 42 CFR §423.120(b)(3) .

CenterLight pharmacy department and contracted Pharmacy Benefit Manager (PBM) will ensure that transition policy will apply to non-formulary drugs, meaning both (1) Drugs that are not on formulary, and (2) Drugs that are on formulary but require prior authorization or step therapy, or that have an approved quantity limit lower than the participant’s current dose, under utilization management rules.

CenterLight pharmacy department and contracted PBM will ensure that policy addresses procedures for medical review of non-formulary drug requests, and when appropriate, a process for switching new participants to therapeutically appropriate formulary alternatives failing an affirmative medical necessity determination. Also, in accordance with CMS requirements, ensure that drugs excluded from Part D coverage due to Medicare statute are not eligible to be filled through the transition process. However, to the extent that CenterLight covers certain excluded drugs under an Enhanced benefit, those drugs should be treated the same as Part D drugs for the purposes of the transition process.

CenterLight pharmacy department and contracted PBM will ensure that it will apply all transition processes to a brand-new prescription for a non-formulary drug if it cannot make the distinction between a brand-new prescription for a nonformulary drug and an ongoing prescription for a non-formulary drug at the point-of-sale.

Implementation Statement

1. Claims Adjudication System: MedImpact has systems capabilities that allow MedImpact to provide a temporary supply of non-formulary Part D drugs in order to accommodate the immediate needs of an enrollee, as well as to allow the plan and/or the enrollee sufficient time to work with the prescriber to make an appropriate switch to a therapeutically equivalent medication or the completion of an exception request to maintain coverage of an existing drug based on medical necessity reasons.
2. Pharmacy Notification at Point-Of-Sale: MedImpact utilizes the current NCPDP Telecommunication Standard to provide POS messaging. MedImpact reviews NCPDP reject and approval codes developed during the External Codes List (ECL) process. Pharmacy messages are modified based on industry standards.
3. Edits During Transition: MedImpact will only apply the following utilization management edits during transition at point-of-sale: edits to determine Part A or B versus Part D coverage, edits to prevent coverage of non-Part D drugs, and edits to promote safe utilization of a drug. Step therapy and prior authorization edits must be resolved at point-of-sale.
   
   MedImpact will ensure that the transition policy provides refills for transition prescriptions dispensed for less than the written amount due to quantity limit safety edits or drug utilization edits that are based on approved product labeling.
   
   As outlined in 42 CFR §423.153 (b), MedImpact has implemented Point-of-Sale (POS) PA edits to determine whether a drug is covered under Medicare Parts A or B as prescribed and administered, is being used for a Part D medically accepted indication or is a drug or drug class or its medical use that is excluded from coverage or otherwise restricted under Part D (Transmucosal Immediate Release Fentanyl (TIRF) and Cialis drugs as an example).
4. Pharmacy Overrides at Point-Of-Sale: During the participant’s transition period, all edits (with the exception of those outlined in section 4 below) associated with non-formulary drugs are automatically overridden at the point-of-sale. Pharmacies can also contact MedImpact’s Pharmacy Help Desk directly for immediate assistance with point-of-sale overrides. MedImpact can also accommodate overrides at point-of-sale for emergency fills.

Procedure: 

1. Participants and situations affected by this transitional fill policy in which CenterLight and contracted PBM will apply a transition process consistent with 42 CFR §423.120(b)(3) as detailed in the policy below:

• New participants into CenterLight PACE dual plan
• Newly eligible Medicare beneficiaries from CenterLight PACE Medicaid only coverage,
• Participants who switch from one plan to another after the start of the contract year,
• Current participants affected by negative formulary changes across contract years,
• Participants residing in long-term care (LTC) facilities.

2. Transition Fills for new participant in the Outpatient (Retail) Setting, CenterLight will ensure:

• Transition policy provides for a one-time temporary fill of at least a month’s supply of medication anytime during the first 90 days of a participant’s enrollment, beginning on the effective date of coverage.i. If participant presents with a prescription written for less than a month’s supply, CenterLight will allow multiple fills to provide a month’s supply of medication.ii.    CenterLight will allow for multiple fills for unbreakable packages that will allow at least a month’s supply to be dispensed during participant’s transition period.

 3. Transition Fills for new participant in the LTC Setting, CenterLight will ensure:

• The transition policy provides for a one-time temporary fill of at least a month’s supply (unless the participant presents with a prescription written for less) which should be dispensed incrementally as applicable under 42 CFR §423.154 and with multiple fills provided if needed during the first 90 days of a participant’s enrollment, beginning on the effective date of coverage
• After the transition period has expired, the transition policy provides for a 31-day supply of non-formulary drugs (unless the participant presents with a prescription written for less than 31 days) while an exception or prior authorization is requested.
• For participants being admitted to or discharged from a LTC facility, early refill edits are not used to limit appropriate and necessary access to their Part D benefit and such participants are allowed to access a refill upon admission or discharge.

