FAQ about Medicare Part D
For the last year, Medicare has covered prescription drugs for seniors and
the disabled. Known as Medicare Part D, this voluntary program is available
to every Medicare beneficiary; however, there is a penalty associated with late
enrollment. It works like other forms of insurance – beneficiaries pay
a monthly premium, and in return, they receive the medications they need at
a reduced price. For those with limited incomes, there is special assistance.
Specifically, for individuals with incomes under about $15,000 (about $20,000
for a couple) and limited assets, Medicare will pay for 95 percent of drug costs.
Seniors who may be eligible for this assistance should call the Social Security
Administration at 1-800-772-1213.While the new drug benefit will provide meaningful
assistance to many seniors, it is far from perfect. In fact, it will fall short
of many seniors' expectations. However, I feel a responsibility to make
the program work because it is critical that our seniors get the drugs they
need in a timely manner – at affordable prices.With that said, I believe
there are steps that should be taken to strengthen the benefit for our seniors.
For example, I am strongly opposed to penalizing those seniors who did not sign-up
during the initial enrollment period and believe that this penalty should be
waived. In addition, I believe that Congress should take additional steps to
lower prescription drug costs by negotiating directly with drug companies and
allowing individuals to reimport safe medications from Canada. Working together,
we can make this program better so that our seniors have access to affordable
prescription drugs.Below is basic information to help in making a decision about
the drug benefit. I hope you find this helpful.
KEY QUESTIONS ABOUT MEDICARE PART D
I am currently enrolled in a Medicare Part D drug plan.
I have a complaint with my plan, who should I call?
What if I'm out of my plan's service area, but need
a prescription?
My doctor says I need a specific drug that my plan won't
cover, what can I do?
What can I do if my plan denies an exception to its formulary?
I am not pleased with my plan, how can I switch to a different
one?
I am eligible for Medicare, but I haven't enrolled in Medicare Part
D.
I missed the initial enrollment deadline. Can I still
enroll?
I hear I may have to pay a penalty if I enroll now. What's
that all about?
I'm thinking of enrolling now, but can't afford the
monthly costs. Can I get extra help?
Could I lose my patient assistance if I enroll in Medicare Part
D?
I am becoming eligible for Medicare soon.
Do I need prescription drug coverage?
How do I choose the plan that works best for me?
Can I get extra help?
Could I lose my patient assistance if I enroll in Medicare Part
D?
What happens if I don't enroll during my initial Medicare
enrollment period?
If you have other questions, please feel free to call my office at 1-800-223-4457.
You may also visit the
Medicare Rights Center.
I am currently enrolled in a Medicare Part D drug plan.
I have a complaint with my plan, who should I call?
First, you should try and contact your plan directly to see if the
problem can be resolved. Customer service numbers should be on your plan identification
card or in the enrollment materials mailed to you. If no action is taken, then
you should contact the Medicare program at 1-800-MEDICARE to file a complaint.
You may also contact my office at 1-800-2234457 to receive assistance.
What if I'm out of my plan's service
area, but need a prescription?
You can get drugs from an out-of-network pharmacy only if you cannot reasonably
obtain drugs at a network pharmacy and you do not get the drugs at an out-of-network
pharmacy on a regular basis. In those instances you will probably need to pay
for the prescription at the pharmacy and then ask for reimbursement from the
plan for it. The plan can charge you more for using an out-of-network pharmacy.
If you regularly spend a few months of the year in another state, you should
consider enrolling in a national drug plan that partners with pharmacies all
around the country.
My doctor says I need a specific drug that
my plan won't cover, what can I do?
You have the right to submit an exception request that asks your plan to cover
a medically necessary drug when:
- You are using a drug currently covered by your plan, but that drug is removed
for reasons other than safety.
- Your doctor prescribes a drug not on your plan's formulary because
it is the only one that will work for you.
You will need an oral or written statement from your doctor to demonstrate
you need the drug. Plans must respond to your request in writing within 72 hours
from the time they receive your doctor's statement, or 24 hours if your
health requires. If a plan grants your request, it determines your copayment.
