Cost Sharing for Dual-Eligible Enrollees Requiring an Institutional

50.6 – Cost Sharing for Dual-Eligible Enrollees Requiring an Institutional Level of Care (Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16) As provided under section 1860D-14 of the Act, Full Medicaid institutionalized individuals have no cost sharing for covered Part D drugs under their PDP or MA-PD plan. Effective January 1, 2012, section 1860D-14 of the Act also eliminates Part D cost sharing for Full Medicaid individuals who would be institutionalized if they were not receiving home and community-based services (HCBS) either through: • A HCBS waiver authorized for a state under section 1115 or subsection (c) or (d) of section 1915 of the Act; • A Medicaid State Plan Amendment under section 1915(i) of the Act; or • A Medicaid managed care organization with a contract under section 1903(m) or section 1932 of the Act. A SNP must determine or an enrollee must demonstrate that s/he is a Full Medicaid individual receiving HCBS under title XIX with the following: • A copy of a state-issued Notice of Action, Notice of Determination, or Notice of Enrollment that includes the enrollee’s name and HCBS eligibility date during a month after June of the previous calendar year; • A copy of a state-approved HCBS Service Plan that includes the enrollee’s name and effective date beginning during a month after June of the previous calendar year; • A copy of a state-issued prior authorization approval letter for HCBS that includes the enrollee’s name and effective date beginning during a month after June of the previous calendar year; or • Other documentation provided by the state showing HCBS eligibility status during a month after June of the previous calendar year. See chapter 16b of the MMCM, “Special Needs Plans” for more information on dual eligible enrollees, SNPs, and D-SNPs at https://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Downloads/mc86c16b.pdf.