Medicare and Long-term care
DSHS Home Page
Search     for:

DSHS Home    Acronyms    Revisions    WAC Number Index    Site Map    WCCC

Medicare and Long-term care

Revised September 19, 2014

Purpose: This section includes the link to Medicare programs. This section includes additional information relating to Medicare and long-term care programs. Long-term care programs are defined as residing in a medical institution 30 days or more or one of the HCS or DDD Waiver programs.

Medicare Programs


Medicare Programs  describes Medicare and Medicare Savings Programs (MSP).    Please refer to this section for a complete description of Medicare programs. 

Medicare Savings Program (MSP) Certification periods

Medicare Savings Program (MSP) Eligibility chart

Medicare Savings Program Desk Aid

Medicare information from the Washington State Office of the Insurance Commissioner  (includes information on the different types of medicare, medicare supplement (called Medi-GAP) plans in Washington and Medicare C Advantage Plans in Washington along with the SHIBA help line.



A client receiving both Medicare and Medicaid is called a full benefit dual eligible (FBDE)

Railroad Retirement

Railroad Retirement Medicare entitlement is NOT in SOLQ.  The client can present a Red, White and Blue Medicare entitlement card or RRB approval or award letter that shows the client's or dependent's Medicare coverage.  RRB award letters do not provide entitlement dates for Part A and Part B.  The RRB Red, White and Blue cards do provide Medicare entitlement dates.

The number for Railroad Retirement Medicare Benefits is:  1-877-772-5772

Do not complete Medicare TPL screens for clients receiving Medicare under Railroad Retirement.  The Medicare buy-in unit must code screens for Railroad Retirement.  Send a barcode tickler to 102@MBU requesting the TPL screens be completed as Medicare is under railroad retirement. 


Medicare buy-in unit

For Medicare Buy-in issues contact: 

1-800-562-3022 Ext. 1-6129.  This phone number is strictly for Medicare premium payment questions only. 

The Medicare buy-in unit no longer has an e-mail mailbox.

You can contact the Medicare Buy in unit on a case related question by using a barcode tickler to 102@MBU


Medicare information specific to long-term care

Nursing Home reimbursement rates for Medicaid clients during Medicare and Medicare co-insurance days.

This link includes:

  • Reimbursement rates for Medicaid clients enrolled in Medicare and Medicare C Advantage
  • QMB only clients entering a nursing home during Medicare days. 
  • Medicaid client participation during Medicare days including co-insurance days

Medicare payment for nursing facility cost of care:

  • Medicare pays the full cost of care for NF services for up to 20 days per benefit period and partial costs for the remainder of 100 days when the client meets Medicare requirements.
  • If the client enters the NF under Medicare coverage, the department determines eligibility and participation the same as for any other institutional client.
  • The client does not pay participation toward Medicare days, but does pay participation toward Medicaid days. 
  • Monitor resource eligibility when a client is on full Medicare days.  A Medicare/Medicaid client on Medicare for the full 100 days and not having a participation responsibility may have excess resources on the 1st day of the month during this period. 


Medicare premiums as a participation deduction

Only out of pocket Medicare B premium are an allowable participation reduction.  If the medicare premium is covered under a medicare savings program (MSP) or state buy-in, it is not an allowalbe participation reduction.  Consult allowable medical services and expenses used to reduce participation  for complete information on medical expenses allowed as a participation reduction.

All FBDE clients are automatically enrolled in the LIS/Extra help subsidy for Medicare D unless the client has credible coverage for prescriptions under another plan.  If a LTC elects to have a non benchmark medicare D plan, the out of pocket cost (difference in the premium minus the LIS subsidy) is an allowable medical expense deduction from participation. 

Any expense deducted from room and board (residential clients in ALFs) is coded as an ETR.  Signed ETRs are needed to deduct any expense from room and board.  Do not request an ETR if there is available participation. 

See ACES instructions below for coding information for Medicare expenses including room and board/ETR coding. 

Medicare D-Prescription Drug Plan


Beginning January 1, 2006, Medicare assumed responsibility for the prescription drug coverage for over 6 million low-income Medicare beneficiaries who are also enrolled in Medicaid.  These beneficiaries are referred to as full-benefit dual eligibles (FBDE).  They qualify for Medicare prescription drug coverage with no premiums.   There are several Prescription Drug Plans (PDP) to choose from in Washington.  Benchmark plans have no premium costs for Medicaid clients.  Benchmark plans are paid by Medicare under the low income subsidy (LIS) program. Medicare will provide prescription drugs for dual eligible clients.

