For both Title 19 and non-Title 19 SMI persons receiving Medicare benefits and DBH mental health services, who pays for their medication when they reach the Medicare coverage gap (donut hole)?
Non-Title XIX/XXI persons determined SMI with Medicare Part D will be responsible for paying for their medications while in the Medicare coverage gap (“doughnut hole”). ADHS/DBHS does not cover this cost as part of the Non-Title XIX/XXI, SMI medication benefit. Because ADHS/DBHS is not a State Pharmaceutical Assistance Program (SPAP), if ADHS/DBHS were to pay for medications while a person is in the Medicare coverage gap, the payments ADHS/DBHS would make would not count toward true out of pocket costs (TROOP). TROOP is needed in order for a person to get through the Medicare coverage gap and reach catastrophic coverage. Dual eligible (people with both Medicare and Medicaid coverage) do not have a coverage gap.
