Gila River Health Care Corporation
Gila River Health Care Corporation
PROVIDER MANUAL
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Arizona Department of Health Services

Division of Behavioral Health Services
PROVIDER MANUAL
Gila River Regional Behavioral Health Authority Edition


Section 7.2 Medical Institution Reporting for Medicare Part D

7.2.1 Introduction
7.2.2 Terms
7.2.3 Procedures
7.2.3-A. Reporting requirements

7.2.4 References

7.2.1 Introduction
The objective of this policy is to inform Tribal and Regional Behavioral Health Authorities (T/RBHAs) of the reporting and tracking requirements for providers designated as medical institutions to ensure Medicare Part D co-pays are waived for dual eligible persons.

Medicare eligible beneficiaries, including persons who are dually eligible for Medicare (Title XVIII) and Medicaid (Title XIX/XXI) receive Medicare Part D prescription drug benefits through Medicare Prescription Drug Plans (PDPs) or Medicare Advantage Prescription Drug Plans (MA-PDs). Medicare Part D coverage includes co-payment and coinsurance requirements. However, Medicare Part D co-payments are waived when a dual eligible person enters a Medicaid funded medical institution for at least a full calendar month. The facility must notify the Arizona Health Care Cost Containment System (AHCCCS) when a dual eligible person is expected to be in the medical institution for at least a full calendar month to ensure co-payments for Part D are waived. The waiver of co-payments applies for the remainder of the calendar year, regardless of whether the person continues to reside in a medical institution. Given the limited resources of many dual eligible persons and to prevent the unnecessary burden of additional co-pay costs, it is imperative that these individuals are identified as soon as possible.

To inform behavioral health providers designated as medical institutions of reporting and tracking requirements for dual eligible persons to ensure Medicare Part D co-pays are waived.

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7.2.2 Terms
Definitions for terms are located online at http://www.azdhs.gov/bhs/definitions/index.php. The following terms are referenced in this section:

Dual Eligible

Institution for Mental Diseases (IMD)

Institutionalized individual

Medical Institution

Medicare Advantage Prescription Drug Plan (Ma-PD)

Prescription Drug Plan (PDP)

7.2.3 Procedures

7.2.3-A. Reporting requirements
To ensure that dual eligible persons’ Medicare Part D co-payments are waived when it is expected that dual eligible persons will be in a medical institution, funded by Medicaid, for at least a full calendar month, the facility must notify AHCCCS immediately upon admittance. Reporting must be done using PM Form 7.2.1, AHCCCS Notification To Waive Medicare Part D Co-Payments For Members In A Medical Institution That is Funded By Medicaid. Providers must not wait until the person has been discharged from the medical institution to submit the form. Reporting must be done on behalf of the following:

  • Persons who have Part "D" only
  • Persons who have Medicare Part “B” only;
  • Persons who have used their Medicare Part “A” lifetime inpatient benefit; and
  • Persons who are in continuous placement in a single medical institution or any combination of continuous placements that are identified below.

Medical Institutions
Medical institutions include the following behavioral health providers:

  • Acute Hospital
  • Psychiatric Hospital – IMD
  • Psychiatric Hospital – Non IMD
  • Residential Treatment Center – IMD
  • Residential Treatment Center – Non IMD
  • Nursing Facility

Additional information regarding Medicare cost sharing for members covered by Medicare and Medicaid can be found in AHCCCS Contractor Operations Manual, Policy 201.

Notification of admission of Gila River RBHA members to an IMD should be faxed to the attention of the Gila River RBHA Billing Clerk at (602) 528-1374 or mailed to the following address utilizing PM Form 7.2-GR, TITLE XIX INSTITUTION FOR MENTAL DISEASE ADMISSION/DISCHARGE NOTIFICATION FORM:

Hu Hu Kam Memorial Hospital
ATT: RBHA Billing Clerk
P.O. Box 38
Sacaton, AZ 85147

7.2.4 References
The following citations serve as additional resources for this content area:

 

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7.2 Medical Institution Reporting for Medicare Part D
Last Revised: 7/31/2015
Effective Date: 7/31/2015

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