Kansas Economic and Employment Services Manual

2000 General Eligibility

10-17

2911 Medicare and Medicare Buy-In - "See Policy Memo #99-10-04 re: "Application of Medicare Premiums to Spenddown".

 

The federal Medicare program provides health insurance coverage to persons who qualify (see 2911.2). Medicare is composed the following parts.

 

  1. Part A (Hospital Insurance) - Provides coverage of inpatient hospital care, hospice and home health benefits. Very limited coverage of skilled nursing facility care is also provided. Part A coverage does not have a premium for most people.
     
  2. Part B (Supplemental Medicare Insurance) - Provides coverage of doctors services, outpatient hospital care. Part B also provides coverage for other services such as clinical laboratory services, some therapies, and certain preventative services such as prostate cancer screens and mammography. All services must be medically necessary. Most people pay a monthly premium for Part B coverage through a withholding from their Social Security or Railroad Retirement benefit.
     
  3. Part C (Medicare Advantage) - Provides coverage under a managed care model and is only open to people who live in an area of the state where a plan is offered. Persons receiving Medicare through an Advantage plan agree to receive services from a contracted network of providers but may have additional services covered (such as dental) they may also have an additional premium for coverage.
     
  4. Part D (Prescription Drug Insurance) - Effective January 1, 2006. Provides coverage of outpatient prescription drugs. Medicare beneficiaries will receive Part D coverage through a private plan, known as Prescription Drug Plan (PDP). A Medicare health plan can also provide coverage under Part D, Medicare Advantage - Prescription Drug (MA PD). All plans must offer prescription drugs in specified therapeutic drug classifications, but the specific formularies may vary. Beneficiaries eligible to enroll in Part D must do so through the private plan. A monthly premium is charged to the beneficiary and is collected through a reduction in the Social Security benefit or paid directly to the PDP. Individuals who are incarcerated are not entitled to Medicare D.
     

From June 1, 2004 - December 31, 2005 Medicare beneficiaries have the option to participate in a Medicare Approved Drug Discount Card. These cards, offered through approved sponsors, provide discounts for specified prescription drugs to the holder of the card. An annual enrollment fee is required. Persons receiving prescription drug coverage through Medicaid are not eligible to enroll. In addition, a special $600 credit also called Transitional Assistance is available to persons under 135% of poverty, except for those participating in Medicaid and other specified forms of prescription drug coverage (e.g., TriCare for Life and employer-based coverage).

 

As part of the Medicaid plan, the state is required to provide Medicare Part B coverage to certain groups of individuals. The state pays the standard premium charge on behalf of each enrolled individual. This is accomplished through the buy-in process. Through this process the state ensures entitled individuals are enrolled in Medicare Part B and Medicaid claims are offset by Medicare payments. The state will also pay the Medicare Part A premium for individuals receiving QMB coverage.

 

Incorporated into the appropriate application form is a statement of client consent to buy-in and for Medicare benefit payments to be made directly to medical providers. Utilization of Medicare is required if eligible for any medical assistance program (see 2120 for cooperation).

 

2911.1 Eligibility for Buy-In - Kansas will buy-in individuals who are entitled to Medicare Part B and are enrolled in one or more of the following eligibility groups:

 

For persons eligible under the medically needy plan only, there is no buy-in coverage unless the spenddown has been met. However, once accreted to buy-in persons with an unmet spenddown will continue on buy-in until the coverage terminates. Medically needy coverage is never to be extended for the sole purpose of protecting buy-in status.

 

2911.2 Medicare Entitlement and Impact on Medical Assistance Eligibility - Persons entitled to Medicare Part B must enroll in Medicare Part B as a condition of eligibility. Failure to cooperate with the enrollment process will result in ineligibility for assistance. For instances where potential entitlement has been identified, based on item 1 below, medical assistance eligibility continues as long as the individual is cooperating with the enrollment process. If the enrollment process is not successful and ineligibility for Medicare has been established, the agency may assist in the enrollment processes through processes described in item.

