Medicare and Long-term care

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Medicare and Long-term care

Revised September 15, 2009

Purpose: This section includes the link to Medicare programs. This section includes additional information relating to Medicare and long-term care programs. Long-term care programs are defined as residing in a medical institution 30 days or more or one of the HCS or DDD Waiver programs.

NOTE:
9-2009. This new section of the LTC manual is currently under construction. Thank you for your patience.

Medicare Programs
Medicare Programs describes Medicare programs.

This link includes the WAC, information on Medicare A, B, C and D, Medicare Savings Programs (MSP), Medicare buy in, referral numbers for help on Medicare related issues, worker responsibilities and information on the HRSA Medicare buy-in unit.

The information in the section below is additional information specific to long-term care programs and post eligibility participation.

NOTE:
The Medicare program includes four kinds of health insurance coverage:

Part A is hospital insurance and is free for people who have worked and have earned the required number of work quarters, or have a spouse who has earned the required number of work quarters. Part A is available at a cost for Medicare entitled people who do not have the required number of work quarters for free Medicare Part A.

Part B is medical insurance (doctor’s visits). Everyone who enrolls in Part B must pay a monthly premium.

Part C is the optional Medicare Advantage managed care plan approved by Medicare but run by private companies.

Part D is Medicare’s prescription drug program. Part D benefits are available to all Medicare beneficiaries.

Medicare premiums as a participation deduction
Medicare Premiums are an allowable participation reduction for the first 2 months of LTC eligibility.

Any expense deducted from room and board (residential clients in ALFs) is coded as an ETR. Signed ETRs are needed to deduct any expense from room and board. Do not request an ETR if there is available participation.

See ACES instructions below for coding information for Medicare expenses including room and board/ETR coding.

Medicare D-Prescription Drug Plan
Beginning January 1, 2006, Medicare assumed responsibility for the prescription drug coverage for over 6 million low-income Medicare beneficiaries who are also enrolled in Medicaid.  These beneficiaries are referred to as full-benefit dual eligibles. They qualify for Medicare prescription drug coverage with no premiums and co-payments. There are several Prescription Drug Plans (PDP) to choose from in Washington. Benchmark plans have no premium costs for Medicaid clients. Benchmark plans are paid by Medicare under the low income subsidy (LIS) program.   Medicare D co payments are paid by DSHS subject to funding. Medicare will provide prescription drugs for dual eligible clients.

All dual eligibles transitioned from Medicaid drug coverage to Medicare drug coverage as of January 1, 2006.

Clients receive their prescriptions through a Prescription Drug Plan (PDP). If they do not enroll in a plan, they are automatically assigned a PDP. The assignment is random.

Dual eligibles can change plans any time and the new plan will be effective the first of the next month.

Medicaid will continue to cover some drugs not covered in Part D including over-the-counter medications and benzodiazepines.  Drugs covered by Medicaid.

Dual eligibles now have co-pays under Medicare Part D that will vary.   The department will start covering co pays up to the maximum of a benchmark plan.

Recipients on a benchmark Medicare D plan have their premiums paid by the low income subsidy program through Medicare. Prescription co payments are paid by DSHS

Recipients that have chosen a non benchmark Medicare D plan may have premium and co payment expenses that are an out of pocket expense. These medical expenses are an allowable post eligibility participation deduction.

Full benefit dual eligibles (Medicaid/Medicare) are entitled to premium-free Part D enrollment, however they may elect enrollment in an enhanced plan. Those who enroll in an enhanced plan are responsible for the portion of the premium attributable to the enhancement and that portion is an allowable deduction in the post-eligibility calculation. They may also pay higher co-pays with the enhanced plan. The state will only pay part of the higher co-pays for clients enrolled in an enhanced plan.

Dual eligibles residing in institutions (nursing homes and ICF-MRs) are exempt from co-pays after residing in a facility for a full calendar month.

HRSA Medicare Part D Resources

Drugs Covered by Medicaid

Health and Human Services Medicare D resources

NOTE:
Medicare D premiums are paid by Medicare's low income subsidy (LIS) program not DSHS. DSHS sends information on all Medicaid recipients eligible to receive Medicare benefits to Medicare in order for Medicare to enroll these clients in the low income subsidy program. Benchmark plan premiums are covered 100% by the Medicare LIS program. Clients need to call 1-800-Medicare if they wish to switch to a benchmark plan. Clients need to call their PDP plan to resolve issues with prescription drug coverage.

DSHS' involvement in Medicare D is paying the prescription drug co payments (subject to funding). Clients enrolled in benchmark PDP plans have their co payments paid at 100% by DSHS. Clients in enhanced Medicare D PDPs have a portion of the prescription co payment paid by DSHS up to the benchmark amount.

DSHS does not enroll clients in Medicare D plans, this is done by Medicare.

Credible coverage and Medicare D
Not all Medicare eligible clients have Medicare D. Individuals that have "credible coverage" are not required to enroll into a Medicare D plan once they become Medicaid eligible.

What is credible coverage?