The plan must continue to cover refills as long as the doctor continues to prescribe
that drug, it continues to be safe, and the calendar year has not expired. It
is up to the plan to continue granting the request the next year if you renew
membership. You cannot ask for an exception for drugs specifically excluded
from Medicare coverage.
You can also request an exception to other coverage restrictions, such as dose
and dosage limitations, substitution requirements and prior authorization.
What can I do if my plan denies an exception to its formulary?
You can appeal the plan's decision. If your plan denies your exception
request, you can request a second review within 60 days of receiving notice
of the plan's decision. The plan must respond no later than seven calendar
days from the date it receives the request (72 hours for an expedited appeal
due to health concerns). If your plan denies coverage after a redetermination
request, you can request a review by a Qualified Independent Contractor (QIC)
within 60 days of getting the notice of denial of your redetermination from
your plan. That notice should also explain how to appeal to the QIC. The QIC
must get the input of your prescribing doctor either orally or in writing and
respond no later than seven calendar days after receiving your request (72 hours
for an expedited appeal). If you disagree with the QIC's decision, or
if the QIC fails to act, there are several other steps that can be taken. These
include: requesting an Administrative Law Judge hearing, appealing to the Medicare
Appeals Council or seeking Judicial Review in federal court.
I am not pleased with my
plan, how can I switch to a different one?
Generally, enrollees are not allowed to switch plans during the calendar year
except during the Open Enrollment Period. This period is from November 15 –
December 31 of every calendar year. At this time, new rates and coverage details
are released by every plan, so that seniors can determine whether to stay in
their existing plan or switch to a new one. Information on how to switch plans
can be found at www.medicare.gov or by calling 1-800-MEDICARE.
I am eligible for Medicare, but I haven't enrolled
in Medicare Part D
I missed the initial enrollment
deadline. Can I still enroll?
If you missed the initial enrollment period, you can still enroll in Part D,
but you will face a penalty of one percent of the national average premium for
every month you delayed. In addition, you cannot enroll until the annual Open
Enrollment Period, which is November 15 – December 31 of every year.
I hear I may have to pay
a penalty if I enroll now. What's that all about?
As with Medicare Part B, the drug benefit does include a penalty for late enrollees
to prevent adverse selection. The penalty is one percent of the national average
premium for every month you delay enrollment.Without a late enrollment penalty,
the authors of the Medicare bill feared that healthier seniors would defer enrollment
until they started to incur significant drug costs. This would have forced the
program to charge higher premiums per beneficiary. In turn, these higher premiums
would cause further adverse selection. The late enrollment penalty was added
to encourage all eligible beneficiaries to enroll, ensuring a larger risk pool
and helping to hold down per beneficiary premiums.
I'm thinking of enrolling
now, but can't afford the monthly costs. Can I get extra help?
Medicare beneficiaries with limited incomes and resources may qualify for extra
assistance in paying for the cost of their prescription drug plan. If your income
in 2007 is less than about $15,000 ($20,000 for a couple) and you have limited
assets, you may be eligible for help. If you think you could qualify, you should
call the Social Security Administration at 1-800-772-1213 or visit them online
at www.socialsecurity.gov for more information. You may also be interested to know that there is no deadline
for enrolling in the low income subsidy and you may also be eligible to waive
the penalty associated with late enrollment if you qualify for extra help.
Could I lose my patient assistance
if I enroll in Medicare Part D?
It is up to the companies. Some pharmaceutical assistance programs (PAPs) require
that you do not have any other drug coverage to qualify for the program. Others
do allow persons with Medicare drug coverage to qualify. However, these programs
must work separately from your Medicare drug coverage. Pharmaceutical assistance
programs are neither permitted to fill in gaps in your Medicare drug plan coverage
nor to count toward your out-of-pocket limit.
I
am becoming eligible for Medicare soon.
Do I need prescription drug coverage?
