{articletitle}

If you have a client that resides in assisted living or a long term care facility, you will come across questions about drug coverage because the resident must use the pharmacy at the long-term care (LTC) facility and it’s typically at the standard Medicare Part D prices/rates which can be frustrating. They do not have an option of using an outside pharmacy. A POA (power of attorney) or family member cannot bring in medications.

These pharmacies play a crucial role in providing medications in a timely manner to their residents and work closely with the facility staff to manage, dispense, deliver medications, plus return, reuse, and dispose of unused medications. This enables medications to be purchased in bulk and sometimes at discounted prices.

LTC pharmacies are reimbursed for their services through Medicare Part A for skilled nursing facilities and Medicare Part D for prescription drugs. They may also receive payments from Medicaid, commercial insurers, and private payers.

LTC pharmacies ensure that residents of long-term care facilities receive the medications they need safely and efficiently, while complying with Medicare regulations and standards.

Learn more: CMS Review of Current Standards of Practice for Long-Term Care Pharmacy Services

{articletitle}

Medicaid provides a wide range of health care services for eligible individuals, including low-income adults, children, pregnant women, elderly adults, and people with disabilities. The specific services covered can vary by state, but there are certain mandatory benefits that all states must provide, as well as optional benefits that states can choose to offer.

Mandatory benefits include:

Inpatient and outpatient hospital services
Physician services
Laboratory and X-ray services
Home health services

Optional benefits that states may choose to provide include:

Prescription drugs
Case management
Physical therapy
Occupational therapy

If someone is on Medicaid & Medicare they do not need to enroll into another Medicare plan. However, D-SNPs are offered to this demographic to provide additional coverages if that makes sense for the client’s needs. It’s also extremely important to verify doctor network since D-SNPs typically work under a HMO network.

Here are some of the key additional benefits that a D-SNP might offer:

Dental, Vision, and Hearing Services: These plans typically include coverage for dental care, vision exams and glasses, and hearing aids
Transportation Services: D-SNPs may offer transportation to and from medical appointments, which can be a significant help for those with mobility issues
Fitness Programs: Many plans include access to fitness programs or gym memberships to help maintain physical health
Care Coordination: D-SNPs often provide care coordinators or personal assistance liaisons to help manage healthcare services and ensure that all aspects of a member's care are well-coordinated
Prescription Drug Coverage: Enhanced coverage for prescription medications is often included, which can help manage the costs of necessary drugs
Additional Support Services: Some plans may offer meal delivery services, over-the-counter allowances, and other support services to improve overall quality of life

These additional benefits are designed to make healthcare more accessible and affordable, while also addressing the broader needs of individuals who qualify for both Medicare and Medicaid.

{articletitle}

The word Medicaid is used to vaguely describe healthcare coverage for Low Income individuals. However, people can have Medicaid in many different forms:

Aged, Blind, and Disabled (ABD) Medicaid
Coverage: This level provides comprehensive medical services, including hospital care, physician services, and long-term care. It often includes additional support services tailored to the needs of elderly and disabled individuals, such as home health care and personal care services.
Home and Community-Based Services (HCBS)
Coverage: HCBS waivers offer services that help individuals live independently in their homes or communities rather than in institutional settings. This includes personal care, homemaker services, respite care, and sometimes home modifications. These services are crucial for maintaining independence and quality of life.
Institutional Medicaid (Long Term Care Medicaid)
Coverage: This level covers the cost of care in nursing homes or other institutional settings. It includes room and board, medical services, and personal care. This is essential for individuals who require a high level of care that cannot be provided at home.
Medicaid for Children and Families
Coverage: Programs like CHIP and Medicaid for low-income families provide comprehensive health services for children and pregnant women. This includes preventive care, immunizations, maternity care, and other essential health services. These programs ensure that children and families have access to necessary healthcare.
Medicaid Expansion (Affordable Care Act Adults)
Coverage: In states that have expanded Medicaid, low-income adults up to 138% of the federal poverty level receive a broad range of health services. This includes primary care, hospital services, mental health services, and preventive care. Expansion has been linked to improved access to care and better health outcomes.
Special Programs
Coverage: These programs target specific populations, such as foster care children or individuals with specific health conditions like breast or cervical cancer. Coverage varies but generally includes targeted health services and support tailored to the needs of these groups.

Impact on Healthcare Needs

Comprehensive Care: Different levels of Medicaid ensure that various populations receive the care they need, whether it's basic medical services, long-term care, or specialized support.
Preventive Services: Many Medicaid programs emphasize preventive care, which helps reduce the need for more intensive and costly treatments later on.
Support Services: Programs like HCBS and special programs provide additional support that can significantly improve quality of life and independence for individuals with specific needs.

Overall, the different levels of Medicaid are designed to address the diverse healthcare needs of eligible individuals, ensuring that they receive appropriate and comprehensive care based on their specific circumstances.

Each state has their own program, here is PA: https://www.compass.dhs.pa.gov/home/#/

{articletitle}

The Qualifying Individual (QI) program is one of the Medicare Savings Programs (MSPs) that helps individuals with limited income and resources pay for Medicare costs. Here’s a breakdown of what Medical Assistance pays for at each QI level:

Qualified Medicare Beneficiary (QMB) Program Coverage:
Pays for Medicare Part A and Part B premiums, deductibles, coinsurance, and copayments. This means that if you qualify for QMB, you should not be billed for Medicare-covered services when seeing Medicare providers.
Specified Low-Income Medicare Beneficiary (SLMB) Program Coverage:
Pays for Medicare Part B premiums. This helps reduce the monthly cost of Medicare Part B, which covers outpatient care, doctor services, and preventive services.
Qualifying Individual (QI) Program Coverage:
Pays for Medicare Part B premiums. This program is similar to SLMB but is available on a first-come, first-served basis due to limited funding. The main benefit is saving money by not having to pay the Part B monthly premium, which can be significant.
Qualified Disabled and Working Individuals (QDWI) Program Coverage:
Pays for Medicare Part A premiums. This program is for individuals who are disabled and working, and who have lost their premium-free Part A due to returning to work.

These programs are designed to help reduce the financial burden of Medicare costs for individuals with limited income and resources. You can double check a person’s level by calling a carrier or by using a carrier tool like Jarvis provides on the UHC portal with a beneficiary’s Medicare number. QMB is the only full dual from the list, the rest are partial dual.

{articletitle}

LINET stands for the Limited Income Newly Eligible Transition Program. It's a Medicare initiative designed to provide immediate, temporary prescription drug coverage for individuals who qualify for Medicare Part D but do not yet have prescription drug coverage.

Here are some key points about LINET:

Eligibility: It is available to low-income Medicare beneficiaries who qualify for Medicaid or the Part D Low Income Subsidy (LIS), also known as "Extra Help".
Coverage: LINET offers temporary coverage, usually for 1 to 2 months, allowing beneficiaries time to choose a Medicare Part D plan that best fits their needs.
Administration: The program is administered by Humana.
Retroactive Coverage: LINET can provide retroactive coverage for out-of-pocket expenses during eligible periods.

Learn more here: