PM 20-18-03: Payment

WAG 20-18-03.

HFS's payment rates for drugs and supplies are listed in the Handbook for Pharmacies, the Handbook for Physicians, and the Handbook for Medical Equipment/Supplies. text deleted

new materialWhen a person who receives medical benefits from the state becomes eligible for Medicare Part D, they are auto-enrolled into a prescription drug plan by the federal Centers for Medicare and Medicaid Services (CMS). State medical assistance programs under Medicaid cannot pay for prescriptions for anyone who must enroll in Part D.

Individuals with other prescription coverage through an employer or retirement plan may opt out of Part D and use the other insurance for their medications. Individuals with Medicare opt out of Part D coverage by calling Medicare at 1-800-633-4227 and stating they want to opt out or disenroll from Part D. Individuals who have not already chosen a prescription plan and who do not opt out are automatically enrolled in a Part D plan by federal CMS when they become "dual-eligible." Depending on the policy of their other insurance, being auto-enrolled into a Part D plan could affect the other insurance coverage. Anyone who is unsure how their other coverage is affected by enrolling in Part D should contact their insurance provider. If the person opts out of Part D, they remain covered for prescriptions by the other insurance and are responsible for following that plan's drug formulary and paying their plan's co-pays and deductibles.

Persons who become eligible for Medicare will receive a "Welcome to Medicare" packet three months before enrollment. The packet explains enrollment in Part D and how it works for people who receive medical benefits from the state. Individuals who have not picked a Part D plan can be temporarily enrolled through the LINET process at the pharmacy (described below).

When a person who receives Medicare begins receiving medical benefits from the state, the Department of Healthcare and Family Services (HFS) centrally notifies Medicare that the person is eligible for Extra Help. Extra Help enrollment may take a few weeks to process. To get Extra Help benefits immediately, the person can provide evidence of Medicaid coverage at the pharmacy or to their Part D provider. Proof may include:

  • state medical card;
  • approval letter; or
  • other evidence the person receives medical benefits from the state.

The plan is required to accept reasonable evidence and immediately adjust the person's costs.

new materialDual-eligible persons who are not auto-enrolled or active in a Medicare Part D plan may be enrolled by the pharmacy through the Low Inocme Newly Eligible Transition (LINET) process. The individual must take their medical card and Medicare card to the pharmacy along with photo identification. With these documents, the pharmacist will be able to confirm eligibility for Medicare Prescription Drug Plan coverage online and initiate enrollment. Using this process, individuals may be enrolled immediately and able to receive needed prescriptions the same day. The person will then be auto-enrolled in a PDP if they have not chosen one.

A dual-eligible person can be enrolled in Medicare Part D at the pharmacy.  LINET is also called a POS (Point of Sale) or facilitated enrollment. The pharmacist can immediately enroll an eligible person in a temporary Part D plan administered by Humana. This option is available at most pharmacies and, when requested by the person, the pharmacist can call the HFS Provider Hotline at 1-877-782-5565 (Option 7) for instructions on how to complete LINET enrollment.

 By choosing a plan, the customer can verify that the plan covers the prescriptions they use for their medical condition(s). To choose a Part D plan, individuals should have a list of their prescriptions for reference and:

  • go to to enroll; or
  • apply by calling Medicare at 1-800-633-4227 (TTY: 1-877-486-2048); or
  • call the Illinois Senior Health Insurance Program (SHIP) at 1-800-548-9034 (TTD: 217-524-4872) or email at

new materialEach Part D plan has an approved medication list called a formulary. Every plan is required to carry at least two drugs in every major treatment category. Individuals on Medicare should choose a Part D plan with a formulary that covers all of their prescriptions. This may require the person to consult with his or her doctor to find medications that are covered by their plan. The state medical card does not cover non-formulary prescriptions.

If a person on both Medicare and state medical assistance does not pick a plan, Medicare will automatically assign him or her to a plan. If this plan does not cover all of their prescriptions, they can change plans. Changes in plans are usually effective the month following the month of request.

Part D costs for premiums in excess of the federal base premium and drug copays are allowable medical expenses toward spenddown.

new materialInformation on how to request a reconsideration or file an appeal will be in the plan's member handbook or the person can call the plan's telephone hotline.

There may be times when a person receiving medical benefits overpays for prescriptions and is due a refund from the Part D plan. This usually occurs:

  • between the time the case is approved and when the Part D plan becomes active; or
  • when the person was eligible for Medicare Part D for backdating months; or
  • when the person pays out-of-pocket for costs that were eligible to be covered by the PDP.

Refunds can include repayment for the monthly premium and the cost of prescription drugs that exceed the co-pay amounts. Customers can obtain a refund by calling their prescription drug plan provider.