Medicare Part D Unraveled: What Do You Need to Know
by
Lolly Lijewski
Many people with disabilities will be eligible for a new prescription
drug benefit beginning January 1, 2006. This benefit is called The
Medicare Prescription Drug Program, or Medicare Part D.
The first and most important thing to know is that Medical Assistance
(MA) beneficiaries currently receiving prescription drug coverage
through Medicaid will have their coverage discontinued as of December
31, 2005. If an MA beneficiary wishes to receive prescription drug
coverage from then on, it will come through Medicare Part D. (People
who are on MA and who are not receiving Medicare will continue to
get their medications through MA.)
The Social Security Administration
(SSA) and The Centers For Medicare and Medicaid Services (CMS) will
be partnering to bring this new program to people with disabilities.
There are two steps to complete in order to receive this new benefit:
• Apply for what is called “Extra Help” (EH)
from SSA.
• Select and enroll in a prescription drug plan through CMS.
Between May and the
end of August 2005, SSA will be sending out letters to beneficiaries
explaining what Medicare Part D is, who’s
eligible for the “Extra Help,” and how to apply. It is
imperative that people with disabilities read through this information
to be informed of their rights and responsibilities in the application
process for this new benefit. If a beneficiary isn’t sure about
whether he/she qualifies for the “Extra Help,” it’s
best to fill out an application and send it to SSA for determination.
Applying for Extra Help (EH)
Who Is Eligible?
SSA will facilitate
the application process for the “Extra
Help.” EH is available for individuals who wish to receive
prescription drug coverage but are unable to pay for the monthly
premiums, deductibles, and co-pays. There are some people who will
automatically be deemed eligible for the “Extra Help”:
• Individuals who receive both Medicare and MA;
• Individuals who are enrolled in Medicare Savings Programs such
as Qualified Medicare Beneficiaries (QMBI), Specified Low-Income
Medicare Beneficiaries (SLMB), and Qualified Individuals (QI), and Individuals
who receive SSI and Medicare.
These people automatically
qualify for assistance with the costs of the Medicare Prescription
Drug coverage. They do not need to fill out an application for EH
with the costs, but they will need to choose a prescription drug
plan in the fall. Under all of these programs, MA helps pay the costs
for Medicare Parts A and B.
Who Is Not Automatically
Eligible?
The following are not automatically eligible:
• Medicare beneficiaries who have limited resources and low income;
• Individuals who do not have Medicaid, or SSI, or who are not
enrolled in a Medicare Savings Program.
These individuals may still
be eligible and are encouraged to apply.
Individuals with an
income of $14,355 or less, OR a married couple living together
with a joint income of $19,245 or less annually, may qualify for
the “Extra Help.” Another way to calculate
eligibility is to determine whether individuals are at 150 percent
of the federal poverty guideline with limited income and resources.
These people will be eligible for the “Extra Help.” This
figure may change annually. Individuals with an income higher than
150 percent of the poverty guideline may still qualify for some “Extra
Help.”
What Gets Counted as a Resource?
Individuals with assets
or resources up to $10,000 and married couples with resources up
to $20,000 may qualify for the EH. Resources are things like bank
accounts, stocks and bonds, and even money allocated for burial
plots up to $1,500. Vehicles and an individual’s
home are not counted as resources.
How To Apply
In the packet
of information sent out by SSA between May 27 and August 31, 2005,
MA beneficiaries will receive an application. Follow the directions
carefully, fill it out and return it as soon as possible. If a beneficiary
doesn’t receive an application, or doesn’t
want to wait for the packet to arrive in the mail, they can call
SSA at 1-800-772-1213 or (TTY 1-800-325-0778) to request an application.
Beneficiaries may call the
toll free number for SSA to ask for help in filling out the application.
Beginning July 1, 2005, MA beneficiaries may apply on-line at www.socialsecurity.gov.
After a beneficiary
submits their application for the “Extra
Help,” SSA will send them a letter indicating whether they
qualify.
Enrolling in a Prescription
Drug Plan
How to Enroll
After sending in an application, the next step is to enroll in a
prescription drug plan. CMS will notify beneficiaries of how to proceed
when information becomes available on the various prescription drug
plans beginning in October 2005. Enrollment in the program runs from
November 15 through December 31, 2005. Coverage begins January 1,
2006.
Can You Still Apply After
the Initial
Enrollment Period?
Yes, if a beneficiary
does not sign up in the initial enrollment period, he/she may still
apply and qualify for the program. For example, if an individual
hasn’t made up their mind, they can still
apply in January 2006 and coverage will begin in February 2006. Individuals
may still apply between January 1 and May 15, 2006. In order to avoid
a gap in coverage, it is highly recommended that interested beneficiaries
apply during the initial enrollment period of November 15 to December
31, 2005. Enrolling early also means beneficiaries will pay a lower
premium.
If a dually eligible
beneficiary doesn’t apply during the
enrollment period from November 15 to December 31, 2005, they will
automatically be enrolled in a plan with a premium covered by the
low-income premium assistance. Coverage will begin January 1, 2006.
They can change plans at any time.
What’s Covered?
Formulary requirements will be posted on the CMS web site, www.cms.hhs.gov.
Two drugs in each category must be covered with the exception of
drugs for anorexia, weight gain, non-prescription drugs, and prescription
vitamins. Six classes of drugs must be covered in full including:
anti-depressants, anti-convulsants, anti-psychotics, drugs for HIV/AIDS,
anti-neoplastics, and immuno-suppressants.
What Does Typical Coverage
Look Like?
An average premium will
be $37.00 per month with a $250 deductible. Once the deductible
is met, Medicare will pay 75 percent of drug costs from $250 to
$2,250. The MA beneficiary’s responsibility
is 25 percent out-of-pocket. From $2,250 to $5,100 the MA beneficiary’s
responsibility for drug costs is 100 percent out-of-pocket. If an
individual is receiving “Extra Help,” this does not apply.
After $3,600 in out-of-pocket costs (or $5,100), Medicare pays approximately
95 percent of the individual’s drug costs.
What If I Live In a Nursing
Home?
Beneficiaries will receive their prescription drugs from a pharmacy
selected by the facility in which they reside. Access for these qualified
beneficiaries must be convenient.
An excellent local resource
for questions on this new benefit is the Senior Linkage Line at 1-800-333-2433.
Watch Access Press for further information on this new Medicare
Prescription Drug Program in the coming months.
