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COMAR 10.09.24.10

State of Maryland Medical Assistance Manual Revised July 2013 institutionalized dual eligible for past months on the state’s monthly file sent to Medicare, the plan will reimburse the individual for any co-pays incurred during those months.

3. For individuals who were enrolled in Medicare Part D, but who were not eligible for Medicaid at the time of institutionalization, the plan may continue to charge co-pays, deductibles, and costs incurred during a coverage gap until the plan is notified by the state of the individual’s status as an institutionalized dual eligible. If the state identifies the individual as an institutionalized dual eligible for past months on the state’s monthly file sent to Medicare, the plan will reimburse the individual for co-pay, deductibles, and costs incurred during a coverage gap for those months.

4. Individuals who qualify for Medicare Part D but are not enrolled in a drug plan, and are not Medicaid eligible at the time of institutionalization, will be fully responsible for their drug costs until their Medicaid eligibility is determined and their Medicare Part D auto- enrollment is processed as an institutionalized person. The plan will be responsible for drug charges as of the effective date of the enrollment. The plan will not charge deductibles or co-pays, or apply a coverage gap to those persons enrolled as institutionalized dual eligibles.

In the first three circumstances above, when Medicaid post-eligibility is calculated for the individual’s cost of care contribution, there should be no deductions for prescription co-pays, deductibles, or coverage gaps. This is because, if these costs are incurred, the individual is not ultimately responsible for these charges.

In the last circumstance above, the individual will remain responsible for Medicare Part D covered drugs purchased prior to the effective date of the Part D enrollment. In this circumstance, the cost of these drugs is allowable as a deduction for non-covered services in the Medicaid post-eligibility calculation.

Creditable Coverage under Part

Individuals who were dual eligibles, institutionalized, and receiving Medicare benefits may also have health and prescription benefits through a union or employer retirement plan. Most of these plans providing prescription drug coverage to Medicare beneficiaries must disclose whether their coverage is “creditable prescription drug coverage” through a Disclosure Notice.

Because this coverage is considered creditable, these institutionalized individuals may have decided to continue their prescription coverage through their union or employer retirement plan. In these cases, they are deemed to have creditable coverage under Part D and do not have to join a Medicare Prescription Drug Plan. Therefore, any documented out-of-pocket payments for premiums, co-pays, and deductibles associated with their retirement plan prescription benefits