MEDICARE PART D IN NEW YORK STATE
by Edith Prentiss
MEDICARE PART D
Check with your pharmacy to see if they participate in the plans you're interested in. (Or ask which plans they are participating in.)
Part D begins on January 1, 2006; enrollment period (November 15, 2005 - May 15, 2006).
There will be a monthly premium (approx $32 in NYS), a $250 deductible, and 25% co-payment until you reach $2,250 in co-payments. From $2,251 to $5,100 (
"donut hole") there is no coverage. Over $5,100 the cost reduces to 5% per prescription. The Medicare Rights Center estimates the annual out of pocket will be $3,600 for those whose prescriptions exceed $5,100.
Low-income beneficiaries are eligible for assistance through the
"Extra Help" program (Low Income Subsidy). (See Below)
You are not mandated to enroll but the penalty for late enrollment is quite high (1% per month).
Part D is not offered by Medicare but by companies approved by Medicare. It is available to all beneficiaries with Medicare Parts A and B.
You can only switch plans (Medigap, MHO/PPO and Part D) during the Annual Coordinated Election Period (November 15 to December 31) or if you qualify for a Special Enrollment Period. (except Dual Eligibles – See Below)
Beginning in 2006, beneficiaries can only switch plans during the Annual Coordinated Election Period (November 15 to December 31) or if there is a Special Enrollment Period caused by particular circumstances.
Each plan will have its own formulary (list of medications) but they are required to carry drugs in all categories. Since they will be allowed to change their formulary, finding one with all of your medications may not be worth the time.
There is a process for a health care provider to request your plan cover a particular medication not on its formulary.
You cannot buy insurance to pay the deductible, co-payments or the
"donut hole" of Part D plans.
Medigap plans H, I and J can no longer be purchased, but if you have one you can keep it. There will be 2 new high deductible Medigap plans (K and L).
DO YOU HAVE MEDICARE & NO DRUG COVERAGE?
EPIC: Are you eligible? You must be 65+; with an annual income less than $35,000.00 (one person); $50,000.00 (couple) 1-800-332-3742. Both EPIC plans have been deemed
"credible" (equal or better than Part D); therefore members do not have to enroll in a Part D and can simply remain in EPIC. If you are only eligible for the deductible plan ($20,001 - $35,000 for 1 / $26,001 - $50,000 couple), you may pay less in a Part D or Part D and EPIC. EPIC members with high drug expenses, who are eligible for the Low Income Program – Extra Help (See Below) partial subsidy may pay less in a Part D. These cases need to be carefully assessed. http://www.wnylc.net/pb/docs/SEPT_05%20LSJ_MEDICARE_PART_D.pdf
Are you considering a Medicare HMO?: Information and comparative information is available in the Medicare & You 2006 handbook or at www.medicarerights.org.
Beginning in 2006, you can only switch plans during the Annual Coordinated Election Period (November 15 to December 31)
DO YOU HAVE MEDICARE & NO DRUG COVERAGE? (includes EPIC)
Is your present coverage equal or better than Part D? Have you received a letter to that effect from the company or plan? If not, call your insurance company or union/retiree plan for information. If it has been certified as
"credible," it is equal or better, and you do not need to purchase a Part D plan and will not be penalized if you lose that coverage through no fault of your own.
If you are in a Medicare HMO, without better options, you may as well keep it. If your HMO is offering a stand alone plan, that any beneficiary can purchase, you can enroll in either their Part D or a
"stand alone" plan. If your HMO does not offer a
"stand alone" plan and you enroll in one, you will lose your HMO coverage.
Part D coverage will coordinate with your present coverage, paying after other coverage.
EPIC: both plans have been deemed
"credible"; therefore members do not have to enroll in a Part D and can simply remain in EPIC. See EPIC (above). http://www.wnylc.net/pb/docs/SEPT_05%20LSJ_MEDICARE_PART_D.pdf
If you have a Medigap plan H, I or J, you cannot purchase a Part D plan unless you drop the Medigap plan.
MEDICARE DUAL ELIGIBLES (MEDICARE & MEDICAID)
As of January 1, 2006, you must use your Part D card at the pharmacy. The enrollment period begins on November 15, 2005 and if you have not enrolled by December 31, 2005, you will be randomly assigned to a Part D plan.
You can switch plans every month, effective the first of the following month. But this will cause problems as you wait for a new card.
Questions remain as to how items and products covered by Medicaid but not by the plans will be covered.
You automatically qualify for the
"Low Income Subsidy" program, and you do not need to apply for it.
DO YOU NEED ASSISTANCE?
Many politicians' offices and community agencies offer assistance.
NYS's SHIP (State Health Insurance Assistance Program): Medicare Rights Center (MRC) Consumer Assistance Hotline (800-333-4114).
NYC's HIICAP (Health Insurance Information Counseling Assistance Program): NYC Department for the Aging (DFTA) HIICAP Hotline (212 333-5511) Monday - Friday, 9 AM – 3:30 PM. HIICAP volunteers are based though out the five boroughs. HIICAP workers will also be deployed in additional locations. Call 311 for information.
