Medicaid Long Term Care Coverage of Prescription Drugs & Dietary Supplements

Summary
Medicaid Long Term Care programs generally cover the cost of prescription medications for their beneficiaries. There are small co-payments and some limits on the total number of prescriptions covered per month that vary depending on the state in which you live. The type of Medicaid program– Nursing Home, HCBS Waivers or Aged, Blind and Disabled (ABD) – also affects the coverage. Non-prescription medications or supplements such as vitamins are not directly covered by Medicaid Long Term Care, but there are some open-ended Medicaid programs that can be used to pay for health care supplements.

Medicaid Long Term Care Coverage of Prescription Medications

Medicaid Long Term Care recipients in all 50 states and Washington, D.C., will have most of the cost of their prescription medications covered. The exact figures change by state, but, in general, Medicaid recipients can expect a co-pay of $1.00-$10.00 per prescription. The number of prescriptions allowed per month is usually between two and six, but that also varies by state.

In California, for example, all prescription medication co-payments for Medicaid Long Term Care recipients are $1 and there is a limit of six prescriptions per month. There are no co-payments in Florida and the monthly limits depend on the type of drug. In Massachusetts, there’s a $1 co-pay for generic drugs and a $3.65 co-pay for non-generic drugs with a limit of $250 per year, but there is no limit on prescriptions per month.

Many of the limits can be lifted with doctor authorization, often referred to as Prior Approval (PA) in Medicaid terms. Medicaid Long Term Care coverage does favor generic versions of prescription medications over the usually more expensive name brand versions, but this can also be changed with Prior Approval.

Prescription Drug Coverage for Medicaid Nursing Home Residents

The most common type of Medicaid Long Term Care is Nursing Home Medicaid. People are eligible for Nursing Home Medicaid if they meet the functional health requirements (needing the type of daily, routine care provided in a nursing home setting), and the financial requirements (low assets and income) set forth by their state. Our Medicaid Eligibility Requirements Finder tool can help you check out your own eligibility situation.

For Nursing Home Medicaid Long Term Care recipients, the nursing home facility will take care of acquiring and distributing prescription medications. Medicaid considers this one of the important benefits of Nursing Home Medicaid coverage.

A few nursing homes may have in-house pharmacies, but the majority of them partner with a local commercial pharmacy. The nursing home contacts the pharmacy with doctor’s prescriptions and deliveries are made, in most facilities, once or twice a day. This could pose a problem in you or your loved one checks in to a facility for the first time after they have already placed their pharmacy order for the day. So, it’s a good idea to bring a day’s worth of any current medication from home or the hospital or wherever you or your loved one was before transitioning to the nursing home. However, any excess medication you bring will be destroyed by the nursing home staff, who are required to do so by law.

Nursing home patients have the right to be informed about all medication they’re receiving and the right to refuse any medications. Family members are encouraged to check in with their loved ones who are in nursing homes, and with nursing home staff, to make sure the proper amount of medication is being dispensed and taken.

Prescription Drug Coverage for Medicaid Beneficiaries Living at Home

For Medicaid beneficiaries who do not live in nursing homes, Medicaid offers coverage through Home and Community Based Service (HCBS) Waivers or Aged, Blind and Disabled (ABD) Medicaid. In most cases, HCBS Waivers recipients must show a need for Nursing Home Level Care, but they will continue to live in their home or in the “community” (an assisted living facility, or the home of a relative, are two examples) while they receive health care services. ABD Medicaid recipients don’t have to show any medical need, they just need to be over age 65, or blind, or disabled. HCBS Medicaid Waivers and ABD Medicaid recipients must also meet financial criteria, just like Nursing Home Medicaid recipients. The asset and income limits for eligibility vary by state and type of Medicaid Long Term Care.

To buy prescription medications at the Medicaid rate, HCBS Waivers and ABD Medicaid recipients just show their Medicaid card at the pharmacy like any other insurance card.

Will Medicaid Cover Brand Name Prescription Drugs?

Medicaid Long Term Care coverage does favor generic versions of prescription medications over the usually more expensive name brand versions, but there are exceptions. New drugs, for example, often don’t have generic options. And some highly specialized drugs don’t have generic alternatives.

Doctors will always search for generic medication options when it comes to Medicaid beneficiaries, and they may even try alternate routes and different medications instead of prescribing expensive brand name drugs, but if there is no alternative they will prescribe brand name drugs to Medicaid patients.

Paying for Dietary Supplements with Medicaid Long Term Care Coverage

None of the three Medicaid Long Term Care Programs will directly cover non-prescribed health supplements such as vitamins, minerals, herbs, probiotics, fish oils, etc. However, there are programs and exceptions within HCBS Waivers and some state’s ABD Medicaid coverage that will help the Medicaid recipient acquire supplements. To understand how this works, there are two Medicaid concepts with which the reader must be familiar.

Using Medicaid Consumer Directed Care Budgets to Purchase Dietary Supplements

Certain HCBS Waivers and ABD Medicaid programs allow for Consumer Directed Care. This gives the Medicaid recipient a set amount of money per month to spend on medical/health products as the recipient sees fit. So, the HCBS Waivers or ABD Medicaid recipients could use the funds in that Consumer Directed Care budget to buy supplements of their choice.

Money from a Consumer Directed Care budget can also be used to purchase durable medical equipment, home care supplies and personal emergency response services. Consumer Directed Care can also be referred to as Consumer Directed Coverage, or Cash and Counseling.

Using Family Supplementation to Purchase Dietary Supplements

While it is not advisable for family members to give money to their loved one who is a Medicaid recipient, giving gifts (like vitamins, for example) can be okay and is known as “Family Supplementation.”

Money given directly to the Medicaid recipient will be considered income and could lessen the amount of coverage Medicaid will provide, or even make the individual Medicaid ineligible. Buying items for a Medicaid recipient is much less likely to cause these issues, but you should be clear on your state’s rules before doing this. Some states are very strict about gifts, but others have rules in place so Medicaid eligibility won’t be impacted by non-cash gifts. These are known as Family Supplementation states. As of 2018, the following states allowed Family Supplementation: Alaska, Arizona, Arkansas, Colorado, Delaware, Florida, Georgia, Idaho, Illinois, Iowa, Kansas, Maine, Minnesota, Missouri, Nevada, New Hampshire, New Jersey, New Mexico, North Carolina, North Dakota, Oklahoma, Tennessee, Texas, Utah, Virginia, Washington state, Wisconsin, and Wyoming. However, it should be noted that Medicaid rules frequently change, so contacting your local Medicaid offices to see if your state allows for Family Supplementation is recommended.