 

  1. The following individuals are eligible for Medicare Part B:
     
    1. Individuals who are age 65 or over who have Medicare Part A (Hospital Insurance).
       
    2. All other individuals who are age 65 or over, who are United States residents, or aliens lawfully admitted for permanent residence and have resided in the U.S. continuously during the five years immediately preceding the month they apply for enrollment. (For the period 6/11/73 through 3/31/76, enrollees did not have to meet the alien residency requirement).
       
    3. Individuals under age 65 who have been receiving monthly Social Security disability benefits under Title II or railroad disability benefits for a certain period of time (usually 24 consecutive months).
       
    4. Individuals who are under age 65 who are eligible for Medicare Part A (Hospital Insurance) because they have chronic renal disease.
       
  2. Enrollment of Eligible Individuals Who Were Not Enrolled In Part B: Persons who are entitled must enroll. The State Medicaid program has the authority to enroll recipient in Part B if the individual does not do so on their own. The method of state-enrollment is dependent upon the Part A enrollment status.
     
    1. Persons enrolled in Medicare Part A shall be enrolled in Medicare Part B through the buy-in process. This process is automated and does not usually require manual intervention to enroll the individual. Upon identification of Medicare Part A entitlement through the EATSS interface, a Part B entitlement date is determined and populated on the KAECSES MEIN screen. This information is sent to the MMIS where it is processed according to general Part B buy-in rules. A buy-in accretion request is sent for the individual. From the buy-in file, CMS identifies the unenrolled individual and initiates enrollment of the individual in Part B.
       
    2. Persons who are not enrolled in Medicare A or Medicare Part B but appear to meet eligibility requirements, are referred to the Social Security Administration for enrollment. If SSA cannot take an application or if the individual refuses to cooperate, the following process is taken:
       
      1. The form, HCFA 1610-U2, Public Assistance Agency Information Request, is sent the appropriate SSA office. On the form, the worker indicates the form is being sent as a lead for Medicare B enrollment and a potential Medicare Part B entitlement date is indicated on the form. SSA will take an application from the beneficiary, if necessary. The results will be communicated back to the worker initially sending the 1610.
         
      2. If the beneficiary cooperates and is eligible for Part B, he will be enrolled and accreted to buy-in. If the beneficiary does not cooperate, the agency is authorized to complete an enrollment application for Medicaid. The beneficiary shall be notified of the agencies action and may request termination of Medicaid coverage if he does not wish to be enrolled in Medicare Part B.
         
  3. The HCFA-4040, Request for Enrollment in Supplemental Medical Insurance, is sent to enroll the Medicaid beneficiary in Medicare Part B. The enrollee does not need to sign the application, the eligibility completes the signature block and annotates the form to show the information came from the case record. The following documentation must be submitted with the application:
     

    The completed form and related documentation should be sent to the Social Security office which services the beneficiary's address.

    After SSA establishes a Medicare claim number for the individual's Medicare record, the individual will be entitled to buy-in. The individual will be accreted to buy-in once a MEIN record is created, is sent to MMIS and eligibility is approved.

 

2911.3 Buy-In Effective Date - The following establish the effective date of buy-in coverage:

 

  1. The buy-in coverage period is determined by the calendar month of medical assistance eligibility.
     
  2. For beneficiaries of cash assistance, SSI or State Supplement or MA CM, the buy-in coverage period begins the first day of the month that cash eligibility begins. Buy-in coverage is continuous for an individual who loses eligibility for cash, SSI or State Supplement, but whose eligibility continues without interruption.
     
  3. For medical only beneficiaries not QMB or LMB eligible, or not previously on Kansas buy-in, buy-in coverage begins the first day of the month following two consecutive months of eligibility for medical assistance, providing that there is medical eligibility on the first day of the third month. The first and third months of medical eligibility do not have to be full months. This also applies to ongoing recipients.
     
