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Medicaid, Medicare and Prescription Drugs

Medicare Part D is Medicare’s prescription drug benefit. In order to be eligible for Medicare Part D, one must be enrolled in Medicare Part A and/or Part B.

A dual eligible beneficiary is an individual who is receiving both Medicaid and Medicare benefits. Dual eligible beneficiaries generally receive their prescription drugs from Medicare Part D.

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Medicare part D plans go through private insurance companies that are approved by  Centers for Medicare and Medicaid (CMS). Dual eligibles can switch to a new Medicare Part D plan at any time. Changes are effective the first day of the next month. Those that are dual eligible beneficiaries will be enrolled in a Medicare part D benchmark plan. Benchmark drug plans have no monthly premium fee. Currently, there are ten $0 premium benchmark plans to choose from.

There are two types of drug plans: Basic and Enhanced, but only the Basic plans can qualify as benchmark plans.

Basic drug plans meet the minimum standards set by Medicare with regard to costs and coverage.

Enhanced drug plans may have more drugs on their formulary.

• Some dual eligibles are still enrolled in a drug plan that is not a benchmark plan. They are paying a monthly premium fee when they would pay $0 if enrolled in a benchmark plan.

• CMS sends a letter to these dual eligible beneficiaries, to inform them that they can switch to a $0 premium benchmark plan if they want to.

• If dual eligible beneficiaries are enrolled in a non-benchmark plan, and don’t pay the monthly premium, the drug plan will dis-enroll them. When this happens, CMS will auto-enroll them into a benchmark plan. In certain instances this may cause a period of non-coverage. It is therefore recommended to be proactive choose a benchmark plan as soon as a Medicaid approval is grant to avoid any lapse in coverage.

• If there is any lapse in coverage during the Medicaid pending phase, Linet program will provide temporary retro coverage. ( see below)

Why Would Dual Eligible Select a Non-Benchmark Drug Plan?

• If a dual eligible needs medications not available on the formulary of benchmark drug plans, but available in non-benchmark plan – it may be more cost-effective to pay a relatively low monthly premium to get the needed medications. (This is really a benefit to the nursing home, the family is not responsible)

Each Medicare part D plan has a formulary. A formulary is a list of prescription drugs that are covered under the plan. Medicare D will also cover commercially available vaccine drugs when medically necessary to prevent illness.

Certain drugs have restrictions regarding quantity and cost and will require extra steps to be taken prior to obtaining the Medication.

Below is a short list of some of the required steps for certain drugs

Prior Authorization: Requires a prescriber/ physician to obtain permission from the plan to prescribe a certain medication. The physician will need to show a medically-necessary need for the drug.

Step Therapy: The practice of trying a more cost effective medication and only stepping up to a more expensive medication if necessary.

Quantity Limits: A drug plan may limit the amount of pills that they cover for a particular drug, generally for safety and cost containment reasons. With documentation from a physician, this requirement may be waived.

When a dual eligible beneficiary enrolls in a benchmark plan, there are two key factors that should be kept in mind:

• It is important that the dual eligible beneficiaries choose a plan in which their regular drugs are covered on the plans formulary

• It is also important to make sure that the plan is affiliated with the dual eligible beneficiaries pharmacy (or the care facility where he/she resides).

When a provider is submitting a claim for drug reimbursement, Medicare will always be billed first.  Most drugs are covered under Medicare D. If a drug is covered under Medicare Part B then Medicare Part D will not cover. In certain instances , If Medicare B or D does not cover a particular drug, Medicaid would then be billed.

Limited Income Newly Eligible Transition Program, with Humana.

This process allows pharmacist to enroll dual eligible beneficiaries into a temporary Part D plan (LINET Humana) in order to get medications immediately.

Two ways dual eligible beneficiaries can qualify for  LINET

• A Medicaid pending Individual that is eligible for Medicare part D, but never actually joined. LINET Humana will give temporary Part D coverage until they get enrolled in a full benchmark plan once there is a Medicaid approval. LINET Humana will cover retroactive to the Medicaid eligibility request date.

• Someone who is Medicaid pending and was dis-enrolled because of failure to pay their premiums, LINET Humana will cover the lapse in coverage until they receive full Medicare Part D benchmark coverage once Medicaid is approved.

Dual eligible are meant to be auto enrolled into Linet temporarily if they meet the criteria, in reality this does not always happen. You can call the office for assistance with Linet at 800-783-1307, ext. 3.

For more information about Medicaid, Medicare and Prescription drugs contact Senior Planning Services at 1855.S.Planning (775-2664).