Mo. Code Regs. tit. 13 § 40-13.040

Current through Register Vol. 49, No.12, June 17, 2024

Section 13 CSR 40-13.040 - Blind Pension Prescription Drug Coverage

PURPOSE: This rule establishes the basis on which Medicare-eligible blind pension participants will receive prescription drug coverage.

(1) For purposes of this rule, the following definitions shall apply:

(A) "Benchmark plan" means a prescription drug plan with premiums at or below the low-income benchmark premium amount established for the Missouri region annually by the Centers for Medicare and Medicaid Services (CMS) as set forth in 42 CFR section 423.780, including de minimis plans as contemplated in 42 CFR section 423.780 (f).

(B) "Covered outpatient drug" has the same meaning as that term is defined in section 1927(k) of the Social Security Act.

(C) "Creditable prescription drug coverage" means non-Medicare coverage as defined in 42 CFR section 423.56, where the actuarial value of that coverage equals or exceeds the actuarial value of defined standard prescription drug coverage under Medicare Part D in effect at the start of each plan year.

(D) "Department" means the Missouri Department of Social Services.

(E) "Prescription drug plan" or "PDP" means prescription drug coverage that is offered under a policy, contract, or plan that has been approved as specified in 42 CFR section 423.272 and that is offered by a PDP sponsor that has a contract with CMS that meets the contract requirements under subpart K of Part 423 of Title 42 of the Code of Federal Regulations.

(F) "Participant" means an individual under section 208.151.1(3), RSMo., who is receiving medical assistance by reason of receiving blind pension benefits and who is eligible for Medicare Part D as set forth in 42 CFR section 423.30, who is not otherwise eligible for Medicaid benefits under Title XIX of the Social Security Act.

(2) All participants shall receive prescription drug coverage through a benchmark plan unless they otherwise demonstrate to the department that they receive creditable prescription drug coverage.

(A) Participants shall be responsible for initial and subsequent enrollment in a benchmark plan as set forth in 42 CFR section 423.32.

(B) Participants shall provide the department with notice of enrollment in a benchmark plan by December 15th of each year. Notice of enrollment may be made in writing on a form made available by the department, or by phone, email, facsimile, or other commonly available electronic means, and shall include, at a minimum:

1. The participant's name, Departmental Client Number (DCN), and Medicare Health Insurance Claim (HIC) number; and

2. The name and Plan ID number of the benchmark plan.

(C) A participant may authorize the department to act on the participant's behalf to enroll him or her in a benchmark plan selected by the department by providing written authorization and any information necessary for the department to do so no later than the midpoint of the annual open enrollment period.

(D) Participants shall provide the department with written notice of disenrollment from a benchmark plan for any reason within fifteen (15) days of the participant receiving notice of disenrollment from the benchmark plan. A participant who voluntarily disenrolls from a benchmark plan and is not able to or elects not to reenroll in a benchmark plan shall be responsible for any late enrollment penalty that results from his or her voluntarily disenrollment.

(E) Participants receiving creditable prescription drug coverage shall notify the department in writing of such coverage with sufficient information to identify the entity providing creditable prescription drug coverage, including the participant's policy number and the insuring entity's name.

(F) A participant receiving creditable prescription drug coverage, who involuntarily loses such coverage, shall notify the department in writing or by phone, email, facsimile, or other commonly available electronic means of his or her loss of creditable prescription drug coverage within thirty (30) days of receiving notice of loss of creditable prescription drug coverage.

(3) The department shall notify a participant prior to the open enrollment period if the participant's PDP will not be considered a benchmark plan for the upcoming plan year. Participants affected by a change in benchmark plan status shall enroll in a benchmark plan for the upcoming plan year.

(A) Participants affected by a change in benchmark plan status shall notify the department by the midpoint of the annual open enrollment period, in writing or by phone, email, facsimile, or other commonly available electronic means, of an intention to enroll in a benchmark plan.

(B) A participant may authorize the department to act on the participant's behalf to enroll him or her in a benchmark plan selected by the department as set out in subsection (2)(C) above.

(C) If a participant has not notified the department of an intention to enroll in a benchmark plan by the midpoint of the annual open enrollment period, the department may act on the participant's behalf to enroll him or her in a benchmark plan for the upcoming plan year. Participants so enrolled shall be notified promptly of the enrollment and-

1. The procedures by which the participant may disenroll from the benchmark plan and enroll in a different benchmark plan;

2. The existence of alternative benchmark plans; and

3. The manner in which the participant may change his or her enrollment to an alternative benchmark plan, or obtain assistance in doing so.

(4) The department shall pay all premiums, deductibles, copayments, and coinsurance associated with a participant's prescription drug coverage under his or her benchmark plan.

(A) The department may pay the prescription drug costs incurred by a participant for covered outpatient drugs that are not part of his or her benchmark plan's formulary or are obtained from a pharmacy that is not in his or her benchmark plan's network. Such payments will comply with the MO HealthNet Division's Pharmacy program set out in Chapter 20 of Division 70 of Title 13 of the Code of State Regulations.

(B) The department will not pay any costs associated with a participant's enrollment in a PDP that is not a benchmark plan.

(5) The procedures set forth in subpart M of Part 423 of Title 42 of the Code of Federal Regulations shall be the participant's exclusive remedies for grievances, coverage determinations, redeterminations, and reconsiderations regarding prescription drug coverage under this section, except that payment determinations made under subsection (4)(A) above shall be afforded administrative hearing rights under section 208.080, RSMo.

13 CSR 40-13.040

Adopted by Missouri Register April 15, 2015/Volume 40, Number 08, effective 5/31/2015