Medicaid and Prescription Drugs

Mark W. Mazzeo

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Elder Law Attorney

Contributor Level 6

Posted about 4 years ago. 1 helpful vote

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Medicaid recipients must rely on their Medicare Part D prescription plan for prescribed medicines. Most Medicaid applicants come to this office with a Part D plan already in place. During the process of becoming eligible for Medicaid, the applicant must decide whether it is best to continue with the applicant's current Part D plan or change to another plan that may better suit the applicant's needs. There are two main factors to consider: first, cost; and second, coverage. These factors are considered below. 1. COST. In 2010, the first $22.63 of a Medicaid recipient's Part D plan is paid by Medicare. That figure is called the "benchmark amount" for premium assistance. If the recipient's current Part D plan premium is more than the "benchmark amount" the insurance will request an authorization to deduct the difference directly from the Medicaid recipient's Social Security check. To avoid a deduction, the Medicaid recipient, or his representative may choose from benchmark plans offered in Florida. This can be done as follows: a. Benchmark plans in Florida can be reviewed at www.medicare.gov., or discussed with a Medicare representative at 1-800-633-4227; or b. The social services representative at the nursing home can assist the Medicaid recipient or his caregiver with choosing a benchmark plan for the patient. The nursing home knows which benchmark plans are best for their patients. 2. COVERAGE. All Part D plans have a "formulary" which is a list of drugs that the Part D plan will pay. If the recipient's needed prescription drug is not on their Part D plan's formulary, the recipient is responsible for payment. The dilemma is that all of the recipient's income less $35 for personal needs is paid to the nursing home as the patient responsibility. In the case of an uncovered drug, the recipient has two choices. a. First, he may change his Part D plan to a plan whose formulary includes the needed drug. A person receiving Medicaid and Medicare may change plans at any time. b. Second, the Medicaid recipient may apply to the Department of Children and Families (DCAF) to decrease his patient responsibility because of the "incurred medical expense." The cost of the drug as part of his "share of cost" which Medicaid will deduct from his patient responsibility. The second choice, although technically possible, is very cumbersome in practice. This office does not recommend this choice unless the "incurred medical expense is a fixed long-term expense. A "share of cost" determination by DCAF for uncovered drugs is beyond the scope of this firm's representation. SUMMARY: It is best for the applicant or his caregiver to meet with the nursing home's representative before this office submits the application for Medicaid. They will help choose a "benchmark" plan that best suits the patient's prescription needs that is fully paid by Medicaid. If difficulties are encountered, contact SHINE (Serving Health Insurance needs of Elders). SHINE is a network of trained volunteer counselors who provide elders and their caregivers with information and unbiased health insurance counseling. These counselors with help you with the information you need to choose a Medicare prescription plan. SHINE usually meets at the Senior Friendship Center on Tuesdays at 8:00a.m. The phone number for SHINE of Sarasota County is 866-505-4088. WORD OF CAUTION: Although nursing home residents (but not beneficiaries receiving services in the community) do not have to pay co-payments for their prescription drugs as covered by their Plan D formulary, the exemption from co-payments does not begin until the beneficiary has been institutionalized in a nursing facility for a full calendar month as a Medicaid beneficiary. The delayed exemption means that a beneficiary who is admitted to a nursing facility as a Medicaid beneficiary on June 3, for example, will be charged co-payments until August 1. If the beneficiary is admitted on June 3 as a Medicare beneficiary and Medicare pays for his or her care until July 3, when Medicaid begins to pay for the stay, the beneficiary will be charged co-payments from July 3 until September. In any of these scenarios, small co-pay may be incurred, even for covered drugs. It is best for the family to pay the few dollars per month if all other aspects of the patient's care needs are being met.

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