Provider Notice issued 06/10/08

Residents in Medicaid Pending Status

The purpose of this notice is to alert long term care providers about the importance of prescription drug coverage through Medicare Part D for residents in Medicaid pending status.  It is essential that, as part of the admission process, residents be screened for Medicare eligibility.  Medicare eligible residents should be assisted with applying for the low-income subsidy available through the Social Security Administration, and enrolling in a Medicare Part D plan.  Exceptions to this policy are residents who have private health insurance that covers prescription drugs that they wish or are required to use for prescription benefits.

Since the inception of the Medicare Part D program on January 1, 2006, individuals who are eligible for Medicare are not eligible for Medicaid drug coverage.  Oftentimes, a Medicare-eligible resident is determined retroactively eligible for Medicaid, but that resident was not enrolled in a Medicare Part D plan.  Therefore, they have no drug coverage for the period during which they were in Medicaid pending status.  Prior to inception of the Medicare Part D program, the pharmacy could bill their prescriptions to the Medicaid program retroactive to the effective date of the resident’s Medicaid eligibility.  This is no longer the case for these residents because of their Medicare eligibility.  For this reason, it is critical that Medicare eligible residents be enrolled in a Medicare Part D plan.

Once the resident is determined Medicaid eligible, the resident’s dual eligibility status will be established and the resident will receive dual eligible benefits such as payment of plan premium by Medicare and no prescription co-payments for months that they were Medicaid-eligible and institutionalized.  The prescriptions will not be billable to the Medicaid program, however.  They must be billed to the resident’s Medicare Part D plan. 

To apply for the low-income subsidy, contact the Social Security Administration at 1-800-772-1213 or at <www.socialsecurity.gov>.  For resident assistance with the Medicare process, contact a local senior center, Senior Health Assistance Program or Area Agency on Aging.  To find an office near your facility, call the Senior HelpLine at 1-800-252-8966.

Theresa A. Eagleson, Administrator

Division of Medical Programs