“Dual Eligibles” and Drug Coverage

If someone on Medicare qualifies for Medicaid (known as TennCare/CHOICES in Tennessee), who pays prescription drug coverage?

A person on Medicare who becomes covered by Medicaid/TennCare/CHOICES is known as a “Dual Eligible.” When it comes to prescription drug coverage for “Dual Eligibles,” here’s what to expect:

  • Prescription drug coverage is provided through Medicare Part D (not TennCare/Medicaid/ CHOICES) unless the individual has primary coverage through another plan such as an employer/retiree plan that is equal to or better than Medicare (known as “creditable” coverage).
     
  • The person will become automatically eligible for a low-income subsidy called “Extra Help” which will pay the patient’s Medicare Part D premium (up to a benchmark amount), any deductibles, and all co-pays for covered drugs (no doughnut hole). In other words, as long as the drug is covered by the drug plan, the patient will pay nothing.
     
  • If the individual is not already in a Medicare Part D plan, Centers for Medicare and Medicaid Services (CMS) will automatically enroll the person in a Medicare Part D (benchmark) plan (unless he/she has primary creditable drug coverage such as through an employer or retiree-sponsored plan).
     
  • Because the TennCare/CHOICES effective date is most often retroactive, the “Extra Help” is usually retroactive, too. If the individual is not already a member of a Part D plan, he or she may be assigned to a temporary Part D plan under Medicare’s Limited Income Net program to fill the gap until the assigned Part D plan becomes effective. 
     
  • The patient might receive refunds for co-pays and/or premiums he/she paid prior to the effective date.
     
  • CMS and the Medicare drug plan will send letters (and cards, if applicable) to the individual regarding ALL of the above.
     
  • If the patient lives in a long-term care facility, family members should share information about changes in drug coverage with facility personnel. 

Keep in mind that when a person becomes “Dual Eligible,” he or she is entitled to a Medicare Special Enrollment Period. This mean that if the individual wants to change drug plans for any reason, he or she may do so anytime throughout the year without waiting for the annual enrollment period.

Clients with questions about prescription drug coverage in “Dual Eligible” situations are invited to call the Elder Law Practice at (615) 824-2571.~ 

 

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