CMS Pub. 100-16, ch. mc86c16b, § 20.2.4.3

As provided under section 1860D-14 of the Act, full-benefit dual eligible individuals who are

institutionalized individuals have no cost sharing for covered Part D drugs under their Prescription

Drug Plan (PDP) or Medicare Advantage Prescription Drug (MA-PD) Plan. As of January 1, 2012,

section 1860D-14 of the Act also eliminates Part D cost sharing for Full Medicaid individuals who

are receiving home and community-based services (HCBS) either through:

• A home and community-based waiver authorized for a state under section 1115 or subsection

(c) or (d) of section 1915 of the Act;

• A Medicaid State Plan Amendment under section 1915(i) of the Act; or

• A Medicaid managed care organization with a contract under section 1903(m) or section 1932

of the Act.

These services target frail, elderly individuals who, without the delivery in their home of services

such as personal care services, would be institutionalized. HCBS eligibility is not based on where an

individual resides. In other words, SNPs cannot assume that all enrollees residing in assisted living

facilities receive HCBS and therefore qualify for the zero-dollar cost sharing. Thus, in order to

qualify for zero-dollar cost sharing, a SNP must determine or an enrollee must demonstrate that s/he

is a full-benefit Medicaid individual receiving HCBS as stated above. Below, we list acceptable

documents that SNPs may use as best available evidence for demonstrating receipt of HCBS:

• A copy of a state-issued Notice of Action, Notice of Determination, or Notice of Enrollment

that includes the enrollee’s name and HCBS eligibility date during a month after June of the

previous calendar year;

• A copy of a state-approved HCBS Service Plan that includes the enrollee’s name and effective

date beginning during a month after June of the previous calendar year;

• A copy of a state-issued prior authorization approval letter for HCBS that includes the

enrollee’s name and effective date beginning during a month after June of the previous

calendar year; or

• Other documentation provided by the state showing HCBS eligibility status during a month

after June of the previous calendar year.