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Medicare Part D Q&A
There are many questions about Medicare's new Part D plan. We provide some of those questions, and answers here.
By TIMES STAFF AND MEDICARE RIGHTS CENTER
Published October 30, 2005
Who can get Medicare prescription drug coverage?
Anyone who has Medicare Part A and/or Part B can get Medicare prescription drug coverage (Part D) through a private company. People on Medicare HMOs and PPOs will get their drug coverage directly through their HMO or PPO.
When does the Medicare drug coverage start?
Actual coverage begins Jan. 1. But you can start signing up for a plan or HMO as of Nov. 15.
How much will my premium be for a Part D drug plan?
In addition to your Part B premium, you will have to pay a monthly premium for a Medicare Part D drug plan. Medicare estimates that the average national premium will be $32.20 a month ($386.40 a year) in 2006, but in Florida you can pay as little as $10.35 and as much as $104.89, depending on the benefits. Premiums will likely increase every year. You can choose to have the premium taken out of your monthly Social Security check (in addition to your Part B premium) or you can pay it directly to the company.
How much will I have to pay for my drugs with a Part D drug plan?
That will depend on the plan you choose. In general, under any Medicare drug plan, you will have to pay a monthly premium, an annual deductible (no more than $250 in 2006) and varying amounts of coinsurance, depending on the total costs of the drugs you buy. In addition, you will likely have to pay the full bill after total drug costs reach $2,250 and before they reach $5,100 (the so-called coverage gap).
Will Medicare prescription drug coverage help me?
Whether a drug plan will save you money when it first becomes available depends on your situation. If you currently do not have drug coverage you may save money from the start if you have drug expenses. If your income and assets are low, a Medicare drug plan may lower your expenses significantly. If you don't have many drug expenses now, a drug plan may not save you money immediately, but it will protect you against a sudden illness. Also, if you reject coverage now, Medicare will impose a stiff premium penalty if you want coverage later in life.
What if my income is too low to pay premiums and copayments?
If your annual income is below $14,355 a year for individuals and $19,245 a year for couples in 2005 and your liquid assets are less than $11,500 for individuals and $23,000 for couples, you may be eligible for extra help paying for your Medicare drug costs.
How do I calculate my assets?
If you are married and live with your spouse, you need to consider your combined resources even if only one of you is applying for extra help. You should include liquid assets (cash and other items that can be converted into cash within 20 days, such as stocks, bonds, IRAs and 401Ks) and real estate that is not your primary residence. The cash value of life insurance policies will be considered only if their face value (death benefit) is more than $1,500 ($3,000 for couples). Nonliquid assets such as cars, the house you live in, household goods/furniture and jewelry will not be counted.
Are there other exceptions to the low-income rules?
Yes. If you support relatives who live with you, your income limits will be higher. Also, some of your income and assets are not counted under law. Examples include:
A $20-a-month general income exclusion
About half of earned income; food stamps, heating, housing and weatherization assistance
Earned income tax credit payments
Tax refunds
Expenses paid to enable you to work if you are disabled
Burial spaces and plots (items such as grave sites and cremation urns, for example)
A line of credit from a reverse mortgage
The Social Security Administration advises you to apply for low-income subsidies if there is any chance at all of qualifying.
Will I lose my subsidized housing or food stamps if I get the extra help paying for my Medicare drug costs?
The extra help you get paying for your Medicare drug costs does not count as income. But if you have been deducting your drug costs when calculating your income for housing assistance or food stamps, you can no longer do so. Your rent may go up and your food stamp allowance may go down. However, Medicare estimates that what you gain in coverage of drug costs will more than offset whatever you may lose in rent or food stamps.
I get drug coverage through Medicaid. Should I apply for the extra help paying for Medicare drug costs?
No. If you have Medicaid you automatically qualify for the extra help paying for your Medicare drug costs. You should have received a letter in May or June letting you know that you automatically qualify for the extra help and do not need to apply.