Creditable Coverage Definition and Determination defined by CMS

As defined in the regulation at 42 CFR §423.56(a), drug coverage is creditable if the

actuarial value of the coverage equals or exceeds the actuarial value of standard Medicare

prescription drug coverage. In general, this actuarial determination measures whether the expected amount of paid claims under the entity’s prescription drug coverage is at least as much as the expected amount of paid claims under the standard Medicare prescription drug benefit. See 70 FR 4225

In other words, if a client has a health insurance that includes comparable prescription drug coverage, they do not have to enroll into a Medicare D plan.

Do clients have out of pocket prescription drug co payments associated with credible coverage plans?

Yes. Credible coverage plans may have co payment charges that are considered out of pocket costs to the client. These out of pocket costs must be verified in order for the department to reduce participation. Once the department has verification of what the health insurance has paid toward the prescription drugs, the out of pocket co payment is an allowable deduction from participation.

What happens if the system automatically enrolls a client with credible coverage into a Medicare D prescription drug plan once they become eligible for Medicaid?

The client or their representative will need to contact 1-800-Medicare and their credible coverage insurance carrier to indicate they want to retain their credible coverage health plan. There are times when Medicaid clients are enrolled into a Medicare D PDP incorrectly when the client has credible coverage.

Medicare D and Adjusting Participation and/or Room and Board
CMS clarification regarding Medicare D and post eligibility

For the majority of clients, the state will pay the co-pays and we should not have to adjust participation or room & board. We will have to adjust participation and room & board for clients who have enrolled in enhanced plans and clients who have purchased prescriptions after being denied an exception from the PDP.

Use the amount the client pays in co-pays as a medical expense deduction until the state begins paying the co-pays. Clients enrolled in enhanced plans may still be required to pay higher co-pays.  In order to mitigate the workload impact of adjusting the co-pays that the client pays monthly, establish a pattern of co-payment amounts paid over three months and use that amount as a medical expense deduction for the restof the certification period. This may mean adjusting participation monthly until you establish the pattern. If the client, with the help of their pharmacy, can provide the projected expenses, use that amount.

Use the additional premium cost, if the client picks an enhanced plan that is not premium-free, as a medical expense deduction. Clients should not be charged a premium if enrolled in a benchmark plan.

Do not deduct co-pays that the client paid in error. During initial implementation PDPs have given inaccurate information to pharmacies and clients have paid incorrect co-pay amounts. It may take time for plans to be notified of new clients being opened on Medicaid and they may continue to charge the non-Medicaid co-pays. These will be reimbursed by the PDP. See CMS clarification on Post Eligibility

Do not deduct for prescriptions the client has paid for unless the client has requested an exception from the PDP and was denied. The client must provide you with proof of the denial.

Do not allow premiums and co-pays as a deduction against room & board if the client has other income to pay the co-pays. Some SSI beneficiaries have the $46 SSI State Supplement that can be used to pay the additional co pay charges.

Request a local ETR to reduce room & board paid by the client in a community residential facility. see ACES information below as ETRs need to be coded in ACES for room and board. (HCS staff)

Inform the client to contact you when their prescription costs change.

Re-adjust participation if there are changes.

The Financial Worker (FW) makes the adjustments for COPES and MN Waiver in ACES. The FW also informs the client and Social Worker/Case Manager of the participation or room and board changes for COPES and MN Waiver using an ACES change letter.

The Social Worker/Case Manager (SW/CM) makes the adjustments in SSPS. The HCS SW/CM also informs the client of the room and board changes for MPC using the Planned Action Notice. The DDD CM/SW informs the client using their DDD letter.

HCS Management Bulletin H06-015-Procedure dated March 7, 2006 includes several handout and Q and A regarding Medicare D.

Text of HCS handouts to clients, both applicant and recipients.

ACES-Tracking Medicare Part D costs-HCS
Tracking Medicare Part D Costs - HCS

In order to capture the amount being allowed as deductions for a budget impact and the workload impact, we need to have the amounts captured in ACES.

P - Room and Board exception types. Code the expenses related to Medicare Part D that are used to reduce room and board on the LTCX screen for COPES and MN Waiver clients. Use the Room & Board Exception Type “P”, Medicare Part D Co-payments. (a signed ETR is needed for a deduction from room and board).

OD - Code the premiums related to Medicare Part D that are used to reduce participation on the LTCX screen for COPES and MN Waiver clients.

OP - Code the Medicare Part D Co-payments not paid by DSHS and used to reduce participation on the LTCX screen for COPES and MN Waiver clients.  This would only apply for individuals that have chosen a non benchmark plan.

For MPC clients that do not have the Part D expenses identified in ACES, send copies of the local ETR adjustments due to Medicare Part D to David Armes at MS: 45600.

ACES-Medicare Savings Programs
Medicare Savings Programs and ACES

LTCX screen coding and Medicare:

OA-Medicare Part A premiums

OB-Medicare Part B premiums

OC-Medicare Part C premiums

OD-Medicare Part D premiums

OP-Medicare Part D co-payments

Additional information on medical expenses and participation
Allowable medical expenses and services that can be used to reduce participation

Additional helpful links for Medicare issues
Statewide Health Insurance Benefits Advisors (SHIBA)

Medicare Website

Medicare Information Source - The Senior Resource Center

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