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Effective: April 1, 2008 |
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04.45.05ar3 - MA/GAMC and Medicare Part D (Archive) |
Archived: February 1, 2009 |
Enrollment in Medicare Part D is not required as a condition of MA or GAMC eligibility. However, there are specific policies established for clients eligible for Medicare Part D who fail or refuse to enroll in, or opt out of, that program.
MA/GAMC and Medicare Part D - General Provisions.
Extra Help and Medicare/Medical Expense Deductions.
MA/SSI Enrollee – Benefit Change.
Temporary Prescription Drug Coverage.
MA/GAMC and Medicare Part D – General Provisions
State and federally funded MA programs and GAMC cannot pay prescription drug costs that would be covered by Medicare Part D for eligible Part D beneficiaries who do not enroll.
Example:
June applies for and is approved for MA in April. She is eligible to enroll in Medicare Part D but has chosen not to enroll.
Action:
Claims submitted to DHS for drug expenses covered by Medicare Part D will be denied. June should contact Medicare to enroll in Medicare Part D if she wants her drug costs covered.
MA and GAMC will continue to pay some specific drug costs for full-benefit dual eligibles, such as over-the-counter drugs currently covered by MA. For information about MA and GAMC covered services, clients can contact the MHCP Member Helpdesk at 1-800-657-3739.
Medicare beneficiaries enrolled in GAMC or state-funded MA will not receive prescription drug coverage, other than the limited categories of drugs that these programs continue to cover, if they do not have other creditable drug coverage and:
l Are not enrolled in Medicare Part D.
l Do not enroll in Medicare Part D.
GAMC and state-funded MA enrollees who are Medicare beneficiaries are not:
l Automatically qualified for Extra Help.
l Automatically enrolled in a Part D plan by CMS.
l Full benefit dual eligibles.
These enrollees must apply for Extra Help to receive subsidies for Part D cost-sharing expenses. See Medicare Part D for more information on how a person can apply for Extra Help.
Full benefit dual eligible and Medicare Savings Programs (MSP) enrollees who are eligible for Medicare Part D are automatically eligible for Extra Help with a full subsidy.
Note: Enrollees who are not enrolled in a Medicare Part D Benchmark Plan may want or need to switch to a benchmark plan to avoid the monthly Part D premium cost.
Extra Help and Medicare/Medical Expense Deductions
l Do not use the premium amount or cost-sharing amounts paid by Extra Help as either of the following:
n A medical expense meet a spenddown as an H bill or P Bill.
n A deduction on a long-term care income calculation for the Medicare premium deduction or the LTC Medical Expense Deduction.
l Do permit the premium amount or cost-sharing amounts, such as copays paid by the applicant or enrollee, as medical expenses to meet a spenddown or as a deduction on a long-term care income calculation.
Note: Amounts that an enrollee pays out of pocket for non-benchmark Medicare Part D plans may be used as a medical expense to meet a spenddown or as a deduction on a long-term care income calculation, since they will not be paid by the Extra Help subsidy. The amounts in excess of the benchmark premium change each year, as the plan offerings, the benchmark amount, and the plan prices change. See 2008 Amounts in Excess of the Benchmark to Apply as Medical Expense.
See Medicare Part D Benchmark Plan for more information on plans available to clients receiving Extra Help and the benchmark premium costs.
Clients enrolled in Minnesota Senior Health Options (MSHO) or Minnesota Disability Health Options (MnDHO) who are eligible for Medicare are full benefit dual eligibles. All plans for MSHO and MnDHO are benchmark Medicare Part D plans with fully subsidized Extra Help.
MSHO or MnDHO enrollees who are full benefit dual eligibles and choose to:
l Disenroll from MSHO or MnDHO must sign up for a new Medicare Part D plan before they disenroll, or they may have a gap in their Part D plan coverage.
l Enroll in another Medicare Part D plan will be automatically disenrolled from MSHO or MnDHO.
These enrollees may need to re-establish home and community-based services managed through the county.