You do need to choose a plan through which to get your Medicare drug coverage. If you do not enroll in a drug plan by December 31, you will be randomly enrolled in one.
If you are currently in traditional Medicare, you will be enrolled in a stand-alone Part D drug plan. If you are in a Medicare HMO PPO, you will be enrolled in the lowest premium prescription drug plan offered by that company.
As of Jan. 1, you will no longer have Medicaid drug coverage.
Medicaid will continue to help pay your other Medicare out-of-pocket costs, including the deductible and coinsurance, and you will have a reduced or free drug plan premium.
Who will keep track of how much I spend on drugs?
The plan is required to do this. When you enroll in a Medicare drug plan, you will get a card to use when you fill your prescriptions. This is how the plan keeps track of your out-of-pocket expenses.
Your plan is required to send you a statement every month showing how much has been spent for the year and how close you are to reaching the out-of-pocket maximum for catastrophic coverage ($3,600 in 2006). You can also request this information from your plan at any time. Some plans may make this information available on their Web sites.
What happens if my Medicare drug plan leaves my area?
You will have a special enrollment period to enroll in another Medicare drug plan. You can go to Medicare's www.medicare.gov Web site to look for Medicare drug plans in your area and compare their costs, covered drugs and pharmacy networks. You can also call toll-free 1-800-633-4227 for help finding a new drug plan.
How soon after I apply for the extra help paying for Medicare drug costs will my benefit start?
If you apply for and get extra help and join a Medicare drug plan before Dec. 31, you will begin receiving extra help and drug coverage on Jan. 1. If you apply for the extra help between Jan. 1 and May 15, or during an enrollment period you are eligible to start receiving the help on the first day of the same month that you applied.
If you are already enrolled in a Medicare drug plan, it will be notified that you are eligible for extra help and must reduce the out-of-pocket costs you have been paying. If your plan already has charged you additional costs from the time you became eligible for extra help (the first of the month in which you applied), it must reimburse you for those costs.
If you apply for extra help outside of an enrollment period and you are not already enrolled in a Medicare drug plan, you cannot use your extra help until you can enroll in one. Your extra help would start when your drug coverage starts.
Can the terms of my coverage change?
The deductibles and premiums cannot change until the following calendar year. However, your coinsurance and overall out-of-pocket costs may change if the drug you need is moved to a different cost tier or is removed from the plan's list of covered drugs.
What else do I need to watch out for?
Drugs plans can require pre-authorization of dosage and usage for some drugs on their formularies. When you check to make sure if your drugs are covered, also find out if the plan imposes any restrictions on those drugs.
How soon after I apply for the extra help paying for Medicare drug costs will my benefit start?
If you apply for and get extra help and join a Medicare drug plan before Dec. 31, you will begin receiving extra help and drug coverage on Jan. 1. If you apply for the extra help between Jan. 1 and May 15, or during an enrollment period you are eligible to start receiving the help on the first day of the same month that you applied.
If you are already enrolled in a Medicare drug plan, it will be notified that you are eligible for extra help and must reduce the out-of-pocket costs you have been paying. If your plan already has charged you additional costs from the time you became eligible for extra help (the first of the month in which you applied), it must reimburse you for those costs.
If you apply for extra help outside of an enrollment period and you are not already enrolled in a Medicare drug plan, you cannot use your extra help until you can enroll in one. Your extra help would start when your drug coverage starts.
What if I get extra help but later qualify for Medicaid, a Medicare Savings Program or Supplemental Security Income (SSI)?
You will then qualify for full extra help and have lower out-of-pocket costs. That means you pay no monthly premium (unless you join a plan that has a premium higher than $33), no deductible, and copays of no more than $0-$2 for generics and $0-$5 for brand-name drugs.
If your plan charges you additional costs after you qualify for Medicaid, a Medicare Savings Program or SSI, it must reimburse you for those costs. Since you automatically qualify for the extra help, you will not have to recertify as long as you continue to be enrolled in any of these programs.