  4. Ongoing medical only recipients who become entitled to Medicare are eligible for buy-in following two consecutive months of mutual Medicare entitlement and Medicaid eligibility.
     
  5. For QMB/LMB eligibles, buy-in coverage (including coverage of Part A premiums) begins the first month of eligibility. In addition, for QWD eligibles, coverage of Part A premiums is effective with the month of application.
     
  6. For individuals previously on Kansas buy-in and whose case is reopened (both cash and medical only cases), buy-in coverage begins the first day of the month of eligibility.
     
  7. State submitted accretions (enrollments) may be adjusted to a different beginning date by SSA. Such conditions may be when:
     
    1. SSA records show that the individual does not meet all the requirements for Part B coverage on the requested accretion date.
       
    2. The accretion date submitted falls in the middle of a period of buy-in coverage for another state on SSA's records.
       

For persons meeting one or more of the above criteria, the earliest possible effective date is used.

 

2911.4 Buy-In Terminations - Buy-in coverage ends when one of the following occur:

 

  1. Death - coverage ends on the last day of the month in which the individual died.
     
  2. Loss of Entitlement to Medicare Coverage - If an individual is under age 65 and loses entitlement, buy-in coverage ends on the last day of the last month for which the individual is entitled to Medicare.
     
  3. Loss of Medical Assistance Eligibility - If an individual loses medical assistance eligibility, buy-in coverage ends on the last day of the last month for which the individual is eligible for medical assistance, except when an individual goes into spenddown status. In this case, buy-in coverage continues. Persons who remain covered only under ADAP (KEESM 2694) after regular medical coverage terminates are also terminated from buy-in.
     

2911.5 Explanation of Social Security Numbers and Health Insurance Claim (HIC) - It is important to distinguish between the beneficiary's Social Security number and the beneficiary's Health Insurance Claim (HIC) number. The Social Security number is the number assigned to an individual by Social Security and is used throughout a wage earner's lifetime to identify his or her earnings under the Social Security program.

 

The HIC number is the Social Security number of the individual on whose earnings Social Security benefits are being paid. In most cases, it is also the number on which Medicare eligibility has been established. The claim number includes an alphanumeric suffix known as the Beneficiary Identification Code (BIC), which designates the type of benefits the individual is receiving (such as wage earner's, spouse, or child's benefits). An example of a claim number is 509681267D.

 

The HIC number may be obtained from BENDEX, TPQY, or SDX records, the beneficiary's Medicare card, letter of notification of eligibility for Medicare, premium notice, utilization notice (Explanation of Medicare Benefits), from SSA or RRB.

 

In some instances, an individual may be entitled to benefits under both Social Security and RRB. All benefits will be awarded under either the Social Security HIC number or the RRB claim number. The local office should verify which HIC number to use by contacting the local SSA office. The case worker is then responsible for updating KAECSES, and BCBS MMIS.

 

Occasionally, a HIC number change may occur if an individual becomes entitled to benefits on another Social Security record or when an individual's status on his account changes. Because of this change, an individual may appear to be receiving buy-in under two HIC numbers. Normally, CMS will automatically institute corrective action to consolidate master records within the next billing month.

 

SSA initiates some claim number changes and notifies the state in the regular monthly update file (State Buy-in Register) of any changes in the beneficiary's claim number and BIC. A claim number and BIC change may be applied to an ongoing buy-in record. Because of a claim number change, an individual may appear to be receiving buy-in under two claim numbers. If this occurs the local office should contact the fiscal agent's Buy-in Analyst. SSA will automatically institute corrective action to consolidate the duplicate master records.

 

2911.6 Buy-In Process - The buy-in process consists of two separate file exchanges with the Centers for Medicaid Services (CMS). The first file is also called the input file and contains a list of all buy-in actions the state is requesting. This includes requests for new accretions, deletions as well as changes. It is sent to CMS on or about the 21st of each month.

The second file is also called the receiving file. It is primarily a response file to the previously sent input file. CMS will respond to each action requested by the state. In addition, the receiving file may also contain changes and other informational messages initiated by CMS. This file is received on the first Thursday following the first Monday of the month.

