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Reimbursement—Dual eligible clients/medicare.
For clients who are dually eligible for medical assistance and medicare benefits, the following applies:
(1) Medicare Part B, the agency pays providers for:
(a) An amount up to the agency's maximum allowable fee for drugs medicare does not cover, but the agency covers; or
(b) Deductible and/or coinsurance amounts up to medicare's or the agency's maximum allowable fee, whichever is less, for drugs medicare and the agency cover.
(2) Medicare Part D:
(a) Medicare is the payer for drugs covered under the medicare Part D benefit.
(b) The agency does not pay for Part D drugs or Part D copayments.
(c) For drugs excluded from the basic medicare Part D benefit:
(i) The agency offers the same drug benefit as a nondual eligible client has within those same classes;
(ii) If the client has another third party insurer, that insurer is the primary payer; and
(iii) The agency is the payer of last resort.
[Statutory Authority: RCW 41.05.021
, 2011 c 5, 2010 2nd sp.s. c 1 § 208 (25), and Section 1902 (n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997. WSR 13-14-052, § 182-530-7700, filed 6/27/13, effective 7/28/13. WSR 11-14-075, recodified as § 182-530-7700, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050
, and 74.09.700
. WSR 07-20-049, § 388-530-7700, filed 9/26/07, effective 11/1/07.]