Whether to enroll in a Medicare drug plan depends on what kind of coverage,
if any, you have today.
If you receive drug coverage through your employer, ask your
employer if your drug coverage will continue and if it will be as good as or
better than Medicare drug coverage. If your employer drug coverage is going
to continue, and you like it, you do not need to join a Medicare drug plan.
But if your coverage isn't as good, you should consider signing up for
Medicare Part D or you could face a penalty if you enroll later.
If you are receiving coverage through a drug company, you
should check with the company to see if your Medicare eligibility affects your
eligibility for patient assistance. Some companies require that you do not have
any other drug coverage to qualify for the program. Others do allow persons
with Medicare drug coverage to qualify. However, the expenses paid for by the
drug company do not count toward your out-of-pocket limit.
How do I choose the plan
that works best for me?
If you decide to join a Medicare drug plan, you will have many plans to choose
from. Finding out which plan works best for you will depend on many factors.
Some information is published in the Medicare & You handbook, which you
should receive prior to turning age 65. The handbook will not provide all the
information you need to choose a plan. But you can contact specific plans that
you want to know about, and you can ask your family, friends, and community
experts for help. You can receive one-on-one assistance by contacting the ND
Seniors Health Insurance Counseling Program or Medicare. Here are some basic
questions to consider:
Traditional Medicare or Medicare Advantage? If you want
traditional Medicare (which lets you choose your doctor and hospital), then
you can enroll in a separate prescription drug plan. Alternatively, you can
join a private Medicare managed care plan, known as Medicare Advantage, that
will cover doctor, hospital and drug coverage altogether. Some Medicare Advantage
plans may offer more generous drug coverage, but they place more restrictions
on which doctors and hospitals you can visit. Be careful! Some plans may try
to enroll you in Medicare Advantage without telling you that you are giving
up traditional Medicare.
Which drugs are covered by each plan? Each drug plan will
cover different drugs and have different rules for obtaining prescription
drugs. Check to see if the prescriptions you take would be covered and whether
they would be considered “preferred” drugs.
Which pharmacies can I use? Each Medicare drug plan will
contract with a network of pharmacies. You could be charged more if you do
not fill a prescription at a pharmacy in that network. Check to see if your
local pharmacist is participating in a plan before you enroll.
How much will it cost? Each plan will charge different premiums,
deductibles, and copayments. You will need to compare these costs for each
plan. Note that sometimes drug plans with lower premiums will have higher
deductibles, and vice versa.
Can I get extra help?
Medicare beneficiaries with limited incomes and resources may qualify for extra
assistance in paying for the cost of their prescription drug plan. If your income
in 2007 is less than about $15,000 ($20,000 for a couple) and you have limited
assets, you may be eligible for help. If you think you could qualify, you should
call the Social Security Administration at 1-800-772-1213 or visit them online
at www.socialsecurity.gov for more information. You may also be interested to
know that there is no deadline for enrolling in the low income subsidy and you
may also be eligible to waive the penalty associated with late enrollment if
you qualify for extra help.
Could I lose my patient assistance
if I enroll in Medicare Part D?
It is up to the companies. Some pharmaceutical assistance programs (PAPs) require
that you do not have any other drug coverage to qualify for the program. Others
do allow persons with Medicare drug coverage to qualify. However, these programs
must work separately from your Medicare drug coverage. Pharmaceutical assistance
programs are neither permitted to fill in gaps in your Medicare drug plan coverage
nor to count toward your out-of-pocket limit.
What happens if I don't
enroll during my initial Medicare enrollment period?
If you fail to enroll during your initial enrollment period, you could face
a penalty if you decide to enroll later. The penalty is equal to one percent
of the national average premium for every month you delay enrollment.
NEED HELP???
The North Dakota Seniors Health Insurance Counseling Program can help seniors
determine whether a Part D plan is right for them. The one-on-one counseling
can help make this difficult decision a little easier.
Call
1-888-575-6611 for an appointment or
Call my office at 1-800-223-4457
