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COMAR 10.09.24.10

State of Maryland Medical Assistance Manual Revised July 2013 m. Prescription Drug Costs and Post-Eligibility for Institutionalized Persons Policy Alert (10-13)

Background

Beginning January 1, 2006, individuals enrolled in Medicare may receive prescription drugs through Medicare Part D (see DHR/FIA Action Transmittal 06-06). For the most part, coverage of prescription drugs is no longer available under Medicaid. Chapter 10 in the Medicaid Manual addresses the deduction of a long-term care recipient’s incurred expenses for health insurance premiums or for non-covered medical or remedial services from the recipient’s available income for the cost of care. See also Policy Alert 10-12, issued in this Manual Release. Following is information about how Medicaid eligibility case workers are to consider pharmacy charges and Medicare Part D costs in the Medicaid post-eligibility calculations for institutionalized persons.

Medicare Part D Premiums

Dual eligibles for full Medicare and Medicaid benefits are entitled for premium-free Medicare Part D enrollment. However, they may choose to enroll in an enhanced prescription drug plan. Those who enroll in an enhanced plan are responsible for the portion of the premium that is attributable to the enhancement. When an institutionalized Medicaid recipient is enrolled in an enhanced Medicare plan, the portion of the premium that remains the individual’s responsibility is an allowable deduction in the post-eligibility calculation for the recipient’s contribution to the cost of care.

Co-pays, Deductibles, and Coverage Gap

Dual eligibles that are institutionalized and enrolled in a Medicare Part D Prescription Drug Plan (PDP) or a Medicare Advantage Prescription Drug Plan (MA-PD) are not responsible for the payment of Medicare Part D deductibles or co-pays, nor are they subject to a coverage gap in their Medicare Part D benefits. A Medicare Advantage plan generally provides all health care, including prescription drug coverage. (These rules do not apply to individuals eligible under a 1915(c) home and community-based services waiver). Listed below are the various circumstances that may apply to institutionalized persons who are dual eligibles:

1. Individuals who were dual eligibles and institutionalized as of January 1, 2006 were auto- enrolled into a PDP or, if in a Medicare Advantage Plan that offers a drug plan, into the MA-PD. For institutionalized dual eligibles, the drug plans may not require co-pays or deductibles and may not impose any coverage gap.

2. For individuals who were dual eligibles prior to institutionalization, and who were subject to co-pays, the drug plan may continue to charge those co-pays until the plan is notified of the individual’s institutionalized status. If the state identifies the individual as an