Both files use special codes called transaction codes to communicate the specific action. A list of transaction codes is available online through the MMIS. Most actions occurring within the Kansas buy-in system are automatic. However, some actions may be manually entered on the buy-in file.

All Medicare information for an individual is contained on the KAECSES MEIN screen. This information is collected from BENDEX and TPQY records provided by SSA as well as information from RRB. The MEIN record is transmitted to the MMIS and is used to initiate buy-in as well as match incoming records from CMS. Because the information is taken directly from SSA's records, it is common for the identifying information contained in the MEIN file to differ from that in the established beneficiary file.

 

  1. Accretion Requests - Automatic accretion requests are generated for persons meeting the guidelines of this section and are sent to CMS on the next input file according the previously noted cycle.

    In order for an individual to be accreted to buy-in, the input record sent much match the following elements on the Medicare master record:
     

    For buy-in purposes, this information is obtained from the MEIN file, not the eligibility file. It is not necessary to adjust a beneficiaries name for buy-in purposes, except through MEIN.

    All state-submitted accretions are screened by SSA to verify Medicare eligibility. In these cases where eligibility exists, the individual's Medicare eligibility date and the state buy-in effective date are compared. If the state buy-in date precedes the individual's Medicare eligibility date, SSA will automatically adjust the state buy-in date to agree with the Medicare eligibility date.

    Note:     If an accretion fails to occur when it appears the beneficiary is entitled to benefits, the local office should verify the accuracy of the information in the MEIN record with the local SSA office. If the MEIN information is inaccurate, it should be changed to match that contained on SSA's record. If SSA's record is incorrect, the local office should notify the local or regional Social Security Office.
     

  1. Deletion Requests - Buy-in deletions occur automatically when a beneficiary has appeared ineligible for medical assistance for two consecutive months.

    The retroactively of the deletion date is limited to two months from the month in which SSA received the deletion request. For example, the state submits a deletion action to SSA in 02-03. The deletion date cannot be earlier than 01-03. If an earlier date is requested by the state, it is adjusted to 01-03.
     

  2. Change Requests - Buy-in records are also sent to request changes in certain elements on the record, such as the Medicare claim number.

 

2911.7 Part A Buy In - Persons entitled to Medicare Part A by paying a premium and who meet QMB and QWD eligibility criteria must enroll for Part A through Social Security before the state will assume obligation for the premium. For persons who are not currently enrolled, Social Security will conditionally enroll the individual pending a QMB determination by DCF. Persons conditionally enrolled are identified by the presence of a Z-99 code and effective date on the SSA record. The Z-99 date is the earliest possible Medicare Part A entitlement date. People conditionally enrolling after the initial enrollment period must wait until the general Medicare enrollment period of January - March of each year. Part A coverage is effective in July of the enrollment year in these cases.

 

Part A buy-in cannot occur unless the individual is already on Part B buy-in. It is frequently necessary to manipulate coding of the eligibility file to ensure these requests are properly submitted to CMS to ensure timely buy-in.

 

2911.8 Refunds - When an individual becomes eligible for medical assistance and has been accreted to buy-in, the individual will receive a refund of any premiums deducted from his or her Social Security check, or paid for personally, since the buy-in effective date. Such a refund of Medicare Part B premiums is not to be considered income when determining eligibility for assistance. Refund checks are usually not received for a period of 90 to 120 days after buy-in coverage is effective.

 

2911.9 Problem Situations - Situations which may arise which will require contact with the fiscal Agent Buy-in Analyst are:

 

  1. A request to adjust the effective date on a buy-in record.
     
  2. A complaint that an individual is on buy-in and is being billed directly for Medicare Part B premiums, or the premiums are being withheld from the Social Security check.
     
