Did Your State Drug Program Enroll You in a Part D Plan?

A qualified State Pharmaceutical Assistance Program can enroll you in a Medicare Part D plan, but CMS guidance says it must tell you first and explain how to decline. If a letter says your state drug program is picking a Part D plan for you, or a parent's program already did, you still have choices: you can accept that plan, decline it, or choose a different plan yourself.1

In This Guide

• Can a State Drug Program Enroll You in a Part D Plan?
• What the Notice Has to Tell You
• Your Choices When the Letter Arrives
• What a State Drug Program Can't Do
• The Question No Rule Answers Yet
• Two States That Write This Into Law
• Before You Accept the Part D Plan Your State Drug Program Picked
• Frequently Asked Questions
• Learn More

Can a State Drug Program Enroll You in a Part D Plan?

Yes, a state drug program can enroll you in a Part D plan if the program is a qualified State Pharmaceutical Assistance Program and your state's law gives it that authority. A State Pharmaceutical Assistance Program, or SPAP, is a state-funded program that helps people with Medicare Part D pay for prescriptions. Federal rules define a State Pharmaceutical Assistance Program narrowly: the definition excludes state Medicaid programs, section 1115 demonstration programs, and any program funded from federal sources.2 Our guide to State Pharmaceutical Assistance Programs covers which states run one.

The enrollment power comes from the CMS Medicare Advantage and Part D enrollment guidance. Section 30.6.9 of that guidance says a person who belongs to a qualified SPAP, "or the state acting as their authorized representative," can request to enroll in a Medicare drug plan or a Medicare Advantage plan with drug coverage once per calendar year.1 An authorized representative is someone allowed to act for you on an enrollment request. Here, the representative is the state program itself.

The program has a reason to care which plan you're in. Under 42 CFR 423.464(b), a Part D plan is always the primary payer relative to a SPAP: the Part D plan pays a prescription claim first, and the state program wraps around it as the secondary payer.2 So the plan you end up in shapes what you pay at the counter and what the state program pays after it.

What the Notice Has to Tell You

CMS sets conditions before a Part D plan may accept enrollment requests from a qualified SPAP. Under section 40.1.11 of the CMS enrollment guidance, the SPAP must attest that it has the authority under state law to enroll on behalf of its members, and it must provide a notice to its members in advance of submitting the request.1

That advance notice has to explain three things to the member, according to section 40.1.11 of the CMS enrollment guidance:1

• That the state program is enrolling the member on their behalf.
• How the Medicare Advantage or Part D enrollment will work with the state program.
• How the member can decline the enrollment.

Keep that notice. It is the document that tells you how your own program handles declining, and it is the first thing a counselor will ask to see. If your state program's letter doesn't explain how to decline, call the program and ask before the enrollment goes through.

State law can add more. Pennsylvania's PACE and PACENET law, for example, requires the Pennsylvania Department of Aging's notice recommending a plan to tell members they can decline enrollment in the recommended Part D plan, that they can file and pursue appeals to that plan on their own behalf, and that their choice of plan may affect their medical coverage if they are enrolled in a Medicare Advantage plan.3

Your Choices When the Letter Arrives

You have three realistic paths once your state program tells you it is choosing a Part D plan for you.

1. Accept the plan. If the recommended plan covers your drugs and works with your pharmacy, accepting it may be the simplest path.
2. Decline the enrollment. Use the method your program's notice describes. CMS requires that notice to say how to decline, and Pennsylvania's PACE law gives PACE and PACENET members at least ten days to decline the recommended plan.3
3. Pick a different plan yourself. In Pennsylvania, the PACE law says the Department of Aging enrolls a member in its recommended plan "unless the claimant notifies the department that the claimant wishes to enroll in another Part D plan."3

If it happens during fall Open Enrollment

Timing matters most in the fall. Medicare Open Enrollment runs from October 15 through December 7 each year, and a person in Original Medicare can join, drop, or switch Medicare drug plans during it, with changes taking effect January 1.4

CMS has a specific rule for a state program enrolling you during that window. Under section 40.1.11 of the CMS enrollment guidance, a SPAP enrollment request made during the fall annual election period carries an application date of October 15, so that an enrollment request you make yourself later in that period supersedes the state program's enrollment in CMS systems.1 In plain terms, if your state program enrolls you in a plan during Open Enrollment and you then pick your own plan before the period ends, your choice wins.

That fall window is open to you whatever your state program does. The once-a-year limit on the SPAP special enrollment period caps that special period only; it does not affect the fall Open Enrollment Period or another special enrollment period you separately qualify for.5

What a State Drug Program Can't Do

Federal rules also limit how often a state drug program can move its members between plans. To meet the federal definition of a SPAP in 42 CFR 423.464(e)(1)(vi), a state program must not make midyear or noncalendar-year plan enrollment changes on behalf of a substantial number of its members when it is authorized to act for them.1 Put plainly, a program that regularly shifts large groups of its members into different Part D plans partway through the year would fall outside the federal definition of a State Pharmaceutical Assistance Program.