  • All FBDE transitioned from Medicaid drug coverage to Medicare drug coverage as of January 1, 2006.
  • FBDE receive their prescriptions through a Prescription Drug Plan (PDP) unless they receive prescriptions through a credible coverage plan.  If they do not enroll in a plan, they are automatically assigned a PDP.  The assignment is random.
  • FBDE  can change plans any time and the new plan will be effective the first of the next month.
  • Medicaid will continue to cover some drugs not covered in Part D including over-the-counter medications  Drugs covered by Medicaid.  
  • FBDE  have co-pays under Medicare Part D that will vary.   
  • FBDE on a benchmark Medicare D plan have their premiums paid by the low income subsidy (LIS) program through Medicare.   
  • FBDE are entitled to premium-free Part D enrollment, however they may elect enrollment in an enhanced plan.  Those who enroll in an enhancedplan are responsible for the portion of the premium attributable to the enhancement and that portion is an allowable deduction in the post-eligibility calculation. 
  • FBDE residing in institutions (nursing homes and ICF-MRs) are exempt from Med D co-pays once they are residing in a facility for a full calendar month.   A FBDE will have no Med D co-pays once they are deemed in a medical institution through the end of the calendar year.
  • FBDE eligible for a Home and Community Based Waiver are exempt from Med D copayments starting 1/1/2012.    Starting 1/1/2012 a FBDE are deemed in the institutional group through the end of the calendar year. 

Example:  FBDE is on COPES 2/1/2011, on 2/28/2011 the client enters the NF.  On 5/3/2011 the client returns home on COPES.  For this client, the Medicare D co payments end on 4/30/2011 and will continue to have no copayments through 12/31/2011 (the end of the calendar year). 

NOTE:  Medicare D co-payments will end for HCB Waivers effective 1/1/2012 due to federal legislation. 

Medicare D payment levels and what they mean.

Health Care Authority (HCA) sends information to Centers for Medicare and Medicaid Services (CMS) regarding a FBDE status.  CMS sends this information to the PDP.

Payment level 1:  QMB, SLMB only

Payment level 2: FBDE client not institutionalized

Payment level 3:  Institutional group.  Effective 1/1/2012 this will include Home and Community based waiver eligibles authorized by DDD or HCS.

If the PDP indicates to the pharmacy that a client is still not showing up as a payment level 3,  the client must present an award letter showing institutional medical eligibility as "best available evidence" in order for the Medicare D co-payments to be waived.  A social service planned action notice (PAN) showing institutional or waiver eligibility can also be used. 

 If the client in an institution or on a HCB Waiver still shows up as a payment level 2 even after the PDP has received an institutional award letter, the pharmacy or PDP should contact CMS Region 10 in Seattle. 

Field staff or the client can call 1-800-Medicare (1-800-633-4227) to report any issues around Medicare D or complaints about the PDP or a pharmacy not accepting an award letter or planned action notice.  If a complaint is made to Medicare, a copy of the complaint will be forwarded to CMS.  It also tracks the complaints to make the PDPs accountable for customer service. 

For HCS clients, refer the issue to the Regional Financial Program Manager to forward to CMS Region 10 contact if the pharmacy or PDP does not accept the Best Available Evidence (BAE) institutional award letter or PAN and a prescription is needed right away. 

Include the client name, client ID, pharmacy and PDP if known.  Indicate the type of BAE presented in order to get the client's payment level changed to a 3. 

HCA Medicare Part D Resources

Drugs Covered by Medicaid

The Medicare D benchmark plan is the maximum monthly premium that will be paid by CMS for persons qualifying for "Extra Help".  If a person receiving the low-income subsidy (LIS) enrolls in a Medicare Part D plan which has a premium higher than the amount listed as a benchmark, the beneficiary is responsible for paying the difference in the premium.

All medicaid clients are automatically enrolled in the LIS/Extra help subsidy.  If a LTC client elects to have a non benchmark plan, the out of pocket cost (difference in the premium) is an allowable medical expense deduction from participation. 

Prescription Drug Coverage handout text for HCS clients

Prescription Drug Coverage Handouts for HCS clients

2012 Medicare D Prescription Drug Plan for newly Medicaid eligibles

Until a FBDE client is auto enrolled in a Medicare D prescription drug plan, newly eligible Medicaid clients get their prescription drugs through the Limited Income Net Program (LI-NET) powered by HUMANA.