  3. A complaint that a claim for Part B benefits was denied due to lack of Part B coverage, and the individual should have Part B coverage as entitlement to buy-in. If it is determined that the beneficiary was deleted from buy-in error because of incorrect KAECSES information, the KAECSES record should be corrected. Refer to the MMIS/DCF User Reference Manual for field staff to remedy these problems.
     
  4. A complaint that an individual received a Medicare Part B termination notice and should be covered by buy-in.
     
  5. An allegation that the individual is no longer on buy-in, but the premiums are not yet being deducted from his or her Social Security check or has been placed in direct billing status.

    The fiscal agent will attempt to resolve a problem case within three updates (approximately 90 days). However, due to the length of time involved in obtaining documentation and the fact that not all corrective actions can be taken in the same update, it may require four updates (approximately 120 days) to make all of the corrections.
     
  6. Retroactive buy-in accretions shall be limited to either the Title XIX eligibility effective date or 6 months prior to the month that the request is received, whichever is less.

    Exceptions shall be limited to the following circumstances:
     
    1. The Medicare entitlement decision is retroactive to an earlier date (such as a decision rendered based on an SSA appeal).
       
    2. Attempts to timely accrete an individual to buy-in have been unsuccessful.
       
    3. The agency has failed to reflect Medicare coverage reported to them in a timely manner, and has also failed to approve assistance timely (other than protected filing date applications due to SSA appeals or applications delayed by the disability determination process).
       

2911.10 Medicare Prescription Drug Coverage - Part D Medicare prescription drug coverage is considered comprehensive coverage. Although specific formularies may vary, all Prescription Drug Plans (PDPs) or Medicare Advantage - Prescription Drug Plans (MA PDPs) offering coverage must offer a range of drugs in specific therapeutic drug classifications. In addition, plans must provide all or substantially all of the drugs available in certain classifications: antidepressants, antipsychotic, anticonvulsant, antiretrovirals, immunosuppressant and antineoplastics. Plans must have an appeal process in place to ensure the beneficiary receives medically necessary drugs.

A small group of drugs cannot be covered by the Part D plan and include the barbiturates, benzodiazepines, prescription vitamins, medications for weight loss/gain, and over-the counter medications. These are knows as excluded drugs.

 

  1. Effect of Medicare Part D on Medicaid - Medicaid will not cover Part D prescription drugs for Medicare beneficiaries as of the date the person becomes entitled to Medicare Part D. There will be no Medicaid coverage of drugs regardless of an individual’s enrollment status in a plan. Medicaid payment is based on entitlement to Part D only. Unlike coverage under Parts A and B, where the Medicaid program can supplement the Medicare payment for a covered service, coverage under Part D is considered comprehensive and Federal Financial Participation (FFP) is not available for supplemental coverage of prescription drugs. In addition, there is no Medicaid payment for drugs not covered by the individual PDP due to formulary restrictions. Supplemental coverage under the QMB program is not applicable to Part D and will not cover coinsurance and deductibles for Part D drugs. However, QMB will consider expenses of prescription drugs covered under Parts A and B.
     
  2. Medicaid may continue to cover the Excluded Part D drugs listed above (see KMAP Provider Manuals for coverage information).
     
  3. Entitlement to Part D - To be entitled to Medicare Part D, the individual must be entitled to Medicare Part A or enrolled in Part B. For individuals who appear to meet the provisions of 2911.2 (2), but have not enrolled in Part B, Medicare Part D entitlement is effective as in (3)(b) below.
     
  4. Effective Date - The effective date is the date the individual becomes eligible to enroll in a Medicare drug plan. It is not the date the individual is actually enrolled in a plan.
     
    1. For prospective Medicare determinations, the effective date of Part D entitlement is the date the individual is initially entitled to Medicare Part A or B, but not before January 1, 2006.
       
    2. For individuals whose Medicare entitlement determination is made retroactively, Part D entitlement begins the month the individuals received the notice of the Medicare entitlement determination.
       

    Examples: John turns 65 in May 2006. John is notified of Medicare entitlement effective May 2006 in February. Because John knows about Medicare entitlement prior to the effective date, the Medicare Part D entitlement is May, 2006.
     

