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By Anisa I. Nayeem, MD, MPH
Editor's Note: In the November/December 2006 issue of Renal Business Today, Dr. Nayeem discusses a practical approach to helping your patients understand the Medicare Part D drug program. Below is a handout that can help guide kidney disease patients in making the best decision about their prescription drug program.
Signing up for Medicare Prescription Drug Coverage--also called Medicare Part D--is a good option for a lot of people with kidney disease. OPEN ENROLLMENT IS FROM NOVEMBER 15 THROUGH DECEMBER 31, and that span is the only time you can join or change plans. There are many plans out there, and it will require some work on your part to find the right one, but don’t get discouraged. Read the information below and contact Medicare if you have any further questions.
Am I eligible for Medicare Prescription Drug Coverage?
If you have Medicare Part A (hospital insurance) and/or Medicare Part B (medical insurance), you qualify for Medicare Prescription Drug Coverage.
| Potentially Confusing Terms |
Medicare Part A (Hospitalization insurance): Covers inpatient care, skilled nursing facilities (not custodial or long-term care), hospice care and some home health care.
Medicare Part B (Medical insurance): Covers doctors’ services and outpatient care, and includes drugs given during hemodialysis and immunosuppressive medications for transplant patients.
Medicare Part C: Also called Medigap (see below).
Medicare Advantage: Medicare coverage that acts like an HMO or PPO, offering hospitalization and outpatient services. Some, but not all, offer prescription drug coverage.
Medigap: Health insurance sold by private insurance companies to fill the “gaps” in original Medicare coverage. Some, but not all, plans offer prescription drug coverage. No new Medigap policies with prescription drug coverage are being sold, so people who drop this coverage will not be allowed to rejoin.
Stand-alone prescription drug plans: These plans offer only prescription drug coverage through Medicare Part D and can be added to the original Medicare plans and some Medicare Advantage and Medigap plans that do not provide prescription drug coverage. |
Should I switch from my current prescription drug coverage?
If you currently have prescription drug coverage through Medigap or your (or spouse’s) employer or union, you should receive a letter from your prescription drug coverage provider by November 15 stating whether your current coverage is at least as good as Medicare Part D coverage. This is called “creditable coverage.” Keep in mind that your insurance company might have made changes since last year, so contact your insurance carrier if you have any questions.
If you have creditable coverage, you will not incur penalties if you join at least 63 days after your current coverage ends. Carefully consider whether switching is right for you. You may not be able to get your previous coverage back once you switch to a Medicare Prescription Drug Plan.
If you do not have creditable coverage, you will continue to incur penalties for every month that you wait to join. The penalties started after May 15, which means that MONTHLY PREMIUMS INCREASE AT LEAST 1 PERCENT FOR EVERY MONTH THAT YOU HAVE NOT PARTICIPATED.
One final word of caution: Always check with your insurance carrier to ensure that dropping your prescription drug coverage will not interrupt your health insurance. Some insurance plans with prescription drug coverage might not let you drop only the prescription drug coverage without also dropping your health insurance, and you may not be able to get the coverage back.
How do I choose a plan that is right for me?
There are three main areas to consider when choosing the best plan for you:
- Coverage--If a plan does not cover your drugs, it will not save you money. Each plan covers different drugs in each category and class (called its formulary), so it is important to find a plan that covers your medications. The Formulary Finder on the Medicare Web site can give you a list of all the plans in your state that cover the drugs you take.
- Cost--You will spend money in four different ways in a prescription drug plan. The first is the premium, which is the monthly charge for the prescription drug coverage. The average premium in 2006 was $25. The second is the deductible, which is the amount that you will pay before Medicare Part D starts paying. In 2006, the highest allowed deductible was $250. The third is the copayment or coinsurance. This is the amount that you will pay for each drug after you meet the deductible. For some plans, this is a flat rate (copayment) and for some it is a percentage of total drug cost (coinsurance). Some plans have different levels, or “tiers,” with different costs. For example, you might pay less for generic drugs (Tier 1) or less expensive drugs (Tier 2) than for expensive brand-name drugs (Tier 3). The fourth is the coverage gap--also known as the doughnut hole. In 2006, if total drug costs are between $2,250 and $5,100, you will have to pay this part of the bill out of pocket in most plans. Plans without a coverage gap have higher premiums. If your total drug costs exceed $5,100, however, Medicare will pay 95 percent of the cost of your drugs above this.
- Convenience--Each drug plan has its own network of preferred and non-preferred pharmacies that accept that plan. Using a preferred pharmacy will cost you less, so make sure there is one close to you. Some plans also offer prescriptions through the mail, which may save you even more.
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What is the low-income subsidy, and how do I know if I qualify?
Approximately 1 in 3 people with Medicare qualify for extra help. If you have a low income (about $14,700 for individual or $19,800 for married couples) and have limited resources (under $11,500 for an individual or $23,000 for a married couple, not counting your home or car) you will pay no premiums or deductibles and small or no copayments. Those with slightly higher incomes pay a little more. If you also have full Medicaid benefits, get help from Medicaid paying your Medicare premiums, or receive disability insurance benefits, you automatically qualify. This subsidy does require a separate application, so contact Social Security if you think you qualify and have not yet received an application.
So now that I have chosen a plan, how do I sign up?
You can sign up by calling the plan and asking them to send you an application or through the company’s Web site, or the Medicare Web site.
| Resources |
Medicare:
(800) MEDICARE (877-486-2048), www.medicare.gov
Social Security:
(800) 772-1213 (800-325-0778), www.socialsecurity.gov
State Health Insurance Assistance Program: See your copy of the “Medicare & You 2006” handbook for the telephone number for your state
Kidney Medicare Drugs Awareness and Education Initiative: www.kidneydrugcoverage.org |
Now what?
One final step to help smooth the transition is to familiarize yourself with your plan’s appeal process. Even if one of your drugs is on a plan’s formulary, you might need “prior authorization.” This means that before the plan will cover these prescriptions, your doctor must first contact the plan and show that there is a medically necessary reason why you must use that particular drug. Drugs on the plan’s preferred list may still require prior authorization. Also, if your plan doesn’t usually cover a drug you need, it still may be covered if you request a “coverage determination” from your plan. For some types of coverage determinations, you will need a supporting statement from your doctor that explains why you need a certain drug, so it is important to familiarize yourself with this process so that it will go smoothly. Learning this information is also important because you might be prescribed new medications or your current drugs could be changed to ones that are not on the plan’s formulary.
Choose carefully! You can usually only join or change to a new drug plan from November 15 through December 31 each year unless your creditable coverage ends, you enter or leave a long-term care facility, or your plan stops offering prescription drug coverage.
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