The Question No Rule Answers Yet

Members of a qualified SPAP have a special enrollment period of their own. Under 42 CFR 423.38(c)(17), a person who belongs to a qualified SPAP can join a Medicare drug plan or a Medicare Advantage plan with drug coverage, but the person "is eligible to make one enrollment election per year," which means one change during the calendar year, not unlimited plan changes.5 The SPAP special enrollment period also stays open after a person loses SPAP eligibility, ending 2 calendar months after the month the person loses eligibility or is notified of the loss, whichever is later.5

Here is the part that is genuinely unsettled. The CMS guidance says the once-per-calendar-year SPAP election can be requested by the member "or the state acting as their authorized representative."1 In our reading of the CMS guidance, the federal regulations, and the Pennsylvania and Maine laws, we found nothing that says whether a state program's request uses up the member's own SPAP election for that year.

So don't plan around either answer. If your state program enrolled you outside Open Enrollment and you're thinking about switching plans later that same year, ask your state program directly whether you can still use the SPAP special enrollment period, and confirm with your SHIP. A SHIP gives free, unbiased counseling to people with Medicare and their families, including help choosing a plan.6 Our article on free SHIP counseling explains what to expect.

Two States That Write This Into Law

The federal guidance allows a state program to enroll members only where state law gives it that authority, so the details depend on your state. Two states' laws spell the power out, and they work differently. Other state programs may handle Part D enrollment their own way, so read your own program's notice rather than assuming either model applies.

Pennsylvania: PACE and PACENET

Pennsylvania's PACE (Pharmaceutical Assistance Contract for the Elderly) and PACENET programs are prescription assistance programs for Pennsylvania residents age 65 and older, reporting to the Pennsylvania Department of Aging.7 Pennsylvania's PACE is not the federal Program of All-Inclusive Care for the Elderly, also called PACE, which is a separate program governed by 42 CFR Part 460.8

Section 533 of Pennsylvania's State Lottery Law, as amended by Act 94 of 2021, says the Department of Aging "Shall initiate enrollment on behalf of the claimant in the Part D plan recommended by the department unless the claimant notifies the department that the claimant wishes to enroll in another Part D plan."3 The same Pennsylvania law requires the department to identify the contracted Part D plans that meet a PACE or PACENET member's prescription drug needs and pharmacy preferences, and lets it require enrollment in the plan that meets those needs in the most cost-effective manner for the state.3

Pennsylvania's law also has a premium rule for some PACENET members. Under the same law, a PACENET member who is not enrolled in Part D through section 533 must pay a monthly premium equal to the regional benchmark premium for each month the member fills a prescription, and no premium for a month without one.3 If you're a PACENET member, ask the program whether that premium could apply to you before you decline the recommended plan. Our Pennsylvania PACE and PACENET guide covers eligibility and costs.

Maine: Low Cost Drugs for the Elderly or Disabled (DEL)

Maine's DEL program, run by the Maine Department of Health and Human Services, takes a different approach. Under Maine law, "To the extent permitted by federal law and to the extent that funds are available," the department may serve as a DEL enrollee's authorized representative for Part D enrollment.9

That is a permission, not a promise, so a Maine DEL member shouldn't assume the department has already acted. Maine's DEL rules also require a member who is eligible for Part D to enroll in Part D and a drug plan at the next available opportunity, and a member who doesn't comply loses DEL eligibility until they do, absent good cause.9 Our Maine DEL guide explains who qualifies.

Side by side, the two state laws compare like this.3,9

Before You Accept the Part D Plan Your State Drug Program Picked

A few checks now can save trouble at the pharmacy later.

• Check every drug. Look up each prescription on the recommended plan's drug list (its formulary), including the dose you take.
• Check your pharmacy. Confirm your usual pharmacy is in the plan's network. Pennsylvania's law tells the Department of Aging to identify plans that fit a member's drug needs and pharmacy preferences, so tell PACE yours.3
• If you have Medicare Advantage, ask first. Pennsylvania's law makes PACE warn members that a choice of plan may affect their medical coverage if they are in a Medicare Advantage plan, so anyone with Medicare Advantage should ask their state program how its choice affects their medical coverage before accepting.3
• Write down the decline deadline. Note the date in the notice and the way the program wants to hear from you.
• Get a second opinion if you're unsure. A SHIP counselor can compare plans with you at no cost.6

If a plan later refuses a drug you need, you can ask it for a coverage decision. Our guide on asking your drug plan to cover a denied drug explains how.

Learn More

Find personalized help sorting out a state drug program's Part D enrollment letter at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.