This information should help Medicare counselors advise Medicare beneficiaries who qualify for full dual Medicare-Medicaid eligibility or for QMB status as to what their options are. Counselors should also keep in mind the Affordable Care Act (ACA) provision, effective January 1, 2013, that requires Medicaid programs to pay the Medicare rate for many primary care services rendered by family physicians, internists and pediatricians in 2013 and 2014. This provision overrides the information provided in the “Pay 100% of Cost Sharing?” columns.

2012 Dual Eligible (D/E) and Qualified Medicare Beneficiary (QMB) Information by State

Which State Medicaid Programs Pay Physicians 100% of a D/E or QMB’s Cost Sharing?

Which State Medicaid Programs Will Pay a D/E or QMB’s Medicare Advantage Premium?

(Note: The cost sharing data is summarized from the MACPAC’s March 2013 “Report to the Congress on Medicaid and CHIP,” which can be accessed at http://www.macpac.gov/reports, while the oremium data comes from the Kaiser Commission on Medicaid and the Uninsured’s October 2012 report “Medicaid Today; Preparing for Tomorrow – A Look at State Medicaid Program Spending, Enrollment and Policy Trends,” which can be found on the Kaiser Family Foundation website www.kff.org.)

                                     Pay              Pay                                    Pay                Pay
                                     100%         Medicare                           100%          Medicare
                                    of Cost    Advantage                        of Cost      Advantage
   State                       Sharing?   Premium?         State        Sharing?      Premium?   

Alabama                      Never     Varies         Montana               Never  Unknown

Alaska                         Never       No              Nebraska              Always     Yes

Arizona                     Never    Unknown       Nevada                   Never       No

Arkansas                    Always    No               New Hampshire     Never      No

California                    Never       No               New Jersey            Never       No

Colorado                     Never      No               New Mexico           Never       No

Connecticut               Never  Unknown        New York                Unique   Yes

Delaware                     Never     No                North Carolina       Never      Yes

District of Columbia  Never     No                North Dakota         Never       No

Florida                        Never  Varies               Ohio                        Never       No

Georgia                       Never   Yes                 Oklahoma              Always      No

Hawaii                        Always   No                Oregon                    Never      No

Idaho                           Never   Yes                 Pennsylvania         Never      No

Illinois                       Never Unknown          Rhode Island          Never     No

Indiana                       Never    No                 South Carolina       Never     Yes

Iowa                          Always   No                 South Dakota       Always     Yes

Kansas                       Never    No                  Tennessee             Never      Yes

Kentucky                   Never    No                  Texas                     Never      Yes

Louisiana                   Never    No                  Utah                       Never       No

Maine                        Always No                  Vermont              Always      No

Maryland                   Never   No                  Virginia                 Never       No

Massachusetts         Never   No                  Washington        Never        No

Michigan                   Never   No                  West Virginia      Never       No

Minnesota              Never Unknown            Wisconsin           Never       No

Mississippi            Always    No                   Wyoming           Always      No

Missouri                Always     No

This information should help Medicare counselors advise Medicare beneficiaries who qualify for full dual Medicare-Medicaid eligibility or for QMB status as to what their options are.  Counselors should also keep in mind the Affordable Care Act (ACA) provision, effective January 1, 2013, that requires Medicaid programs to pay the Medicare rate for many primary care services rendered by family physicians, internists and pediatricians in 2013 and 2014.  This provision overrides the information provided in the “Pay 100% of Cost Sharing?” columns.

Preview of Medicare Part C and Part D for 2014

The actuaries at the Centers for Medicare & Medicaid Services (CMS) must have been burning their midnight oil, because they have already laid the foundation for Medicare Advantage (managed care) plans and Part D prescription drug plans for 2014. The good news for beneficiaries is that it looks like they have taken action to control increases in premiums for Medicare Advantage plans, and beneficiaries in Part D will see a lower deductibles and co-payments for drugs.


Part of the reason for this is in 2014 Part C and Part D plans will have to adhere to the Affordable Care Act provision to maintain a medical loss ratio of 85%, that is, they must spend 85% of revenue on clinical services, prescription drugs, quality improvements, etc.

And Part D will also improve for those beneficiaries who fall into the donut hole, as not only will manufacturers have to discount brand name drugs by 52.5%, as they do in 2013, but the program will discount generic drugs by 28%, up from the 21% in effect this year.

As 2014 is a long way off, there is no use to going into great detail about this at this point in time, and we will know more particulars as the year progresses and plans submit their specific offerings to CMS. But one interesting trend is that there will be more emphasis on quality of care. For one, Medicare will be refining its Part D Medication Therapy Management (MTM) program and tying it into the Million Hearts initiative to improve access and adherence to anti-hypertensive medications. It will also encourage beneficiaries to tie their medication reviews into their annual wellness visits to their physicians. And, interestingly, the Part D program has been in place for a long enough time that it is producing data on how Medicare beneficiaries are medicated. For example, it now has data on the use of anti-psychotic medications in the long-term care setting, and will begin using this to deal with the longstanding quality of care issue of the overuse of these drugs in this setting.

So stay tuned, and as we approach the annual enrollment period in the Fall (it always starts October 15), I’ll blog more about what beneficiaries should be looking for and what action they should take to ensure they are in the best plans for their circumstances in 2014.

Medicare Part D - Point of Service Denial Notice

Beginning April 1, the Centers for Medicare & Medicaid Services (CMS) will begin enforcing a requirement in Part D that a beneficiary who goes to one of their plan’s network pharmacies and whose prescription is denied at the point-of_service (POS), which usually means at the pharmacy window, will get a written notice about the denial. This notice is titled “MEDICARE PRESCRIPTION DRUG COVERAGE AND YOUR RIGHTS” and is Form No. CMS-10147.

The notice tells you only that your drug is not covered, and gives you some instructions on how to proceed. Basically, you’ll need to call your prescription drug plan and ask why the drug in question was not covered. You Plan then has to give you a coverage determination (a formal denial and the reason for the denial). If you or your doctor still thinks you should get the drug, you can make an exception request. The instructions in the notice will give you some details on this, and it’s also spelled out beginning on page 206 of Managing Your Medicare. Too, your doctor’s office probably has some experience with these (you almost certainly will have to get them involved), and you can also call your State Health Insurance Assistance Program (SHIP). Their number is on the back of your Medicare & You booklet; they are often quite skilled at dealing with drug denials.

You should note that you will not always get this notice. For example, if you were prescribed an over-the counter (OTC) drug (these are not covered by Part D), or if it isn’t yet time to refill your prescription, you will not get this formal notice.