Effective: September 1, 2011
15.10.05.10 - Medicare Cost Effective Premium Requirements
Evaluate whether Medicare Parts A or B are cost effective for people who qualify for Medicare with a premium but do not qualify for the Buy-In The process of having some or all of the client’s Medicare costs paid through MA. or for a Medicare Savings Program (MSP).
Medicare Part A.
Medicare Part B.
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Medicare Part A
Request a cost effective review of Medicare Part A premiums from the Benefit Recovery Section (BRS).
Javier pays a premium for his Medicare Part A
If Javier does not qualify for the QMB benefit which pays for Part A premiums, submit verification of Javier’s Medicare Part A premium to BRS for a cost effective insurance evaluation.
BRS determines that Javier’s Medicare Part A is not cost effective. Javier drops his Medicare Part A.
Continue Javier’s MA coverage. Javier is not required to maintain coverage that is not determined to be cost effective.
Request a cost effective review from BRS if any of the following is true:
l The person must pay an increased premium for Part B due to late enrollment.
Exception: Do not reimburse Part B premiums for MA-EPD enrollees whose income is greater than 200% FPG. Do not count spousal income in this determination. Do not refer to BRS.
l The person must be removed from the MA buy-in because they are residing in an IMD and the actual Part B premium (what the person would pay if not on the MA buy-in) is an increased premium due to late enrollment.
l The person has coverage through an employer group health insurance plan that is permitted as a substitute for Part B and would automatically terminate the person's enrollment in Medicare Part B.
Note: Also consider the person's coverage for prescription drugs.
People with disabilities who are eligible for MA and Medicare Part C (Medicare Advantage) may cancel their Medicare Part C coverage. The person must then enroll in a Medicare Part D plan to maintain prescription drug coverage.
Medicare beneficiaries eligible for MA, whether disabled or age 65 or older, may cancel non-Medicare group health insurance, with or without prescription drug coverage, regardless of whether that coverage is cost effective, without penalty. A person who cancels group health insurance that includes prescription drug coverage must then enroll in a Medicare Part D plan to get prescription drug coverage.
Note: MA will not pay any co-payments or other cost-sharing required by a non-Medicare group health insurance plan for any Medicare Part D covered drug. An enrollee who chooses to continue non-Medicare group health insurance, that is not cost effective may use the premiums and other cost sharing they incur to meet a spenddown.
Reimburse Medicare Part B premiums retroactive to the date of MA-EPD eligibility for all enrollees who have income less than or equal to 200% FPG and who are not eligible for QMB or SLMB.
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