MRC and HIICAP can help regardless of your age! You cannot be refused.
WHAT TO DO IF A DUAL ELIGIBLE IS AUTO ASSIGNED
Try to enroll all Dual eligibles as early as possible!
Go to http://www.cms.hhs.gov/medicarereform/enrollmentqa9-08-05withcoversheet.pdf to see a sample of the letter that will be sent to clients who are auto enrolled.
Warn clients, families, staff, etc. that you must see it (keep a copy in your file) and any other letter (CMS, SSA or plans) received about drug plans.
This other than the card will probably be the only communication with information about the plan and the contact information.
Contact the plan to help client assess if the plan is good for them. Remember Dual Eligibles can switch plans monthly effective the first of the next month but there will be a time lag getting a new card although there is still confusion as to the process of obtaining medications before receiving a card.
EXTRA HELP / LOW INCOME SUBSIDY (LIS)
Those who receive SSI, or who are a dual eligible or in a Medicare Savings Program are automatically eligible for the full subsidy and should not apply. They should have received a letter from CMS (
"Important Information from Medicare about Paying for Prescription Drugs"). If they did not receive this letter, call SSA at 1-800-772-1213 to request a duplicate. Save it in your files.
There are 2 categories in the LIS program, full and partial subsidy depending upon income/assets. Those only eligible for partial subsidies will need more assistance in assessing their options.
General Eligibility: With a monthly income less than $1,197 for a single person ($14,355 annual income) or less than $1,604 for a married couple living together ($19,245 annual income), the full covers about 85-100% of costs, saving about $2,100 per person.
In NYS, Medicare Savings Plans (MSP) do not have an asset limit for those with higher incomes / assets than the limits set in the SSA application process. Apply for MSP at your local Medicaid office. http://www.cms.hhs.gov/medicaid/allStateContacts.asp.
A Low Income Subsidy (LIS) application does not enroll the client in Part D. They must enroll in a Part D plan. Applicants approved for Low Income Subsidy but who have not enrolled by May 15, 2006, will automatically be enrolled in a plan effective June 1, 2006. It is to their advantage to enroll earlier.
If an applicant, who applied directly to SSA is rejected, there is an appeal process; the applicant can request a case review. Appeals must be requested within 60 days (at a SSA office in person, by mail, by fax, or call 1-800-772-1213). Determinations will be reviewed on a telephone hearing and the applicant will receive a written decision. SSA's appeal decision is binding, unless an appeal is made in Federal district court within 60 days. Those applications submitted to Medicaid would go to a Medicaid Fair Hearing.
Applying directly through SSA will be faster than applying through Medicaid. Therefore, if an applicant meets SSA's eligibility, you should apply directly.
A question by question application guide is at www.accesstobenefits.org.
Application submitted must be on an original scannable SSA, either the form the beneficiary received in the mail or a replacement available from your local SSA office.
General Instructions for Completing The SSA Application (SSA 1020 form):
Paper forms will be scanned by SSA so you must use an original form. Determinations of eligibility of applications on any photocopied forms (or downloaded and printed) will be delayed as SSA has to key them into their computer. To obtain scannable forms contact your local SSA (1-800-772-1213) office. Although instruction sheets are available in multiple languages (www.ssa.gov/organizations/medicareoutreach2/), applications must be in English.
Write or mark only in the boxes with black ink or #2 pencils.
Make CAPITAL Xs, no checks or dashes, or write in CAPITAL LETTERS only in boxes.
Since the $ is printed on the form write amounts rounded to nearest dollar.
Refold form as originally folded.
Use preaddressed envelopes or mail to: SSA -Wilkes Barre Data Operations Center, P.O. Box 1020, Wilkes Barre, PA 18767-9910.
Apply online: www.ssa.gov or www.socialsecurity.gov
If information is not complete, the program will not accept the application. An application is complete when the
"click and sign" electronic application is selected.
Do not use your web browser's BACK button or ENTER button.
Do not use the Enter key to move between questions or use dropdown lists.
Each page has a time limit, and you will be warned if you are going too slow.
You can stop and save an application if you need more information or more time.
More Information on Part D:
www.medicareadvovacy.org Center for Medicare Advocacy
www.medicarerights.org Medicare Rights Center
www.wnylc.net Western New York Law Center
www.familiesusa.org Families USA
www.accesstobenefits.org Access to Benefits Coalition
www.cms.hhs.gov Centers for Medicaid and Medicare Services
www.ssa.gov Social Security Administration
Information and Action for People With Disabilities:
A great deal of Medicare Part D information is written as if all beneficiaries are seniors. Medicare Part D is the same regardless of the beneficiary's age.
Our problem is that New York State's EPIC does not include us unlike all other State Pharmaceutical Assistance Programs (SPAP) in the Northeast.
Be sure you contact your state legislators to complain that we are still not eligible for EPIC and how you will be adversely affected. Many people do not understand we're not eligible for EPIC! Let them know the facts!