Medicare D premiums are paid by Medicare's low income subsidy (LIS) program not HCA.    HCA sends information on all Medicaid recipients eligible to receive Medicare benefits to Medicare in order for Medicare to enroll these clients in the low income subsidy program.  Benchmark plan premiums are covered 100% by the Medicare LIS program.   Clients need to call 1-800-Medicare if they wish to switch to a benchmark plan.  Clients need to call their PDP plan to resolve issues with prescription drug coverage.

HCA does not enroll clients in Medicare D plans, this is done by Medicare. 

Credible coverage and Medicare D

Not all Medicare eligible clients have Medicare D.  Individuals that have "credible coverage" are not required to enroll into a Medicare D plan once they become Medicaid eligible.

What is credible coverage?

Creditable Coverage Definition and Determination defined by CMS

As defined in the regulation at 42 CFR §423.56(a), drug coverage is creditable if the

actuarial value of the coverage equals or exceeds the actuarial value of standard Medicare

prescription drug coverage.  In general, this actuarial determination measures whether the expected amount of paid claims under the entity’s prescription drug coverage is at least as much as the expected amount of paid claims under the standard Medicare prescription drug benefit. See 70 FR 4225

In other words, if a client has a health insurance that includes comparable prescription drug coverage, they do not have to enroll into a Medicare D plan.

These plans are required to send a document to the individual indicating they provide comparable prescription drug coverage. 

Refer individuals to the Washington State Office of Insurance Commissioner Health Insurance Benefit Advisors (SHIBA) if clients have questions about switching insurance. 

Do clients have out of pocket prescription drug co payments associated with credible coverage plans?

Yes. Credible coverage plans may have co payment charges that are considered out of pocket costs to the client.  These out of pocket costs must be verified in order for the department to reduce participation.  Once the department has verification of what the health insurance has paid toward the prescription drugs, the out of pocket co payment is an allowable deduction from participation. 

What happens if the system automatically enrolls a client with credible coverage into a Medicare D prescription drug plan once they become eligible for Medicaid?

The client or their representative will need to contact 1-800-Medicare and their credible coverage insurance carrier to indicate they want to retain their credible coverage health plan.  There are times when Medicaid clients are enrolled into a Medicare D PDP incorrectly when the client has credible coverage.

Medicare D and Adjusting Participation and/or Room and Board

CMS clarification regarding Medicare D and post eligibility


Adjust participation and room & board for clients who have enrolled in enhanced plans and clients who have purchased prescriptions after being denied an

exception from the PDP.


  • Clients enrolled in enhanced plans may still be required to pay higher premiums (and higher co payments if not in an institutional a . 
  • Medicare D co-payments end for FBDE in a NF or IMR a calendar month.  Do not allow a co payment once a client is in the NF or IMR a calendar month as a participation reduction.   
  • Effective 1/1/2012 Medicare D co-payments end for FBDE on a home and community based Waiver authorized by DDD or HCS.  
  • Use the additional premium cost, if the client picks an enhanced plan that is not premium-free, as a medical expense deduction.  Clients should not be charged a premium if enrolled in a benchmark plan. 
  • Do not deduct co-pays that the client paid in error.  During initial implementation PDPs have given inaccurate information to pharmacies and clients have paid incorrect co-pay amounts.  It may take time for plans to be notified of new clients being opened on Medicaid and they may continue to charge the non-Medicaid co-pays.  These will be reimbursed by the PDP.  See CMS clarification on Post Eligibility
  • Do not deduct for prescriptions the client has paid for unless the client has requested an exception from the PDP and was denied.  The client must provide you with proof of the denial.
  • Do not allow premiums and co-pays as a deduction against room & board if the client has other income to pay the co-pays.  Some SSI beneficiaries have the $46 SSI State Supplement  that can be used to pay the additional co pay charges. 
  • Request a local ETR to reduce room & board paid by the client in a community residential facility.  see ACES information below as ETRs need to be coded in ACES for room and board. (HCS staff)
  • Inform the client to contact you when their prescription costs change with verification of the out of pocket costs.
  • Re-adjust participation if there are changes.
  • The Financial Worker (FW) makes the adjustments for COPES and MN Waiver in ACES.  The FW also informs the client and Social Worker/Case Manager of the participation or room and board changes for COPES and MN Waiver using an ACES change letter.
  • The Social Worker/Case Manager (SW/CM) makes the adjustments in SSPS.  The HCS SW/CM also informs the client of the room and board changes for MPC using the Planned Action Notice.  The DDD CM/SW informs the client using their DDD letter.


