Important
News for Seniors About the New Drug Plans
Read
all mail carefully during the Fall !
The
federal government has created a new program that will change the
way you and your loved ones obtain and pay for prescription medications.
The new law, the Medicare Modernization Act of 2003, added a 'Part
D' to the Medicare benefit program to cover prescription medicines
for those eligible, effective January 1, 2006.
The
most important change made by the law is that Medicaid payment for
prescription drugs will no longer be available if you are also eligible
for Medicare benefits. In order to qualify for drug coverage under
the new law, you or your loved ones will be required to sign up
with a private insurance plan in a timely manner whether or not
they are currently obtaining assistance today from Medicaid, Medicare
or a private plan. Thus, millions of individuals will be forced
to change the way they obtain medication payment coverage under
this new 'Part D' program.
IMPORTANT
MILESTONES
Those
enrolled in Medicare should begin to receive details about the new
Part D drug program in
October,
2005. Materials to look for in your mail include:
•
A new 'Medicare and You' booklet published by the federal government's
Center
for
Medicare Services ( CMS)
•
Information about the various private drug insurance plans that
will be
available for your
enrollment within your home geographic region
•
Information from the provider of any insurance policy you currently
have
(former or current employer, union, private pay insurance policy,
etc.)
that explains how
your particular policy will be impacted by the new law.
FRIA
will be opening its Helpline an extra day, Tuesday-Friday, 10am-5pm,
starting October 1, 2005, to accommodate your questions. Or you
can contact the Medicare Rights Center at
1-800-333-4114
or the federal CMS line at 1 800 MEDICARE. We would appreciate learning
of any problems or questions you have so that we can best address
problems in the program call, email at fria@fria.org or write to
us!
PRESCRIPTION
DRUG PART D GENERAL PRINCIPLES
Generally,
people will be required to select a private Part D insurance drug
plan, enroll in the plan and pay a premium, deductible and copays
for the drug coverage. The program payment requirements are based
on (household) income and asset level. Those who are eligible for
both Medicaid and Medicare, also called 'dual eligibles, have different
payment requirements than those who are not. Also, those institutionalized
( i.e., nursing home residents) are subject to different criteria
than those in the community. However, there are several principles
that apply to everyone, regardless of income or institutionalization:
•
In order to obtain ANY financial assistance from the federal government
for medications, the medicare beneficiaries must
enroll in a private drug plan
approved by
the
government.
•
Enrollment is permitted only during specified times during the
year (unless
institutionalized).
•
If a medication is needed but not covered by the drug insurance
plan, an
appeal or exception can be filed by the senior with
the
insurance company to
request coverage.
•
For New Yorkers, the EPIC Prescription Drug plan will continue.
(As of this
writing, EPIC promises to be available to fill gaps
that may exist in
coverage through other plans).
•
As with all important materials, mail related to drug insurance
plans should be
read carefully and kept for documentation and ready
reference.
•
Currently, it is clear that anyone can apply for financial 'extra
help' on
behalf of a senior. It is also clear that a health
care proxy, power of
attorney or guardian can enroll a senior in a plan.
It is not clear at this
time who, if anyone, can enroll a senior other than
those named above
in New York State. NYS does not recognize 'designated
representatives'
for this purpose; nor does the state recognize spousal,
sibling, child or
other relative or caregiver authority to make decisions
on behalf of
another individual. This issue again
demonstrates how important it
is that everyone in New York State complete
a Health Care Proxy
form!
FOR
DUAL ELIGIBLE NURSING HOME RESIDENTS
- Those
covered by Medicaid will still be required to select a Part D
approved Drug Prescription Plan and enroll in the plan.
- Plan
enrollments for dual eligible individuals MUST
be received by December 31, 2005 or the you will be automatically
enrolled in a plan by the federal government, effective January
1. The plan will be selected randomly
and will not be matched to the person's needs. At this time, the
Part D plans have not been made public so it is hard to tell whether
plans will vary significantly and what the breadth of coverage
will be. Beneficiaries should receive information from the government
in November as to which is the specific plan they will be enrolled
automatically.
- No
premium payment will be required nor will there be a deductible
amount or co-pay assessed for medications that are covered by
the plan while residing in the nursing home.
- We
are advised that as long as the senior is living in the nursing
home the home will be held responsible for providing medications
that are prescribed by their physician even if the drug
is not covered by the plan. It remains to be seen if nursing homes
in fact provide medications for which they are not receiving reimbursement
from the insurer.
FOR
SENIORS WHO ARE NOT DUAL ELIGIBLE
- The
monthly premium for Part D insurance coverage is currently expected
to run around $29 per month in New York State.
- Beneficiaries
will also pay the first $250 of all covered drug expenses (the
deductible) in each calendar year.
- For
each drug, the senior will pay $2 for covered generic drugs and
$5 for covered brand name drugs.
- After
satisfying the deductible, the beneficiary will pay 25% of drug
costs incurred between $251-2250.
- The
beneficiary will pay 100% of all drug costs above $2250 until
costs reach $5100.
-
95%
of all drug costs incurred above $5100 will be paid by Medicare
and the senior will pay the remaining 5%.
EXTRA
HELP BENEFITS
Some
individuals may be eligible for 'extra help' in paying for
the Part D insurance plan. If the senior qualifies for Medicaid
then he or she is automatically qualified for the extra help. If
the senior does not qualify but his or her 2005 income is less than
$14,356 ($19,245 couples) and assets are less than $11,500 ($23,000
couples) extra financial help may be possible.
Individuals
will need to apply for the extra help to the government and then
separately apply to their selected Part D plan to obtain the insurance
coverage- it is a two step process. (PLEASE NOTE these income figures
will change as they are pegged to the federal poverty level calculated
by the federal government). Extra help will come in the form of
premium and co-pay amount reductions.
If
you have any question about your eligibility for the extra help-
APPLY ANYWAY- there is nothing to lose. We suggest that you apply
through the local Social Security Administration office because
we have been told it may be easier and require less documentation
up front than the local Medicaid offices.
Medicare
beneficiaries must enroll in an approved Part D Drug plan by May
15, 2006 or a financial penalty will be assessed
in the amount of 1% of the monthly premium for every month after
May 15,2006 that the senior was not covered by an insurance drug
plan at least as good as what Part D plans provide ( also called,
'creditable coverage).
Comparisons
between drug insurance plans can be obtained by going to the internet
site of the Center for Medicare Services, www.cms.gov
. Or call them at 1-800-633-4227. There may also be other internet
sites or telephone assistance lines that offer to provide comparison
data on the insurance plans of choice for consumers.
At
this time, we cannot say whether those sites will be accurate or
consumer friendly. We believe that the site personnel will try to
sign people up to prescription drug plans when they access the site
or telephone line. We would caution consumers to not sign up for
drug coverage through those sites unless and until they have assured
themselves that they have obtained all the information they need
to make an informed decision. For example, given that there may
be confusion and misinformation at the roll out of this program,
a consumer may want to talk to several sites or help lines to verify
information before enrolling in any particular plan.
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