Medicare Part D Copayment Billing for CILA Residents


Informational Notice

Date: November 30, 2012

To: Participating Pharmacies

Re: Medicare Part D Copayment Billing for CILA Residents

Effective January 1, 2012, Medicare Part D began fully subsidizing Medicare Part D drugs for Dual Eligible (Medicare and Medicaid) participants residing in Supportive Living Facilities (SLFs) or Community Integrated Living Arrangements (CILAs) who are also in a Home and Community Based Waiver (HCBW) program. This means that under Medicare Part D, those participants are not charged copayments. At that time, the Department discontinued allowing copayment-only claims for SLF and CILA residents.

All SLF and the majority of CILA residents participate in an HCBW program. However, certain Dual Eligible CILA residents are not enrolled in a HCBW program, and therefore, are responsible for copayments under Medicare Part D. These participants are eligible for the full low-income subsidy, so their copayments are minimal. Effective with dates of service on or after January 1, 2012, the department will allow pharmacies to bill Medicare Part D copayments to the department for non HCBW participants who are CILA residents. Instructions for copayment-only billing are below.

The pharmacy should first bill Medicare Part D in order to determine the copay amount charged to the participant for that drug. The pharmacy may then submit the claim to the Department with the appropriate copayment amount.

In addition to the pharmacy and client specific information required on the NCPDP D.0 claim submission, the claim must also contain the following elements:

Claim Code
NCPDP D.0 Claim Segment Field Valid Value
Other Coverage Code (308-C8) Value = 08
NCPDP D.0 Pricing Segment Field Valid Value
Other Amount Claims Submitted Count (478-H7) Value = 1
Other Amount Claims Submitted Qualifier (479-H9) Value = 04
Other Amount Claimed Submitted (480-H9) Value = Copay amt ($1 - $6.50)
Gross Amount Due (430-DU) Value - Copay amt ($1 - $6.50)
Usual and Customary Charge (426-DQ) Value - Amount charged cash customers for the prescription exclusive of sales tax or other amount claimed.

Copay-only claims must not contain a NCPDP D.0 COB/Other Payments Segment.

Any questions regarding this notice should be directed to the Bureau of Pharmacy Services at 1-877-782-5565.

Theresa A. Eagelson, Administrator

Division of Medical Programs