700.005 Medicare Part D

Policy Number  700.005
Effective Date  June 14, 2006
Revision Date  May 22, 2024
Subject Matter Expert Texas HIV Medication Program Manager
Approval Authority  HIV/STD Section Director
Signed by  D'Andra Luna

1.0 Purpose

To ensure Medicare-eligible clients living with HIV have continued access to medications.

2.0 Authority

Ryan White Care Act, 2009; Centers for Medicare and Medicaid Services.

3.0 Background

On January 1, 2006, the Centers for Medicare and Medicaid Services introduced prescription drug coverage for people with Medicare. The Centers for Medicare and Medicaid Services call this benefit Medicare Part D and market it to the public as a Medicare Prescription Drug Benefit. Insurance companies and other private companies work with Medicare to offer a variety of plans. The Centers for Medicare and Medicaid Services provide this benefit through Prescription Drug Plans (PDP), Medicare Advantage Plans (MA), and some employers and unions for their retirees. Medicare Part D offers comprehensive drug coverage for prescription drugs, including HIV medications.

4.0 Definitions

Low-Income Subsidy (Extra Help) – A federal program administered by the Social Security Administration that assists with the out-of-pocket costs associated with Medicare Part D.

Medicare – A federally funded health insurance program for people aged 65 or older, people under 65 with certain disabilities, and people at any age living with end-stage renal disease.

Medicare Savings Programs – A federal program that assists with out-of-pocket costs associated with Medicare Part B. This includes the following benefits: Medicaid and the Qualified Medicare Beneficiary (MQMB), Qualified Medicare Beneficiaries (QMB), Specified Low-Income Medicare Beneficiaries (SLMB), and Qualified Individuals (QI). The Social Security Administration automatically approves individuals who receive these benefits for the Low-Income Subsidy.

Wrap Around Resources – Services from Ryan White financial assistance and state-funded agencies available to Medicare beneficiaries to help pay for out-of-pocket costs associated with Medicare Part D, including premiums, deductibles, co-pays, and coinsurance.

5.0 Policy

Medicare beneficiaries who do not qualify for the full low-income subsidy must enroll in a Medicare Part D Prescription Drug Plan (PDP) and access medications through their PDP prior to receiving medication assistance from the Texas HIV Medication Program (THMP).

6.0 Persons Affected

This policy affects Medicare beneficiaries living with HIV seeking medication assistance from THMP.

7.0 Revision History

Date Action Section
5/22/2024 Updated 2.0, Authority; Correction to 6.0, Persons Affected; grammar edits throughout All
4/1/2015 Update references and delete changed procedures. All
10/7/2014 Converted format (Word to HTML) -