MSHO enrollees whose MA eligibility is closed may continue to receive Medicare Part D and other Medicare benefits through the MSHO plan for up to three calendar months. Clients who enroll in a Medicare Part D plan prior to three calendar months will receive Part D benefit coverage through the chosen plan.
The MMIS User Services Help Desk identifies MA and GAMC enrollees each month who become entitled to Medicare and issues a Benefit Change Notice, due to the change in prescription drug coverage once a person is eligible for Medicare Part D.
l The MMIS User Services Help Desk sends the Benefit Change Notice to the enrollee and enters a MAXIS case note.
l Workers will receive a copy of the Benefit Change Notice from the MMIS User Services Help Desk through interoffice mail.
n Encourage enrollees to enroll in a Medicare Part D plan as soon as possible after receiving the Benefit Change Notice, unless they have creditable drug coverage, to continue prescription drug coverage after the effective date of the MA/GAMC benefit change with limited disruption.
l Enrollees have the right to appeal these benefit changes. Enrollees may be able to continue prescription drug coverage through MA or GAMC during the appeal process if the appeal is received before the effective date of the change, or within ten days of receiving the Benefit Change Notice.
Note: Workers must contact the MMIS User Services Help Desk via MAXIS email at code MHLP if:
n An enrollee appeals the change in prescription drug coverage. The subject line should be ”r;Medicare Part D Appeal.”
n An appeal has been decided. The subject line should be ”r;Medicare Part D Appeal Update.”
MA/SSI Enrollee - Benefit Change
The MMIS User Services Help Desk processes a monthly report which identifies MA enrollees who receive SSI three months in advance of their 65th birthdays. These MA enrollees are required to apply for Medicare well in advance of their 65th birthdays to ensure ongoing prescription drug coverage and continuing MA eligibility.
Follow the process established in Referrals to Medicare upon receipt of a MAXIS email from the Help Desk identifying an enrollee on the monthly report.
Temporary Prescription Drug Coverage
Encourage full benefit dual eligibles to proactively enroll in a Medicare Part D plan and not wait for CMS to enroll them in a plan. These people have access to temporary prescription drug coverage until they are enrolled in a Medicare Part D plan.
The Centers for Medicare and Medicaid Services (CMS) has contracted with a national point of sale contractor to temporarily cover Medicare prescription drugs for full benefit dual eligibles not enrolled in Medicare Part D.
This temporary coverage is available to:
l New full benefit dual eligibles who have:
n Not yet chosen a Medicare Part D plan.
n Chosen a plan but it is not effective yet.
l Any full benefit dual eligibles who are not currently enrolled in a Medicare Part D plan, although they may have been in the past or may be enrolled effective in a future month.
Note: Full benefit dual eligibles changing Medicare Part D plans can avoid gaps in Medicare Part D coverage, and potential pharmacy problems with using the temporary prescription drug coverage, by enrolling in the new Part D plan but not disenrolling from the old Part D plan. Enrollment in the new plan will automatically trigger disenrollment from the old plan.
Full benefit dual eligibles not enrolled in a Part D plan:
l Should be able to fill prescriptions through the point of sale plan if they present both their MHCP and Medicare cards at the pharmacy.
l Will not be automatically enrolled in a Part D plan by CMS if they have enrolled in a Part D plan and are just waiting for the effective date.
l Will be automatically enrolled in a Medicare Part D plan by CMS if they do not have a plan enrollment pending. Enrollment effective dates can vary.
Example:
Melissa is a Medicare beneficiary but is not enrolled in Part D. She applies for MA on June 5, with coverage requested back to March 1. Melissa is eligible for MA effective March 1.
Action:
MA cannot pay for prescription drugs that would be covered by Medicare Part D for Melissa because she is eligible but not enrolled in Part D.
Melissa contacts the Linkage Line in June and enrolls in a Medicare Part D plan effective July 1. However, she reports to her worker that she needs to fill several prescriptions.
Action:
Melissa can bring her MHCP card and her Medicare card to the pharmacy when she fills her prescriptions. The pharmacist will use the point of sale plan to provide Melissa with her prescription drugs for June. Because she has already enrolled in a Part D plan for July 1, CMS will not enroll her in another plan.