For those eligible for both Medicare and MassHealth/Medicaid, with a few exceptions, MassHealth no longer covers medications. Medication coverage for this population is now covered by Medicare D. This group of people, also known as “Dual Eligibles”, should have been automatically enrolled in a Medicare D plan. The little-noted but large impact change for this group is that they are now responsible for paying co-pays for their medications.
Massachusetts had previously instituted co-pays for some, but it included a “safety-valve”-- pharmacies were required to fill the prescription if the client claimed hardship. This protection no longer applies. Federal law reportedly requires collection of the co-pay. Dual eligibles with income at or below 100% FPL ($798/month individual, $1,070/month for a couples through March 31, 2006) should have a co-pay of $1 – 3 per drug. Those above 100% FPL are responsible for a co-pay of $2 - 5. The MGH pharmacy will also be charging co-pays to those with Free Care.
MassHealth will continue to pay for benzodiazepines (such as clonazepam), barbiturates (such as phenobarbital), and some over-the-counter drugs (such as ibuprofen) prescribed by a doctor, as these are not covered by Medicare D.
Different rules apply to those in Medicare Advantage Plans (such as BlueCare 65, Fallon Senior Plan, First Seniority, or Secure Horizons), Programs of All-Inclusive Care for the Elderly (PACE, also known as the Elder Service Plans); Senior Care Organizations (such as Commonwealth Care Alliance, Evercare SCO, and Senior Whole Health); or a drug plan offered by a past or current employer or union.
On our website's Medicare D section is a link to two letters sent by MassHealth to dual eligibles depending on their income.
Medicare D Dual Eligibles area of our website:
For those AT OR BELOW 100% FPL ($1 - $3 co-pay):
For those ABOVE 100% FPL ($2 - $5 co-pay):
-Thanks to Joe Ianelli, Manager of Patient Financial Services/Financial Access Unit, for providing background for this story.
02/06