Are there any criteria Medicare drug plans must meet?
Yes. While companies have great flexibility to design their own plans, there are some criteria they have to meet. For example:
The overall value of the drug coverage must be the same or greater than the basic plan outlined in the law.
The annual deductible cannot be more than $250 in 2006.
Catastrophic coverage must be at least as good as it is under the plan outlined in the law.
Plans must cover at least two drugs in each drug class in their formulary.
Plans must cover all or substantially all drugs in six categories: antidepressants, antipsychotics, anticonsulvants, antiretrovirals (AIDS treatment), immunosuppressants and anti-cancer.
Plans must have a process in place for members to request exceptions to the plan's formulary if a non-covered drug is medically necessary.
Plans must have a network of pharmacies that meets federal standards for convenient access.
Plans must make information about their pharmacy network and formulary easily available (some information is only required upon request.)
Plans must have a Medicare-approved transition process for new members whose condition has been stabilized on medications that not on the plan's formulary.
What happens if I was enrolled in extra help because I have a Medicare Savings Program, Medicaid, or Supplemental Security Income (SSI), but I lose eligibility for these programs during the year?
If you were automatically enrolled in extra help paying your Medicare drug costs because you had Medicaid, a Medicare Savings Program or SSI, and you no longer qualify for that program, you will continue to have extra help for the rest of the calendar year.
Medicare will let you know if you no longer qualify for extra help after 2006 and need to complete an application for extra help to continue getting it.
If you still qualify for extra help, the amount of help you receive may be reduced. If you do not get extra help, you will have to pay your monthly drug plan premium and plan cost-sharing.
Who will keep track of how much I spend on drugs?
The plan is required to do this. When you enroll in a Medicare drug plan, you will get a card to use when you fill your prescriptions. This is how the plan keeps track of your out-of-pocket expenses. Your plan is required to send you a statement every month showing how much has been spent for the year and how close you are to reaching the out-of-pocket maximum for catastrophic coverage ($3,600 in 2006). You can also request this information from your plan at any time. Some plans may make this information available on their Web sites.
Which drugs will Medicare drug plans cover?
Each drug plan will have its own formulary (list of covered drugs), which will include both brand and generic drugs. Plans will be allowed to change their formularies at any time as long as they give a 60-day notice of the change by mail. Drug plans must offer at least two drugs options under each drug class. In addition, plans must cover a majority of drugs in certain classes, including: antidepressants, antipsychotics, anticonvulsants, antiretrovirals, anticancer and immunosuppressants. While some drugs are explicitly excluded from Medicare coverage by law, some plans may cover them as an additional benefit.
Can the terms of my coverage change?
The deductibles and premiums cannot change until the following calendar year. However, your coinsurance and overall out-of-pocket costs may change if the drug you need is moved to a different cost tier or is removed from the plan's list of covered drugs.
Can I change plans if my drug plan stops covering the drug I need?
Everyone has a one-time chance to change plans until May 15, 2006. After that, you may be locked in for the rest of 2006, even if your plan drops coverage of your drugs. People on Medicaid can change plans once a month.
In addition, entering, residing in, or leaving a nursing home will entitle you to change your drug plan. Nursing home residents can change plans every month. Persons who leave a nursing home can change plans within two months after leaving the institution. Details on this are still being worked out.
Medicare drug plans must provide convenient access to long-term care facility pharmacies in their networks. If you are living in a nursing home or other medical institution and qualify for Medicaid for at least one full month, you will be automatically eligible for the extra help paying for Medicare drug coverage and you will not have any out-of-pocket expenses for your drug costs. If you join a Medicare drug plan with a premium that is higher than the extra help premium amount, the difference is a medical expense that counts toward the monthly amount you must contribute toward the cost of your care ("share of cost"). If you do not have Medicaid, you will have the same out-of-pocket costs as other plan members.
