Dual Eligibles

How do I contact Medicare? What types of questions can Medicare answer for me?
You can call 1-800-Medicare (1-800-633-4227) or visit www.medicare.gov. Medicare can answer any questions you may have about your enrollment into a Part D plan, how to change plans or how to disenroll from a Part D plan. Medicare is also your best source for information if you are experiencing problems with your Part D plan.
How do I choose a Medicare Part D plan? Who can tell me about the different prescription drug plans to find the one that is best for me?
The best sources for assistance are: Medicare or call 1-800-MEDICARE (1-800-633-4227); and CLAIM at 1-800-390-3330, which provides free health insurance counseling to Medicare participants in Missouri.
What is Missouri’s benchmark premium? What happens if a dual eligible chooses to enroll in a plan with a premium above the benchmark?
Missouri's 2016 benchmark premium is $26.13. Dual eligibles enrolled in a below benchmark Basic Prescription Drug Plan, do not pay a monthly premium for prescription drug coverage. If a dual eligible joins a plan that has a premium higher than the benchmark, they will have to pay the difference.
What changed in my MO HealthNet coverage when I became a dual eligible?
Only the pharmacy benefit changes for individuals who become dual eligibles. Dual eligibles will receive pharmacy benefits through their Medicare Part D plan and MORx.
What is the MORx benefit for dual eligibles?
The MORx benefit will pay 50% of co-pays, deductibles and costs remaining on prescription drugs after the Medicare Part D plan pays. For dual eligibles, certain drugs excluded by Medicare will continue to be paid for by MO HealthNet.
Will MO HealthNet pay for any drugs?
For MO HealthNet participants, MO HealthNet will continue to pay for drugs excluded from Medicare Part D coverage that are covered by MO HealthNet. Medicare Part D excluded drugs that are generally covered by MO HealthNet include barbiturates, benzodiazepines, and certain over-the-counter medications.
If Medicare Part D does not cover a drug and the drug is not a Medicare Part D excluded drug, will MO HealthNet pay for the drug?
No.
If a participant has Medicare Parts A and B, and is eligible for MO HealthNet under Blind Pension, do they need to enroll in a Part D plan? If they do not enroll in a Part D plan and later lose their blind pension, will they have to pay a late enrollment penalty?
Yes. Individuals eligible for Blind Pension must enroll in a Part D plan.
What are the Medicare co-pays for dual eligibles?
Medicare co-pays for full benefit dual eligibles for 2016 should not exceed $2.95 for generic and $7.40 for brand name prescriptions.
Are Medicare co-pays required for dual eligibles in Long Term Care?
After the first full month of residence in a skilled nursing facility, an intermediate care facility for the mentally retarded or an inpatient psychiatric hospital, dual eligibles will have no co-pay.
What are the Medicare co-pays for dual eligibles in Residential Care Facilities (RCF)?
Medicare co-pays for full benefit dual eligibles in 2016 should not exceed $2.95 for generic and $7.40 for brand name prescriptions.
Do I have to pay the Medicare co-pays?
MORx will pay for half of the Medicare co-pay, but you will need to pay the rest. Medicare Part D co-pays are real co-pays. Unlike MO HealthNet co-pays, your pharmacy may refuse you service if you do not pay your portion of the co-pay.
If a dual eligible does not enroll in a Medicare Part D plan, will MO HealthNet pay for Part D drugs?
No. A dual eligible must be enrolled in a Part D plan for MO HealthNet to pay for Part D drugs.
Will excludable drugs be covered if a dual eligible does not enroll in Part D?
Yes.
Will MO HealthNet pay for any Medicare Part B drugs for dual eligibles?
MO HealthNet does not pay for Part B drugs.
If a participant is receiving their diabetic supplies and nebulizer drugs from a mail order pharmacy, do they need to change?
No. These are covered by Medicare Part B and the participant may continue to get these through the Part B provider.
Who will cover Blood Glucose Test Strips?
Blood Glucose Test Strips are covered by Medicare Part B and the participant may continue to get these supplies through the Part B provider.
Will MORx work with mail order pharmacies?
No. MORx does not work with mail order pharmacies. You can fill your prescriptions at any non-mail order pharmacy that is contracted with your Part D plan and MORx will provide wrap-around benefits. Many MORx participating pharmacies provide home delivery services at minimal or no additional charge.
Will the MORx benefit apply to the purchase of a 90-day supply of medication?
No. The MORx benefit will not cover a 90-day supply of medication. If your doctor writes a prescription for a 90-day supply, simply turn it into your pharmacy and ask them to fill it in 30 or 31 day increments. The MORx benefit will cover up to a 31-day supply of each prescription at a time. You can get a full day’s prescribed dosage for each day of the month with a maximum of 31 days each month.
Currently MO HealthNet covers an array of over-the-counter (OTC) medications. How will OTC medications be covered for dual eligible participants who have no spend down?
MO HealthNet will continue to pay for drugs excluded from Medicare Part D coverage, including certain over-the-counter medications for dual eligibles. Claims for these drugs will need to meet current MO HealthNet edits.
Will I still have to pay my spend down every month, since MO HealthNet will no longer be covering my prescriptions?
Yes, if medical services other than prescription drugs are required.
For residential care facility (RCF) residents with an income that is higher than the facility rate and who are MO HealthNet spend down clients, can they apply and prepay their spend down and be eligible for the entire month?
Yes. If a participant prepays their spend down they are eligible for the entire month and MO HealthNet will cover their Part D excludable drugs for the entire month.
How does spend down affect Medicare Part D drug costs?
If you have a Medicaid spend down requirement, the spend down must be met at least once during the calendar year for MORx benefits to work. When you meet the spend down requirement one time MORx will start paying 50% toward your medication cost.
If I am a dual eligible and have been enrolled in Part D, but I have not met my spend down yet this month, will excludable drugs be covered by MO HealthNet?
No, but the cost of the excludable will count toward spend down.
Do drugs not on the Part D formulary count toward spend down?
Yes, if they are prescribed by a physician.
Will Medicare Part D premiums count toward spend down?
If the participant pays the premiums, this amount will count toward their spend down.
Since MO HealthNet is not covering my prescriptions any longer, will the amount of my spend down be reduced?
No.