Medicare Prescription Drug Coverage
Screening for Medicare Beneficiaries
Pre Insurance Questions
1. Do you currently have prescription drug
coverage?
If YES, skip to Question #3, If NO: You need to join
a Medicare prescription drug plan when first eligible
because Medicare prescription drug coverage will pay,
on average, about 50% of yearly drug costs. Most people
with Medicare need or will come to need prescription
drugs to stay healthy. Medical practice has come to
rely more on new therapies to treat chronic conditions.
Medicare prescription drug coverage will protect you
from high out of pocket costs. If you don’t join
when first eligible, you will pay a higher premium if
you wait to join until later.
You must sign up by May 15, 2006 to avoid paying a
higher premium if you enroll later.
You should contact one or more of the following resources
to help evaluate which plan to select: SHI/HICAP, 1-800-MEDICARE,
www.medicare.gov.
2. Are you single, with resources below $11,500
and an annual income below $14,355 OR Are you married,
with resources below $23,000 and annual income below
$19,245? (Note: these are 2005 figures which will increase
in 2006)
If YES: You should apply for “extra help”
through SSA, (800) 772-1213 or www.socialsecurity.gov,
unless you have already received a letter of automatic
enrollment. If eligible for extra help, you should still
choose and join a Medicare drug plan before May 15,
2006. “Extra help” means that the government
will cover more of the costs of the plan, perhaps even
all of the costs.
3. Do you have Veterans Administration (VA),
TRICARE for Life, or Federal Employees Health Benefits
(FEHB)
If YES: You do not need to enroll in a Medicare drug
plan and you will not be penalized if you join a drug
plan after May 15, 2006, as long as you join within
63 days of losing TRICARE, VA or FEHB coverage. (If
you have VA coverage and pick up drugs at a private
store (not at the VA facility) you should consider enrolling.)
4. Do you have prescription drug coverage through a
former employer or union?
If YES: You should have received information from your
employer or union by November 14, 2005 stating whether
your coverage is “creditable”. Creditable
coverage is coverage that is at least as good as the
standard Medicare prescription drug coverage. If the
letter says that your coverage is “creditable,”
then you do not need to join a Medicare drug plan and
will not be penalized if you join a drug plan after
May 15, 2006, as long as you join within 63 days of
losing your employer or union coverage. If your existing
drug coverage is terminated or you are notified that
it is not “creditable”, you should consider
joining a Medicare drug plan and may want to do more
research to compare your current plan with this Medicare
D plan.
5. Do you have Medicaid?
If YES: Beginning January 1, 2006, you will receive
drug coverage through Medicare instead of Medicaid.
You should choose and join a drug plan. If you don’t,
Medicare will automatically enroll you in a drug plan.
You will get a yellow letter from Medicare telling you
the plan in which you will automatically be enrolled.
You do not choose the plan. You can change plans at
any time, and the change will be effective on the first
day or the month after you make the change.
6. Are you a member of a Medicare Advantage Plan (like
a Medicare HMO)?
If YES: Your plan will let you know about the prescription
drug options they will offer. If you choose to remain
in your Medicare Advantage health plan, you must receive
your drug coverage through that plan, if it is offered.
Do not sign up for a Medicare D plan with a different
entity or you can lose your primary Medical insurance
coverage.
7. Do you have a Medigap (Medicare Supplement) policy
with prescription drug coverage (plans H, I or J)?
If YES: If your Medigap policy currently covers prescriptions,
the insurer should have sent you a letter by November
14, 2005 telling you what your options are. In most
cases, Medigap drug coverage is not considered “creditable”
(as good as) Medicare’s coverage, so you may want
to join a Medicare drug plan; you will be penalized
if you do not join by May 15, 2006. You may want to
do more research before deciding to cancel your Medigap
drug coverage since you will not have the option to
to restore drug coverage under a Medigap policy again.
If you are happy with your current plan and elect Medicare
D drug coverage, your Medigap insurer should modify
your policy to exclude drug coverage and/or tell you
what other Medigap plans are available to you.
8. When are you able to enroll if you are happy with
your current plan?
The initial enrollment period is November 15, 2005 to
May 15, 2006. The program began January 1, 2006.
Post Enrollment Questions
1. How do I switch plans?
If you are in a Prescription Drug Plan (PDP),
you can switch plans once between January 1 and May
15, 2006.
If you qualify for Medicare and Medicaid you can switch
at any time
You will be able to switch plans if you move out of
the plan’s service area or move in to or out of
a nursing home.
Unless you qualify under an exception, you must wait
until the next annual enrollment period, which will
be November 15 - December 31, 2006.
You can switch plans by enrolling in a new plan or
by calling 1-800-Medicare.
2. How do I question a plan’s decision?
If you disagree with a plan’s decision
you should contact the plan and ask them to issue a
“coverage determination” that explains the
plan’s reasons and how to appeal. If you think
the plan should pay for a drug that is not on the formulary,
or you think you should pay a lower co-payment for a
drug you will need to ask the plan for a special type
of coverage determination called an “exception.”
You will need to include a statement from your doctor
explaining why you cannot take a similar drug to your
drug that is on the formulary or why you cannot take
a less expensive drug.
By Judith Lee Sterling
|
