Adult Medicaid Manual MA-2312 MEDICARE PRESCRIPTION DRUG BENEFIT

ISSUED 01/01/06 – CHANGE NO. 03-06

i. introduction TO The Medicare Modernization Act of 2003

The Medicare Modernization Act of 2003 provides for prescription drug benefits under Medicare Part D. Medicare beneficiaries must enroll in a Prescription Drug Plan (PDP) to receive these services. Medicaid recipients who are entitled to Medicare Part A and /or enrolled in Medicare Part B will not have prescription drug coverage through Medicaid. Medicaid recipients who are entitled to Medicare must be enrolled in a PDP to have prescription drug coverage, unless there is other prescription drug insurance coverage. Medicaid recipients have no gap in coverage and may or may not have a premium to pay depending on the plan chosen. Medicaid recipients will continue to be responsible to pay co-payments. This includes, but is not limited to, recipients who receive Medicaid through CAP, Work First, State/County Special Assistance, Family and Children’s Medicaid, and Aged, Blind and Disabled Medicaid. Institutionalized recipients will not pay a co-payment. Medicaid will continue to pay for other medical services.

Medicaid recipients, entitled to/or enrolled in Medicare, qualify for this Medicare drug coverage. Medicaid recipients, including LTC recipients, may enroll in the plan of their choice and may choose to change plans at anytime. LTC recipients cannot be required to enroll in the PDP the nursing facility requests. Recipients who enroll in a plan other than the basic plan may have to pay a portion of the premium cost. This additional cost cannot be paid by Medicaid and is the responsibility of the enrollee.

Medicaid recipients, entitled to/or enrolled in Medicare, can opt to not be covered by Medicare Part D. This is called affirmatively declining. Medicaid recipients who affirmatively decline Medicare Part D coverage will not be auto-enrolled into a prescription drug plan. Therefore, they will not have prescription drug coverage, unless they have other prescription drug insurance coverage.

Medicaid recipients who affirmatively decline Part D enrollment and do not have other prescription drug insurance coverage, will pay a penalty of 1% of the base benefit premium for each month not enrolled. This penalty will be assessed if the individual chooses to enroll in a Prescription Drug Plan more than 63 days after the loss of Medicaid eligibility.