What does Medicare cover?
Individuals on Medicare and Medicaid are called Full Benefit Dual Eligible (FBDE). Individuals on institutional Medicaid and HCB waivers do not have copayments toward Medicare services.
Individuals on institutional and HCBS waiver services on Medicare D for prescription drugs may have a premium cost that is an allowable medical deduction if the client has chosen a non-benchmark Medicare D PDP.
Drugs that are allowed under ANY PDP formulary under Medicare D, but not allowed in the specific PDP the client has chosen is not an allowable deduction from participation. Guidance from CMS has indicated if the drug is in any formulary it is a covered item.
Individuals on "credible coverage" for prescriptions are not enrolled in Medicare D. Prescription copayments due to credible coverage insurance is an allowable medical deduction from participation.
Medicare has a web tool to check for covered items under the Medicare program .
CMS notice to providers regarding QMB and Medicaid eligible clients. Providers are not allowed to charge QMB clients copayments.
If you have an institutional or HCB Waiver client being charged a Medicare D copayment, refer them back to the provider and indicate if the provider doesn't refund the copayment, the client will need to call the 1-800-MEDICARE helpline .