US · guidance
CMS Pub. 100-11, ch. 14, § 30.6
Dual Eligible Beneficiaries
CMS fully subsidizes dual-eligible individuals’ Part D coverage in PACE organizations.
Therefore, consistent with PACE rules, there is no beneficiary out-of-pocket expense.
However, True Out-of-Pocket (TrOOP) is to be tracked and reported, although the
processes may vary by plan. If a beneficiary disenrolls from a PACE plan mid-year, the
participant will need to be provided their Gross Covered Drug Costs and TrOOP amount
(even if that amount is $0). For plans that do not participate in the automated troop
balance transfer, there is a manual calculator that plans can use to provide information to
their participants. It’s important to note that if a participant disenrolls to a stand-alone
PDP mid-year (either a full dual or Medicare-only) they will have co-pays. For a dual
eligible, the participant will not be exempt from co-pays until they reach the catastrophic
level, at which time TrOOP can be applied.
History
(Rev. 2, Issued: 06-09-11; Effective: 06-03-11; Implementation: 06-03-11)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
adc9c28fa3dfe8b8c009217e8480d37c370f9dd65975a5b0f1feee7494bc30b8
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