    Betty is determined disabled in July 2006 with an onset date in 2002. Also in this month, she finds out she is retroactively entitled to Medicare beginning February, 2005. Because the effective date of entitlement is prior to the current month, Medicare Part D entitlement is the first day of the month the individual is notified of the approval, or July 2006.
     

  5. Enrollment - The Medicare beneficiary enrolls directly with the PDP through an approved method of enrollment (e.g., mail, internet). Upon receipt of the enrollment request, the PDP will verify the individual’s eligibility to enroll through CMS. Once completed, information on the approved enrollment request will be sent to CMS within 30 calendar days of receipt of the enrollment application.

    Persons in an approved PACE plan (see 8300) will not be enrolled in Medicare Part D as their PACE provider will be responsible for all prescription medication. Persons in a Medicare Advantage plan with an approved Part D benefit will receive drug coverage through the MA PDP plan.
     

    Beneficiaries may elect to initially enroll or change plans only at certain, designated times. The Initial Enrollment Period (IEP) for new Medicare beneficiaries is concurrent with the Part B period. The IEP for Part B is the seven month period that begins three months before the month an individual meets the eligibility requirements for Part B and ends three months after the month of eligibility. An annual open enrollment period occurs from November 15 - December 31. In addition, plans must offer a Special Enrollment Period for special situations. Examples include:
     

  6. Enrollment Effective Date - The Part D Enrollment Date is the date the individual’s coverage begins under the plan. The PDP sponsor is responsible for establishing the effective date of enrollment. For new Medicare beneficiaries initially enrolling, the effective date is the first day of the month of Medicare eligibility if the request is received prior to the month of eligibility. Enrollment requests after the initial period or received during the annual enrollment period are effective the month following the month of request. Enrollment dates will vary during Special Enrollment Periods. Initial enrollment due to the individual’s status as a dual eligible are effective the first month of full Medicaid eligibility, but not prior to the Medicare entitlement date, if the beneficiary incurred drug expenses in the prior month(s) as per item (c) below.
     
  7. Auto Enrollment Process - Automatic enrollment into an approved Part D plan for all dual eligibles receiving full Medicaid coverage, those eligible only for QMB, LMB only and those eligible for subsidy will be initiated if the individual is not already enrolled in an approved plan.

    This includes those who have other approved employer, union or group based health coverage:
     
    1. For persons with Medicaid (under any program, including Title XIX, Medically Needy with spenddown met, QMB and LMB) who become entitled to Medicare, auto enrollment will be the first day of Part D entitlement. This includes persons who initially apply on or before the initial month of Medicare entitlement, even though Medicaid eligibility may not be approved until a later date.

      Example:       A person with ongoing Medicaid become entitled to Medicare in May 2006. Auto enrollment is effective May 1, 2006 (may be retroactive if CMS fails to flag the individual timely).
       
    2. For persons with Medicare who become eligible for full Medicaid, auto enrollment is effective the first day of Medicaid eligibility.
       

      Example: A Medicare beneficiary is approved for full Medicaid on August 17, with coverage beginning June 1. The information on the beneficiary will be sent to CMS in the September MMA file. Auto enrollment is retroactive to June 1.
       

    3. For persons with Medicare who become eligible for QMB or LMB (a Partial Dual) auto enrollment is effective the second month following the month CMS identifies the individual on the auto-enrollment file. This process is also called Facilitated Enrollment.
       

      Example: A person is approved for LMB on June 5, 2006 effective May 1, 2006. This information will be sent on the June file to CMS. CMS notifies the individual the following month (July) of pending auto-enrollment to afford them the opportunity to select a plan.
       
      Auto-enrollment is effective September 1, 2006 if the individual hasn’t already enrolled.
       

    4. For full Medicaid beneficiaries with Medicare who had previously enrolled in a Part D plan, but disenrolled and failed to enroll in a new Part D plan, auto enrollment is effect the first day of the month after the disenrollment effective date from the part D plan.
       
