Effective January 1, 2012, there has been a change in the rule for co-pay on medications. Individuals who are Dual Eligible (having both Medicare and Medicaid) and are on the Home and Community Based Care (HCBC) waiver, either Acquired Brain Disorder (ABD) or Developmental Disability (DD), are no longer required to pay a co-pay for their medications via their Part D plan. Some individuals are still being asked for co-pays because updates to records have been delayed, but it is expected this will be cleared up by the end of February.

The Center for Medicaid Services (CMS) implemented the provision of this change as of January 1, 2012, the earliest date permitted by the statute, so states are now officially required to include HCBC status in their submissions to CMS. However, CMS urged but did not require states to send a special submission in December so that HCBC status could be noted on CMS and plan records by January 1.

It is not clear how many states made this special December submission or where NH stands with this, but from what we've heard, the update to records is not fully made. Some individuals are still being asked for co-pays on their medications.

Your pharmacy may not know about this new rule, so it is best that we help them process the information. If you are asked for a co-pay, you can remind the pharmacist of the rule and the status of the individual. Ask what further documentation they require in order to not be charged a co-pay.

We're hoping the systems will be 'caught up' with each other by February, and we will see less and less of this problem. If the problem persists, please contact Sandra Metivier so that a report can be made to the Division.

CMS has not submitted any plans about reimbursement for those co-pays that were paid out in error. We expect information regarding those situations in the near future and will pass that on to you. As a best practice, please save receipts for purchases where co-pays were required.

If you have any questions or require assistance, please call MDS Benefits Coordinator Sandra Metivier at 603-352-1304 ext. 290 or email her at This email address is being protected from spambots. You need JavaScript enabled to view it..