4. Edits for Transitional Fills

• CenterLight will only apply the following utilization management edits during transition at point-of-sale: edits to determine Part A or B versus Part D coverage, edits to prevent coverage of non-Part D drugs, and edits to promote safe utilization of a drug. Step therapy and prior authorization edits must be resolved at point-of-sale.
• CenterLight will ensure that the transition policy provides refills for transition prescriptions dispensed for less than the written amount due to quantity limit safety edits or drug utilization edits that are based on approved product labeling.
• As outlined in 42 CFR §423.153 (b), CenterLight contracted PBM has implemented Point-of-Sale (POS) PA edits to determine whether a drug is covered under Medicare Parts A or B as prescribed and administered, is being used for a Part D medically accepted indication or is a drug or drug class or its medical use that is excluded from coverage or otherwise restricted under Part D

5. Cost sharing for Transition Fills

• Cost-sharing for a temporary supply of drugs provided under its transition process will never exceed the statutory maximum co-payment amounts for low-income subsidy (LIS) eligible participants. There is no cost sharing for CenterLight PACE dual participants for transition fills.

6. Transition Extension

• CenterLight will make arrangements to continue to provide necessary drugs to participants via an extension of the transition period, on a case-by-case basis, to the extent that their exception requests or appeals have not been processed by the end of the minimum transition period and until such time as a transition has been made (either through a switch to an appropriate formulary drug or a decision on an exception request).
• On a case-by-case basis, point-of-sale overrides can also be entered by the CenterLight or by contracted PBM (if authorized by CenterLight) in order to provide continued coverage of the transition drug(s).

7. Transition Across Contract Years

• New Participants to CenterLight PACE dual plan: CenterLight will extend its transition policy across contract years should a beneficiary enroll in a plan with an effective enrollment date of either November 1 or December 1 and need access to a transition supply.
• For current participants whose drugs will be affected by negative formulary changes in the upcoming year, the Sponsor will effectuate a meaningful transition by either: (1) providing a transition process at the start of the new contract year or (2) effectuating a transition prior to the start of the new contract year.i. Negative changes are changes to a formulary that result in a potential reduction in benefit to participants. These changes can be associated to removing the covered Part D drug from the formulary, changing its preferred or tiered cost-sharing status, or adding utilization management. The transition across contract year process is applicable to all drugs associated to mid-year and across plan-year negative changes.

8. Emergency Supplies and Level of Care Changes for current participants

• An Emergency Supply is defined by CMS as a one-time fill of a non-formulary drug that is necessary with respect to current participants in the LTC setting. Current participants that are in need of a one-time Emergency Fill or that are prescribed a non-formulary drug as a result of a level of care change can be placed in transition via an NCPDP pharmacy submission clarification code.
• CenterLight contracted PBM can also accommodate a one-time fill in these scenarios via a manual override at point of- sale. Upon receiving an LTC claim transaction where the pharmacy submitted a Submission Clarification Code (SCC) value of “18”, which indicates that the claim transaction is for a new dispensing of medication due to the participant’s admission or readmission into an LTC facility, PBM’s claims adjudication system will recognize the current participant as being eligible to receive transition supplies and will only apply the point-of-sale edits described in section 1.5(c) of this policy. In this instance, the CenterLight does not need to enter a point-of-sale override.

9. Transition Notification

1. CenterLight contracted PBM will send written notice consistent with CMS transition requirements to participants within three business days of adjudication of the temporary transition fill. If the participant completes his or her transition supply in several fills, notification is required with the first transition fill only.
2. The notice must include
   • an explanation of the temporary nature of the transition supply a participant has received;
   • instructions for working with the plan sponsor and the participant’s prescriber to satisfy utilization management requirements or to identify appropriate therapeutic alternatives that are on the formulary;
   • an explanation of the participant’s right to request a formulary exception;
   • description of the procedures for requesting a formulary exception.
3. For long-term care residents dispensed multiple supplies of a Part D drug in increments of 14-days-or-less, consistent with the requirements under 42 CFR 423.154 (a)(1)(i), the written notice must be provided within 3 business days after adjudication of the first temporary fill.
4. CenterLight and contracted PBM will use the CMS model Transition Notice via the file-and-use process or submit a non-model Transition Notice to CMS for marketing review subject to a 45-day review. Contracted PBM will ensure that reasonable efforts are made to notify prescribers of affected participants who receive a transition notice.
5. CenterLight contracted PBM provides the prescriber of record with a copy of the transition notice that was sent to the participant labeled “PRESCRIBER COPY” via U.S. first class mail or fax.
6. CenterLight will make general information about the transition processes available to participants on the web site, along with a link to CMS’ Medicare Prescription Drug Plan Finder relating to plan transition process information.  CenterLight will also include transition process information in pre- and post-enrollment marketing materials as directed by CMS.

10. Exception Process

• CenterLight contracted PBM will make available prior authorization or exceptions request forms upon request to both participants and prescribing physicians via a variety of mechanisms, including mail, fax, email, and on web sites.
• CenterLight’s exception process integrates with the overall transition plan for participants in the following areas:
  • Exception process complements other processes and strategies to support the overall transition plan.
  • When evaluating an exception request for transitioning participants, the exception evaluation process considers the clinical aspects of the drug, including any risks involved in switching, when evaluating an exception request for transitioning participant.
  • The exception policy includes a process for switching new participants to therapeutically appropriate formulary alternatives failing an affirmative medical necessity determination.

Oversight Process:

CenterLight clinical pharmacy department is responsible for overseeing this process via weekly transition claim and transition letter notification review.  

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Participants may be liable for the cost of services not authorized by your CenterLight Healthcare PACE.

If you have questions or concerns about your plan of care, your care providers or any other aspects of your care, please contact a care team member. Alternatively, you can give us a call at 1-833-CL-CARES (1-833-252-2737) (TTY: 711) from 8:00 a.m. to 8:00 p.m. EST, Monday-Friday.