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Medicare Part
D Prescription Drug
Info Alerts
Bulletin Board
Info Alerts
Re: Application to Social Security Administration for
Help With
Prescription Drug Plan Costs
Info Alert
1) You and
your spouse have not filed the SSA application because you know that
your combined Social Security and pension income is more than the
published maximum income eligibility amount. However, you failed to account for
the fact that you and your spouse are supporting (at least 50%) two
grandchildren, which allows you to do the following: multiply $3600
(effective 2008) for each additional dependent family member by
applicable percentage of poverty (135% or 150%), and add the amount to the
published income eligible amount, making both Medicare beneficiaries
eligible for help with prescription costs.
Info Alert
2) The SSA
application, in the main, except for a small group of applicants, will
give to most (successful) low-income subsidy applicants (LISA) the same
low purchase prices for prescription drugs as given to eligible persons
in the state-administered Medicare Savings Program (MSP). And the point of this message for
applicants is, not withstanding that fact, check to see whether they
qualify for MSP in their respective states. The reason is that they will be
eligible for the following additional important benefit: MSP pays for
the Medicare Part B monthly premium (96.40 in 2008). So LISA applicants
should do both -- go through with their SSA application, and file for
MSP if they believe they qualify.
Info Alert
Re: Enrollment for Medicare Part D and Switching Plans
Info Alert
3) Beneficiaries,
with certain exceptions, cannot be enrolled in an MA plan and a
PDP. Therefore, individuals
enrolled in an MA plan with prescription drug coverage who then enroll
in a PDP – in error or in the belief it is a better plan – will
be automatically disenrolled from their MA plan This fact is
insufficiently emphasized in PDP enrollment forms. Therefore, I felt there was a need
for this alert.
Info Alert
4) If you
currently have Medicare or will be eligible for Medicare in January
2008, you will be limited to switching plans mainly in the Annual
Coordinated Election Period – between November 15, 2007 and
December 31, 2007, and Open Enrollment Period between January 1 and
March 31, 2008. This Alert 4
advises that you have still another opportunity to switch plans –
a Special Enrollment Period (SEP) to become a member of an MA-PD for
the first time for a trial period of 12 months – knowing that you
can disenroll at any time during those 12 months to go back to Original
Medicare and Medigap, and enroll in a stand-alone drug plan (PDP). The qualifications for this SEP is
your being a first time member of an MA-PD and the entry points of
enrollment into the MA-PD are as follows: you selected an MA-PD during
the initial coverage election period surrounding your 65th
birthday (at which time you enrolled in Medicare) or you transferred
from Original Medicare (and dropped your Medigap policy and PDP) to
enroll in the MA-PD for the first time.
Info Alert
Re: The State Pharmaceutical Assistance Program (SPAP) – how does
it coordinate with Medicare Part D?
Info Alert
5) A SPAP
goes by different names. In New
York State it is Elderly Pharmaceutical Insurance Coverage -- more
commonly known as EPIC. It is
incumbent on every Medicare beneficiary residing in a state where there
is a SPAP to check it out.
I
will try to answer the question: How does EPIC coordinate with Medicare
Part D in supplementing the beneficiary’s Medicare Part D plan
coverage? The mechanics of
coordinating your Medicare Part D drug plan and Epic are really simple. Show both cards, advising the
pharmacist that your Medicare Part D drug plan is your primary
prescription coverage and the charge for payment must be submitted to
them first. The balance due will
be charged to Epic. If the Part
D co-payment due is $25, you will have to pay (the Epic co-payment of)
$7 and Epic will pay $18, but the entire $25 will be included in your
TrOOP out-of-pocket costs for covered drugs. In 2008, the entry point for
“bargain” not to exceed 5% pricing for future purchases of
prescription drugs will be TrOOp costs of $4050.
Most
members have been notified that as of July 1, 2007 they will have to
enroll in a Medicare Part D plan.
With some exceptions the Epic member will no longer have the
option of using Epic as primary drug coverage -- it will solely be
supplemental insurance covering Medicare Part D plan’s
deductible, co-payments, gaps in coverage and non-covered drugs. With the recent change noted in Item
2 below, Epic members will save even more by Epic’s covering the
cost of their Part D premium.
Therefore,
at this time, it is particularly important to refer to new revised Epic
eligibility and benefit details in Medigap segment 03 regarding the following:
1) Three groups of Epic members
do not have to take Part D. They
will continue to use Epic as their primary prescription drug coverage.
2) Epic will pay the Part D
plan premium (up to $24.45 in 2007) for the fee plan member who must
enroll in a Medicare Part D Plan.
3) The Epic deductible plan
member who takes Part D will have a reduced deductible, but they must
pay the Part D premium.
Info Alert
6) New York
State’s Epic does even more than supplement the
beneficiary’s Medicare Part D Plan coverage (described in above
Info Alert 5 – it will cover a drug for which the plan requires
prior authorization or an exception.
Epic’s coverage will give you the time to get the prior
authorization or use the Exceptions process to persuade the plan to
cover a particular non-formulary drug.
