Medicaid and Prescription Drugs
Medicaid recipients must rely on their Medicare Part D prescription plan for prescribed medicines. Most Medicaid applicants come to this office with a Part D plan already in place. During the process of becoming eligible for Medicaid, the applicant must decide whether it is best to continue with the applicant’s current Part D plan or change to another plan that may better suit the applicant’s needs. There are two main factors to consider: first, cost; and second, coverage. These factors are considered below.
1. COST. In 2016, the first $28.07 of a Medicaid recipient’s Part D plan is paid by Medicare in Florida. That figure is called the”benchmark amount” for premium assistance. If the recipient’s current Part D plan premium is more than the “benchmark amount” the insurance may request an authorization to deduct the difference directly from the Medicaid recipient’s Social Security check. To avoid a deduction, the Medicaid recipient, or his representative may choose from benchmark plans offered in Florida. This can be done as follows
Benchmark plans in Florida can be reviewed at www.medicare.gov., or discussed with a Medicare representative at 1-800-633-4227; or
The social services representative at the nursing home can assist the Medicaid recipient or his caregiver with choosing a benchmark plan for the patient. The nursing home should know which benchmark plans are best for their patients.
2. COVERAGE. All Part D plans have a ”formulary” which is a list of drugs that the Part D plan will pay. If the recipient’s needed prescription drug is not on their Part D plan’s formulary, the recipient is responsible for payment. The dilemma is that all of the recipient’s income, less $105.00 for personal needs, and any applicable spousal allowance, is paid to the nursing home as the patient responsibility. In the case of an uncovered drug, the recipient has two choices:
First, he may change his Part D plan to a plan whose formulary includes the needed drug.
Second, the Medicaid recipient may apply to the Department of Children and Families (DCAF) to decrease his patient responsibility because of the “incurred medical expense.” The cost of the drug as part of his “share of cost” which Medicaid will deduct from his patient responsibility. The second choice, although technically possible, is very cumbersome in practice. This office does not recommend this choice unless the “incurred medical expense” is a fixed long-term expense.