HCS Management Bulletin H06-015-Procedure dated March 7, 2006 includes several handout and Q and A regarding Medicare D.


Text of HCS handouts to clients, both applicant and recipients.  

What about medicare insurance supplements, also called MEDI-Gap plans?

Medi-Gap plans are private insurance supplements that provide additional coverage for certain medicare co-payments.

Medi-Gap insurance premiums are an allowable post eligibility deduction from participation.

Medi-Gap insurance is not allowed as an ETR from room and board.  The reason for this is because all LTC clients are eligible to receive a Medicare Savings Program (MSP) which provides the same co-payment coverage as a Medi-GAP plan.  Do not allow Medi-GAP insurance as a deduction from state-funded room and board. 

Clients can choose to cancel Medi-GAP plans when going on LTC services and QMB.  If the client goes off Medicaid, they have 30 days per the Office of Insurance Commissioner to notify their Medi-GAP plan that they want to be reinstated.  Refer client's to their local SHIBA counselor if they have questions about cancelling and reinstating their Medi-GAP plans. 

Medicare C - Medicare Advantage Plans

Medicare Advantage plans are another way to get original Medicare (Parts A and B).

Medicare pays a private insurance company you select to manage your care.

You pay:

  • Part A premiums (if any)
  • Part B premiums
  • The Medicare Advantage plan's premium (if any)
  • Any deductibles, co-pays, or coinsurance

For individuals on institutional medicaid, the only out of pocket expense would be the Medicare Advantage plan premium if any.

Since institutional medicaid clients receive both medicaid and QMB medicare savings program, the deductible and copayments are covered (up to the state rate).  Providers with a medicaid contract are to accept payment at the state rate. 

What do these plans cover? 

All medically necessary care covered by original medicare.

They could include prescription drug coverage (Medicare Part D)

They could include additional coverage for vision, hearing, dental, foot care.

For additional information on Medicare advantage plans including approved Medicare Advantage Plans in the State of Washington by county, see Medicare Advantage. Additional information reimbursement rates in a NF under Medicare Advantage C. 


Medicare Savings Program (MSP) and Long-term care. Effective date

Individuals on institutional or HCB Waivers are eligible to receive S03 the first of the following month eligibility has been established for long term care. 

This section describes the start date for MSP programs when someone is found eligible for institutional or HCB Waiver. 

The date eligibility is established for QMB/S03 is based on the financial worker having all the information needed in order to make a decision on the application.   

HCA has clarified that QMB needs to be open the first of the following month the action could have been taken by the FW. 

QMB/S03 starts the first of the month following the date eligibility is established.  If LTC eligibility is needed in order to open S03 because income is over the FPL, then the S03 opens the first of the month following the month that all information needed for LTC eligibility is received. The date eligibility is established is the date that is indicated on the VERF screen.  

S05/SLMB starts in the month the client is income/resource eligible for the program.  This includes a retro month.  

S06/QI 1 starts in the month the client is income/resource eligible for the program.  This includes a retro month. 

What is a retro month?  A retro month is 3 months prior to the date the application was received. 

What is a plug in?  A plug in is needed when P1 does not pick up the eligibility from ACES.  MPA indicates it is always needed for MSP or state buy in coverage in a retro month.   To request a plug-in contact the Medicare buy-in unit using a barcode tickler to:  102@MBU

State buy-in.   This is state funded and picks up the Medicare B premium in the 3rd month of Medicaid eligibility.  State buy in is used when the client is not eligible for a federally matched MSP program but is eligible for a Medicaid program.   State buy-in is frequently used for the HWD program and spenddown as most of these clients have income that exceeds the MSP income standards. 

If we are opening a LTC program back several months and a client was not eligible for the S03/QMB until the first of the month following the month we had all the necessary information to open S03, the state will still buy in the Medicare premium in the 3rd month of eligibility.

ACES-Medicare Savings Programs

Medicare Savings Programs and ACES

LTCX screen coding and Medicare:

OA-Medicare Part A premiums

OB-Medicare Part B premiums

OC-Medicare Part C premiums

OD-Medicare Part D premiums

OP-Medicare Part D co-payments

Additional information on medical expenses and participation

Allowable medical expenses and services that can be used to reduce participation


Assignment of Excess Resources When Medicare pays 100%

Assignment of excess resources when medicare pays 100% can be found in the resource section.  Scroll down to the section that discusses this topic. 

Additional helpful links for Medicare issues

Statewide Health Insurance Benefits Advisors (SHIBA)

Medicare Website

Apply Online for Medicare

Modification Date: September 19, 2014