Can I be randomly enrolled in a drug plan with a premium that is higher than the extra help will pay?
Possibly. The extra help will not pay more than about $33 toward the monthly premium. If you are enrolled in a state Medicare Savings Program, receive Supplemental Security Income (SSI) or have Medicaid, you automatically qualify for the extra help and Medicare will enroll you in randomly assigned drug plan unless you pick one yourself.
If you are currently in a Medicare HMO or PPO you will be assigned to a plan offered by the same company that offers the lowest premium Medicare drug coverage. If that plan's premium for drug coverage exceeds $33, you would have to pay the difference.
You can drop the Medicare private health plan and switch to traditional Medicare and pick a stand-alone drug plan with a premium at or below $33.
After I join a Medicare drug plan, can the deductibles, premiums and coinsurance change?
The deductibles and premiums cannot change until the following calendar year. However, your coinsurance and overall out-of-pocket costs may change if the drug you need is moved to a different cost tier or is removed from the plan's list of covered drugs.
Will my Medicare drug plan cover medications that I am currently getting covered by Medicare?
During an enrollment period, if you have a Medicare drug plan already and enroll in a new one, you will be automatically disenrolled from your previous plan. Additionally, if you make multiple plan selections during a month, the last one you make will become effective on the first of the following month.
Choose another Medicare drug plan before May 15 and you will be automatically disenrolled; send a letter to your plan asking to be disenrolled.
If you do this after May 15, you will not be able to enroll in another Medicare drug plan. Therefore, you will have a premium penalty if you later signed up for another Medicare drug plan unless you have drug coverage at least as good as Medicare's from another source.
What are my enrollment rights?
You can enroll in any Medicare private drug plan in your area during the initial enrollment period. The plan must provide you "prompt notice" of whether it has accepted or denied your enrollment.
Can network pharmacies charge different prices for the same covered drug?
It depends. If you are getting the extra help paying for your Medicare drug costs (the low-income subsidy), you will pay no more than $5 for your drugs as long as you go to a pharmacy that is in the plan's network. If you are not getting the extra help, what you pay for drugs may vary, depending upon which plan you choose and how it sets up its network. Medicare drug plans can have preferred network pharmacies, where you pay less than at and nonpreferred network pharmacies. Also, you may pay less if you use a mail-order pharmacy through your plan than if you get your drugs from a retail pharmacy.
What is my Medicare drug plan required to tell me?
Drug plans are required to provide information to their enrollees about their service areas, benefits offered, cost-sharing amounts, formularies, pharmacy network, and any other aspect of coverage. This information must be provided in writing at the time of enrollment and annually after that. It must also be available on request and on the plan's Web site. The plan must also operate a toll-free number during business hours that can give you this information. In addition, plans and pharmacists must tell you if you could save money by using a generic drug.
Can private health or drug plans make unsolicited calls to me about their products (telemarket)?
Yes. In addition to marketing their Medicare drug plans, insurance companies can market additional products and services to you by phone. However, plans cannot use information that they have obtained from you (such as your name and address) to market nonhealth-related products and services without your written consent. There are some restrictions: Telemarketers cannot enroll you in their plan.
Plans must abide by the "Do Not Call" list and "Do Not Call Again" requests. They must also comply with federal and state consumer protection laws for telemarketing. The toll free number for the National Do Not Call Registry is 1-888-382-1222 or visit www.donotcall.gov
If my health condition significantly changes and my plan does not cover the drugs I need, can I switch plans?
Generally no. You can change drug plans until May 15. After that, you can't, even if your health changes. But you can request an exception to the plan's formulary and if you have Medicaid, you can switch plans at any time. Also, if you enter or leave a long-term care facility, you will probably have the chance to change plans.
-- Sources: Times files and Medicare Rights Center www.medicarerights.org/Index.html
[Last modified October 29, 2005, 08:19:45]
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