You will not have to depend on the plan’s transition
process in place for temporarily providing drugs that are not covered
by the plan. Aside from the
temporary nature of this benefit (usually 30 days), it has other
restrictions that may affect the individual. Epic membership will give you better
coverage for providing drugs that are not covered by the plan. But remember to bring two cards to
the pharmacy – Part D Prescription Drug Plan and Epic.
Keep an eye
on the bulletin board for updated postings about
Medicare
Part D.
The Mail Box
Read your
mail carefully. Keep it –
even if you have never heard of the particular prescription drug
plan. You may have never heard
of the plan, but if you have Full Medicaid, SSI or Medicare Savings
Program (state pays your Medicare Part B premium), you may have been
assigned to the plan. If you
have difficulty understanding the letter, look for a telephone
information number, ask the social worker at your senior center, or
call 1-800-Medicae (633-4227).
The mail
could be source material for a reference file. This file should include folders of
(possible) correspondence between you and the Centers for Medicare and
Medicaid, Social Security Administration, local Medicaid agency, EPIC
(or the Pharmaceutical Assistance Program in your state), Health
Insurance Retirement Plan, Current Employer, Supplemental (Medigap)
Insurance Prescription Drug Coverage, (stand alone) Medicare
Prescription Drug Plan (PDP) and (MA-PD) Medicare Advantage (PPOs and
HMOs) Plans with prescription drugs.
And the reference file should supply a paper trail to all the
events and changes happening to you under Part D. The paper trail will be particularly
important to low income persons eligible for extra help for
prescription drugs. They have
had the right to change plans every month so some may already be
involved in an Enrollment Reconciliation Process (April/May 2006)
–to ensure that people are
enrolled properly and there is complete and up-to-date billing
information available at the pharmacy.
You will then need the reference file (paper trail) to help if,
for example, you are involved in a duplicate enrollment, or you have
received prescription drug benefits from one plan, but you are enrolled
in another.
The following outline of dates
provides guidance as to when you could expect to receive mail depending
on your status.
July 2007
Each state will send to CMS in July
2007 a file of persons who have retained their eligibility in the
Medicare Savings Program (MSP) or Medicare/Full Medicaid. Therefore,
they will be redeemed eligible for prescription drug assistance, which
will be extended through December 2008.
Additionally, the above group also includes those who receive
SSI, but are not eligible for Medicaid, and CMS will rely on SSA files
for those individuals.
August to December 2007
CMS will review submitted state files
from August to December for above
individuals. Persons who
appear eligible for the first time will be deemed eligible for
prescription drug help from the earliest month of deemed eligibility
through December 2008. CMS will
send (Purple Letter) notices on a monthly basis to those beneficiaries,
to let them know they will get extra help without needing to apply for
it.
August 2007
Other low-income beneficiaries
received their eligibility through the Social Security Administration
(SSA). SSA conducted in August
2007 a new cyclical redeeming of a portion of the beneficiaries, who
became eligible for extra help from May 2006 to April 2007. The sample of people received a form
(SSA 1026), based on standards used for examining new applicants. The completed Income and Resources
Summary must be returned in 30 days, but beneficiaries may call SSA for
an extension. Beneficiaries who
received and did not respond to the letter will lose Extra Help in
2008.
August 2007
Also, in August SSA selected from the
above 5/06-4/07 group select cases where there are signs of a
disqualification. They received
the form “Social Security Administration Review of Your
Eligibility for Extra Help” which had to be completed and
returned within 30 days.
September 2007
CMS/SSA sent a joint (Gray) letter to
beneficiaries who no longer qualify for extra help as of January 1,
2008. The mailing includes an
application for extra help with a postage paid envelope to return to
SSA.
October 2007
CMS will send separate letters if the
person’s plan either leaves the Medicare program (Blue Letter),
no longer is at or below the low-income regional benchmark (Blue
Letter) or income has changed, affecting co-payments (Orange
Letter). Medicare will also
advise recipients of the Blue Letters (their plans leaving Medicare)
that Medicare will reassign the individual to a new plan effective January
1, 2008, unless they join a new plan on their own by December 31,
2007. Medicare will do the same
reassignment for holders of plans that are no longer at or below the
low-income regional benchmark, but only if Medicare enrolled them into
the plan in 2007.
October 2007
Beneficiaries whose prescription drug
plan or Medicare Advantage plan will be terminating with Medicare for
2008 should have received a notice from the plan.
In Addition To Epic (NY), The Following Prescription Drug
Programs Are Considered Creditable Coverage
At VA health care
facilities there are free outpatient pharmacy services for veterans with
compensable service-connected conditions. These services are available, as
well, for those whose income and net worth are below the established
dollar thresholds. Call
1-877-222-8386 for further information.
Tricare
Senior Pharmacy Program, a health care program of the
Department of Defense (DoD) is a prescription drug assistance program which started April 1, 2001 -- sixty-five and over
retirees from the uniformed services (including guardsmen and
reservists), their 65 and over family members and survivors, are
eligible to receive comprehensive prescription drug coverage. Call 1-877-363-6337 for additional
information and updates, which are posted on their web site, www.tricare.osd.mil.
Updated:
October 22, 2007
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