Plan Benefit Design – Medicare Part D Sample Clauses

Plan Benefit Design – Medicare Part D. The BHS Program is payer of last resort, however, when it is determined that the client being served does not qualify for the many other programs sponsored by the state and federal agencies (i.e., Medi-Cal, Healthy Families, etc.), services provided by the BHS Program do not exclude persons with other coverage and the BHS Program does xxxx these funding sources for the services it provides. As a result, BHS Program psychiatrists prescribe medications for these persons as well as those for whom the prescription costs are covered in accordance with section B.1 above. With the recent changes in the Medicare Prescription Drug Coverage Benefit, specifically Part D, the BHS Program desires to ensure that its clients with this coverage are not financially deterred from obtaining their medications and decompensating as a result of not maintaining their medication regimens. Therefore, the BHS Program will cover co-pays for clients receiving Medicare benefits as well as deductibles for certain groups. For future discussion, it can be noted that certain subgroups are also responsible for premiums. The BHS Program may want to consider subsidizing those, or subsidizing the difference to change from a basic benefit to an enhanced benefit, depending on cost analyses. This does not affect Contractor considerations discussed below. The following details the desired Plan Benefit Design for these populations, which are subject to change as defined by Medicare regulations, provided, however, in all cases – the cost of the medication should be billed to Medicare or Medi-Cal as appropriate and the County will only be billed for the appropriate co-pay and/or deductible for BHS Program clients. a. Medicare/Medi-Cal beneficiaries (“dual eligibles”): b. Medicare-only beneficiaries with PDP plan and with low-income subsidy: 1) If qualified for the greater subsidy, based on— o Individual-- $12,920 annual income, $6,000 savings o Couple-- $17,321 annual income, $9,000 savings • Premium—None for basic benefit. Client is responsible for differential between basic and enhanced benefits. • Deductible—None. • Medicare will cover the cost of medications on the PDP formulary, less a co-pay of $2 to $5 per prescription/refill. • If the co-pay is not waived by the pharmacy, the BHS Program will pay only the co-pays for these medications, prescribed by BHS Program prescribers. • If prescribed medications are not on the PDP formulary, the BHS Program will assist with the appeal process to obtain...
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Related to Plan Benefit Design – Medicare Part D

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