13 CSR 40-13.040 - Blind Pension 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.
Notes
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