Adult Medicaid Manual MA-2312 MEDICARE PRESCRIPTION DRUG BENEFIT

iii. enrollment

All Medicare beneficiaries, including those receiving Medicaid, can choose to enroll in a PDP upon entitlement to Medicare. Medicaid recipients entitled to Medicare, including individuals eligible for the Medicare Savings Plans (MQB-Q, B, & E), may choose to change plans at anytime.

Enrollment in a PDP provides prescription drug coverage. If Medicaid recipients entitled to/or enrolled in Medicare, affirmatively decline Medicare Part D, have no other prescription drug insurance coverage, or fail to enroll in a PDP, they will not have prescription drug coverage.

Medicaid recipients entitled to Medicare and not enrolled in a PDP will be automatically enrolled in a PDP by the Centers for Medicare and Medicaid Services (CMS). The purpose of this auto-enrollment is to ensure prescription drug coverage for Medicaid individuals entitled to Medicare.

Recipients receiving Medicaid and entitled to Medicare will be identified through a system of data exchanges. Data will be exchanged between the Division of Medical Assistance (DMA) and CMS. Part of this exchange process will include:

- Identifying Medicaid recipients entitled to/or enrolled in Medicare

- Updating the EIS Medicare Data screens

- CMS enrolling recipients into a PDP, if not previously enrolled

- EIS generating a notice to the newly identified Medicare/Medicaid recipients regarding the change in Medicaid benefits

All Medicaid recipients receiving Medicare and all Medicare beneficiaries who become Medicaid eligible will be enrolled through this process, unless enrollment in a PDP already exists. Recipients who affirmatively decline Part D will not be enrolled, and will be coded in EIS as entitled to Medicare, which will prevent Medicaid from covering prescriptions. Therefore, recipients who affirmatively decline Medicare Part D will not have prescription drug coverage, unless they have other prescription drug insurance coverage.

The process of identifying recipients, updating EIS, enrolling in a PDP, and generating a notice will take at least two months. Until the process is complete and enrollment is finalized, newly eligible Medicaid recipients who did not previously enroll in a Prescription Drug Plan will not have drug coverage through Medicaid. For this reason, applicants not enrolled in a PDP and without other prescription drug insurance coverage, must be advised to enroll in a PDP. Individuals can enroll directly with the PDP of their choice, or seek the help of Medicare or the North Carolina Seniors’ Health Insurance Information Program. Individuals who enroll while Medicaid eligibility is being determined will avoid further delay of prescription drug coverage. Refer to X., Other Places to Contact for Medicare Information, below.

REVISED 04/01/09 – CHANGE NO. 05-09

A. Data Flow for Enrollment Process

Flow of data for enrollment in LIS and Part D for a recipient with Medicaid coverage who is entitled to or enrolled in Medicare Part A and/or B:

1. When an individual is approved for Medicaid (Adult or Family and Children’s), Work First, CAP, or SA and is entitled to Medicare, he is eligible for the State to pay the Medicare Part B premium through buy-in. A file of recipients who are eligible for buy-in is sent each month to CMS.

2. When a recipient is on buy-in or we are attempting to accrete him to buy-in, he is included on the MMA file the State sends to CMS twice each month. Federal policy requires each state to send to CMS this file of recipients who have both Medicaid and Medicare coverage

3. CMS does a match of the information the State submitted on the MMA Data file with information on Medicare records. CMS returns information to the State within 48 hours about Medicare A, B, C, (Part C is Medicare Advantage) and D and also identifies recipients who did not match the Medicare records. This is called the MMA Response file.

4. If a recipient on the MMA Response file is entitled to Medicare Part D and is not enrolled with a PDP, CMS will automatically enroll him with a PDP by the middle of the next month.

5. The Medicare A, B, C, and D information from the MMA Response file is added to the Medicare A/B/C and D screens in EIS at the end of each month.

EXAMPLE: A Medicare beneficiary previously eligible for Part D, but not enrolled in a PDP is approved on January 20th for Medicaid. Worker keys “y” for Medicare A and/or B on the DSS-8125 approval. The recipient is included on the February buy-in file and is included on the February MMA file. The MMA Response file is returned to the State within 48 hours and is loaded to EIS at the end of February. If the recipient is a match with CMS data, the MMA Response file will include the recipient’s Medicare A, B, C, and D information. However, the MMA Response file does not include the plan the recipient is auto enrolled in. CMS automatically enrolls the recipient in a PDP and sends the recipient the PDP information around the middle of March. The plan information is included in the March MMA Response file and is loaded to EIS the end of March.

6. Recipients that do not match CMS data are returned to the State on an error report. These errors will be reconciled by the State Claims Analysis Unit.

REVISED 09/01/06 – CHANGE NO. 21-06

B. Medicare beneficiaries who become Medicaid eligible

1. Usually Medicare beneficiaries who become Medicaid eligible and are not already enrolled in a PDP will be automatically enrolled by CMS the month following the month the recipient is included on the buy-in file. If there is a non-match with CMS data, the enrollment is delayed until the non-match is resolved. The following list includes, but is not limited to, recipients who will be automatically enrolled:

a. Recipients with creditable coverage;

b. CAP recipients;

c. Recipients receiving Medicaid through State/County Special Assistance

d. Recipients receiving Medicaid through Work First

e. Recipients in Family and Children’s Medicaid

f. Recipients in Aged, Blind and Disabled Medicaid, including private living arrangement and long-term care.

These recipients will not have prescription drug coverage until the enrollment is complete. However, applicants not enrolled in a PDP and without other drug coverage insurance should be advised to enroll in a PDP while Medicaid eligibility is being determined. The county worker should also complete the LIS application during the initial interview. Refer to MA-2310, Taking the LIS Application.

2. Prescription drug expenses cannot be paid or reimbursed by Medicaid. Excluded drugs may be billed to Medicaid. Refer to VI. A. Excluded Drugs, below.

C. Medicaid recipients who become eligible for Medicare

Medicaid recipients who become entitled to Medicare will be automatically enrolled in a PDP. Coverage by the PDP will be retroactive to the month of Medicare eligibility, except when retroactive eligibility for Medicare Parts A and/or B is determined. Eligibility for Medicare D is effective the first day of the month in which the beneficiary received notification of retroactive Medicare A/B entitlement. Medicare Part D entitlement cannot be retroactive.

REVISED 09/01/06 – CHANGE NO. 21-06

Example: On July 1, 2006, SSA determines an individual disabled effective January 1, 2004, and entitled to Medicare January 1, 2006. Notification of SSA and Medicare eligibility is sent to the individual July 1, 2006. This individual is eligible for Medicare D effective July 1, 2006. An existing Medicaid recipient would be enrolled in a plan effective July 1, 2006. A non-Medicaid individual would not be enrolled until the month after he/she requests enrollment with a plan.