*** The Health Care Programs Manual (HCPM) has been replaced by the Minnesota Health Care Programs Eligibility Policy Manual (EPM) as of June 1, 2016. Please refer to the EPM for current health care program policy information. ***
Effective: September 1, 2011 |
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15.10.05.10 - Medicare Cost Effective Premium Requirements |
Archived: June 1, 2016 (Previous Versions) |
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 or for a Medicare Savings Program (MSP).
Request a cost effective review of Medicare Part A premiums from the Benefit Recovery Section (BRS).
Example:
Javier pays a premium for his Medicare Part A
Action:
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.
Action:
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.