The Centers for Medicare & Medicaid Services (CMS) created the Limited Income Newly Eligible Transition (LI NET) Program to provide immediate, temporary medication access for low-income Medicare beneficiaries without prescription drug coverage. CMS awarded the LI NET program contract to Humana. 

Who is eligible for LI NET?

Medicare beneficiaries are eligible for LI NET if they:

• Have been found eligible for Medicare Part D Extra Help. This includes: Full duals—those who are deemed eligible for Extra Help because they receive Medicaid or Supplemental Security Income (SSI), and Partial duals—those who receive a Medicare Savings Program (MSP). It also include individuals who applied for Extra Help through Social Security and have received a Notice of Award letter.

AND

• Are not enrolled in a Part D plan, or have prescription drug coverage through Medicare Advantage.

How does someone enroll in LI NET?

Full dual eligibles are automatically enrolled in LI NET; they will receive a letter from CMS on purple paper indicating they are deemed eligible for Extra Help and opted in to LI NET.

Partial duals and those who applied directly for Extra Help must enroll in the LI NET program at the pharmacy. These beneficiaries must provide “best available evidence” (BAE) to pharmacy staff for immediate prescription fills and LI NET enrollment. This BAE includes one of the following documents:

• A letter from Social Security or CMS indicating award of Extra Help (e.g., official award letter, notice of change, notice of planned action)
• A copy of the current state Medicaid award letter with effective dates.
• State eligibility verification system queries (interactive voice response, online).

What if the LI NET claim system does not recognize the beneficiary’s information?

If this occurs, the pharmacist can ask for an override for each medication. The pharmacist should fax the BAE to Humana at 1-877-210-5592, and call the Humana help desk at 1-800-783-1307.

Which drugs are on the LI NET formulary and are there restrictions?

LI NET has an open formulary and contains all Part D drugs. LI NET does not cover drugs excluded from the Part D program. 

There are limits on some drugs for safety reasons, including quantity limits or prior authorization. For example, beneficiaries are only permitted a maximum 30-day supply limit of opioids (though pharmacies should follow their state regulations, if these are more restrictive), regardless of diagnosis or place of residence. “Opioid naïve” patients who are new to opioids will be limited to an initial 7-day supply for the treatment of acute pain.

All other medications are limited to a 60-day supply under LI NET.

Does LI NET have a pharmacy network?

All pharmacies can submit claims to LI NET following the instructions from Humana LI NET.  Pharmacies may not know about LI NET and may need a copy of the Four Steps for Pharmacy Providers or LI NET Program Brochure available at the Humana LI NET website.

Is LI NET retroactive?

If full Medicaid or SSI eligibility is retroactive, then LI NET is retroactive and the beneficiary will receive a CMS yellow letter no. 11429 (counts as BAE).  The beneficiary will receive another notice from Medicare LI NET with instructions on how to get reimbursed for covered drugs during the months of retroactive coverage. People with retroactive coverage may be eligible for reimbursement of covered Part D prescriptions they paid for, from any pharmacy, during any past months in which they were entitled to retroactive coverage under Medicare’s Limited Income NET Program. They must present a notice or award letter within 90 days of the date on the notice or letter.

Not all LI NET is retroactive, however. Beneficiaries who receive a CMS yellow letter no. 11154 indicating auto-enrollment into a Part D plan do not get retroactive coverage. The yellow notice letter includes the date coverage is effective.  

Can a beneficiary be reimbursed for out-of-pocket expenses while enrolled in LI NET?

A beneficiary who paid out-of-pocket for prescription drugs while enrolled in LI NET may be eligible for reimbursement. See the first page of the “Welcome Letter” for the beneficiary’s LI NET coverage dates and follow the instructions on the enclosed Prescription Drug Claim Form to request reimbursement for claims. A beneficiary has 36 months from the date the prescription was filled to request reimbursement. A copy of the claim form is available on the Humana LI NET webpage.  

Can a beneficiary be reimbursed for out-of-pocket expenses prior to being enrolled in LI NET?

If a beneficiary paid out-of-pocket for medications prior to their LI NET coverage effective date, they may be eligible for reimbursement, provided they meet the following eligibility requirements on the date the prescription was filled:

• Eligible for Medicare Part D
• No other prescription drug coverage (Medicare Part D, retiree drug subsidy)
• Not enrolled in a Medicare Advantage Plan (Medicare Part C)
• Have not opted out of Medicare’s auto-enrollment
• Permanent address in the 50 states or Washington, D.C.
• Full dual eligible

How long can a beneficiary keep LI NET?

CMS enrolls all Extra Help beneficiaries into Part D plans within one or two months. Full duals with full Medicaid or SSI are automatically and randomly enrolled the first day of the following month after the award and notified by a CMS yellow letter no. 11429. 

All other Extra Help beneficiaries have a random and facilitated enrollment into a Medicare Part D drug plan two months after their Extra Help award date and receive notice via a CMS green letter no. 11191. 

What other assistance can I offer a beneficiary new to Extra Help?

Help the beneficiary make a Part D comparison using the Medicare Plan Finder and enroll in a plan with the best coverage and costs. Even though CMS enrolls beneficiaries with Extra Help into a Part D plan, the plan is chosen at random and doesn’t ensure that the beneficiary’s specific prescriptions are covered on the plan’s formulary. 

Likewise, some plans may require restrictions like step therapy, quantity limits or prior authorization that limit access to the drug.