    5. For persons with Medicare who are eligible for Part D Subsidy only, auto enrollment will be effective the first day of the month following the expiration of the beneficiary’s next open enrollment period.
       

      Example: A person is approved for Subsidy only in September 2006. The next open enrollment period is the annual election period running November 15 through December 31. Since the period ends December 31, 2006, auto enrollment is effective January 1, 2007, if the individual is given adequate time to change plans.
       

  8. Retroactive Enrollment for Full Medicaid Eligibles - A special retroactive enrollment period is available to full Medicaid eligibles who will not be auto-enrolled because the beneficiary has voluntarily enrolled in Medicare Part D plan. The special retroactive enrollment is only available for months in which the beneficiary has been determine eligible for full Medicaid and the beneficiary incurred out-of-pocket prescription drug expenses. The retroactive period is effective with the first month of out-of-pocket expenses in which the individual was a full dual eligible. This special enrollment is not available to partial duals (QMB or LMB only) or to those receiving Part D Subsidy only. Persons must contact their current Medicare Part D PDP to request retroactive enrollment.

    Example:     Bill, a Medicare beneficiary, is approved for Medicaid coverage on May 24, effective March 1. Bill enrolls in the A-1 Medicare PDP, with coverage beginning June 1. However, Bill incurred out-of-pocket expenses in the months of February, March, April and May. The special enrollment period will allow Bill to retroactively enroll in the A-1 Medicare PDP beginning March 1. Although Bill had non-coverge drugs in February, he was not a full dual in the month of February.
     
  9. Affirmatively Decline - Persons may refuse auto enrollment into a Part D plan by contacting Medicare or the PDP into which auto-enrollment has been assigned. By affirmatively declining, the individual forfeits auto enrollment. Persons who want to preserve coverage through an employer, union or group may wish to affirmatively decline coverage. However, Medicaid will not provide drug coverage to persons who affirmatively decline auto-enrollment. Persons who wish to enroll in Medicare Part D later may do so by making an enrollment request with the Part D plan.
     
  10. Late Enrollment Penalty - Except for persons with approved creditable coverage described below, individuals who do not enroll in a Medicare Part D plan during the Initial Enrollment Period (IEP) will be subject to a penalty fee if they later choose to enroll. The surcharge will be compounded monthly beginning with the first month following the expiration of the IEP. Persons eligible for Medicare Part D subsidy may receive help with payment of the surcharge (see 2675).
     
  11. Creditable Coverage through an Employer, Union or Group - Employers, unions or group health plans offering approved prescription drug plans to retirees, current employees or other Medicare beneficiaries at least as good as the Medicare Part D plan may have such plans designated as creditable coverage. Medicare beneficiaries may elect to receive prescription drug coverage through a creditable plan rather than through Medicare Part D. Beneficiaries making a formal election through CMS to receive coverage through retiree/employer plan coverage will not be subject to the late enrollment penalty if they later elect to receive Medicare Part D. However, the individual will not realize any benefits through Medicare Part D Subsidy if they elect the private health plan over Medicare Part D.
     

    NOTE: Persons enrolled in a Medicare Supplemental Plan with drug coverage may continue to receive coverage under this plan, but new enrollees will not be accepted. In addition, it is highly unlikely that any supplemental plan will meet the definition of creditable coverage above and the beneficiary may be subject to a Medicare Part D surcharge if they elect to switch coverage later. Subsidy will not provide coverage of any expenses through a supplemental plan.
     

  12. Failure to Enroll - Failure to enroll in a Medicare Part D plan will not impact Medicaid eligibility or coverage. Because the exclusion of prescription drug coverage is determined by Medicare Part D entitlement, not enrollment, no additional benefits will be provided to those who fail to enroll in a plan. However, a person who elects to refuse Part D coverage may be without drug coverage.
     
  13. Termination of Part D Coverage - Entitlement to Part D ends when an individual loses entitlement to both Medicare Parts A and B.